Little Flower Manor

In the surveyor’s words

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

• Immediate jeopardy, isolatedF693Mar 24, 2022

  Based on review of clinical records, review of facility documentation and interviews with staff, it was determined that the facility failed to follow physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This failure resulted in actual harm to Resident R1 who received the incorrect volume of the enteral formula, developed vomiting, required transfer to the hospital and was diagnosed with acute respiratory failure secondary to aspiration, for one of four residents reviewed on enteral feeding. (Resident R1). […]

• No harm, potential for more than minimal, widespreadF812Mar 12, 2024

  Based on review of facility policy, observations, and staff interview it was determined that the facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. Findings Include: Review of facility policy revealed products transferred from the manufacturers ' original packaging or opened must be stored and labelled in accordance with the manufacturers after opening instructions. Perishable foods must have limited shelf life and must be refrigerated. This is normally 72 hours for in-unit produced foods. An initial tour of the Food Service Department was conducted on March 8, 2024, at 9:30 a.m. with Employee E4, Assistant Food Service Director. […]

• No harm, potential for more than minimal, patternF761May 11, 2023

  Based on observation, interview with staff and review of facility policy, it was determined that the facility did not ensure that controlled substances were stored is a safe and secure compartment for two of two medication rooms. (Unit A and Unit B) Findings include: Observation of the Medication Room in Unit B conducted on May 11, 2023, at 10:08 a.m. with unit manager Employee E7 revealed that the refrigerator where the controlled substances were stored did not have a lock. Further observation revealed a hand carry narcotics box with a lock but was not permanently affixed to the refrigerator. […]

• No harm, potential for more than minimal, isolatedF656Jan 9, 2025

  Based on review of clinical records, facility policy, and staff interviews, it was determined that the facility failed to develop a person-centered comprehensive care plan for one of 18 residents reviewed (Resident R70). Findings include: A review of the facility policy Care Plan, revised May 2023, revealed the facility will develop and implement a comprehensive person-centered care plan for each resident. The care plan will include measurable objectives and time frames to meet a resident's medical, nursing, and psychosocial needs that are identified in the comprehensive assessment. […]

• No harm, potential for more than minimal, isolatedF757Jan 9, 2025

  Based on review of clinical records and staff interview, it was determined that the facility failed to ensure that a resident's drug regimen was free of unnecessary drugs for one of 18 residents reviewed (Resident R30). Findings included: Review of facility policy tilted Medication Regiment Review, revised June 2024, revealed if an irregularity is not time-sensitive but should be addressed before the consultant pharmacists' next monthly MRR, the facility staff and the consultant pharmacist will confer on the timeliness of attending physician/prescriber responses to identified irregularities based on the specific resident's clinical condition. […]