Flagstone

In the surveyor’s words

From the most serious findings on record at Flagstone, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600May 4, 2022

  Based on interview and document review, the facility failed to ensure 2 of 3 residents (R1, R3) were free from ongoing staff to resident sexual abuse. This resulted in an immediate jeopardy (IJ) situation for R1 who sustained psychosocial harm related to staff to resident abuse. The IJ began on 4/23/22, when nursing assistant (NA)-A sexually abused R1, which was identified by the facility on 4/26/22. In addition, R3 stated NA-A applied lotion to her in a sexual manner making her uncomfortable. The campus administrator, care center administrator and the director of nursing (DON) were notified of the IJ on 5/4/22, at 4:25 p.m. The IJ was removed; and the deficient practice was corrected on 4/26/22, prior to the start of the survey and was cited as past non-compliance. […]

• Actual harm, isolatedF690Feb 4, 2021

  Based on interview and document review, the facility failed to assess complaints of a urinary tract infection [MEDICAL CONDITION] for 1 of 2 residents (R1) reviewed who had indwelling urinary catheters. The facilities failure to assess for signs of infection and notify the practitioner, resulted in actual harm for R1, when she required hospitalization for septic shock due to UTI. Findings include: R1's annual Minimum Data Set ((MDS) dated [DATE], included, cognitively intact and required extensive assist to total dependence for activities of daily living (ADL). R1's quarterly MDS dated [DATE], identified an indwelling urinary catheter and was cognitively intact. […]

• No harm, potential for more than minimal, patternF658Jul 17, 2025

  Based on observation, interview, and document review, the facility failed to ensure professional standards of practice were followed during medication administration for 5 of 5 residents (R1, R2, R4, R5, R6) observed for medication administration.Findings include:R1R1's annual Minimum Data Set (MDS) assessment dated [DATE], indicated she was cognitively intact and required moderate assistance in activities of daily living.R1's physician order from the medication administration record, dated 1/6/25, indicated Ativan Oral Tablet 0.5 milligrams (Lorazepam). Give 0.5 milligrams by mouth every 6 hours as needed for panic attack. Camera footage dated 6/21/25 at 12:53 a.m., showed registered nurse (RN)-A entered R1's room with a medication cup and spoon. […]

• No harm, potential for more than minimal, patternF880Jul 17, 2025

  Based on observation, interview, and document review, the facility failed to ensure hand hygiene was completed during medication administration for 5 of 5 residents (R1, R2, R4, R5, R6) observed for medication administration.Findings include:On 7/17/25 at 8:46 a.m., trained medication assistant (TMA)-A was observed administering medications to R4. TMA-A entered the room and touched R4, assisted her to stand up from her bed and then touched the resident's personal fridge to retrieve some apple sauce. TMA-A did not sanitize her hands before administering the medications to R4. TMA-A administered the medications mixed in applesauce by spoon and handed her a cup of water after every spoonful. After administering the medications, TMA-A used hand sanitizer but then touched her face. […]

• No harm, potential for more than minimal, patternF565Jan 29, 2025

  Based on interview and document review, the facility failed to ensure residents were provided a private meeting place without staff present for resident council meetings. This deficient practice had the potential to affect all five residents (R29, R39, R45, R35, and R12) who regularly attended the monthly resident council meetings. Findings include: R29's quarterly Minimal Set Data (MDS) dated [DATE], revealed R29 had mild impaired cognition. R39's annual MDS dated [DATE] ,revealed R29 had no cognitive impairment. R45's annual MDS dated [DATE], revealed R45 had no cognitive impairment. R35's quarterly MDS dated [DATE], revealed R25 had mild cognitive impairment. R12's significant change MDS dated [DATE] ,revealed R12 had no cognitive impairment. […]