Flanagan Rehabilitation and Health Care Center

In the surveyor’s words

From the most serious findings on record at Flanagan Rehabilitation and Health Care Center, in the surveyor’s own words.

• Actual harm, isolatedF760Sep 18, 2025

  Based on interview and record review the facility failed ensure a controlled medication was not stopped abruptly without notifying the physician for one of two residents (R1) reviewed for medication errors in the sample list of three. This failure resulted in R1 becoming unresponsive, falling, and being transferred to the hospital with benzodiazepine withdrawal, delirium, and syncope after R1's Ativan (benzodiazepine) was stopped abruptly.Findings include:R1's Minimum Data Set, dated [DATE] documents R1 has moderate cognitive impairment. R1's active Care Plan dated 7/18/25 documents the following: R1 has anxiety and intellectual developments. Interventions include give medication as ordered and monitor/document side effects and effectiveness, and to monitor for signs/symptoms of behaviors. […]

• Actual harm, isolatedF684Jul 29, 2025

  Based on observation, interviews and record review the facility failed to address resident's care needs to obtain appointments in a timely manner, resulting in a delay in the removal of a gastrostomy feeding tube and a delay in podiatry services for an infection for (R15). R15 is one of three residents reviewed for infections/ medical devices in the sample list of 27.These delays resulted in R15's transfer to the local hospital, for antibiotic treatment of G-tube infection, and ingrown toenail infection.Findings include:1. […]

• Actual harm, isolatedF550Jan 24, 2024

  Based on interview and record review, the facility failed to treat residents with respect, dignity and provide care in a manner that promotes quality of life by not allowing a resident to have a say in medical treatment for one of four residents (R3) reviewed for respiratory care in the sample of six. This failure resulted in R3 being fearful of staff and experiencing ongoing psychosocial harm of R3; which resulted in R3 being sent to the emergency room for an anxiety attack. Findings Include: R3's MDS (Minimum Data Set) dated 12/24/24 documents R3 is alert and oriented. […]

• Actual harm, isolatedF686Jan 24, 2024

  Based on observation, interview and record review, the facility failed to notify the physician of a pressure ulcer to obtain an appropriate wound treatment, assess and document the pressure ulcer, notify the resident representative of a pressure ulcer and prevent cross contamination of the wound during a treatment for one of three residents (R2) reviewed for wounds in the sample list of six. This failure resulted in R2's MASD (Moisture Associated Skin Damage) progressing to an unstageable pressure ulcer. Findings Include: R2's ongoing diagnoses listing documents R2 has TBI (Traumatic Brain Injury), Morbid Obesity, and Hemiplegia and Hemiparesis following unspecified Cerebrovascular Disease affecting Right Dominant Side. […]

• Actual harm, isolatedF695Jan 24, 2024

  Based on observation, interview and record review, the facility failed to follow physician orders for respiratory care including oxygen, BiPAP and C-PAP usage, change oxygen tubing and humidifier bottles as ordered and document resident complaisance/non-compliance of respiratory care for four of four residents (R1, R2, R3, R4) reviewed for respiratory care in the sample list of six. This failure resulted in psychosocial harm of R3. R3 was sent to the hospital after having a panic attack and remains fearful of facility staff's action related to R3's respiratory care. Findings Include: 1. […]