A list of the most recent deficiencies for Flanagan Rehabilitation and Hcc. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-01-24 | 2024-02-20 | Y |
| Respond appropriately to all alleged violations. | Health | 2024-01-24 | 2024-02-20 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-01-24 | 2024-02-20 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-01-24 | 2024-02-20 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-01-24 | 2024-02-20 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2024-01-24 | 2024-02-20 | Y |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2024-01-24 | 2024-02-20 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-01-24 | 2024-02-20 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2024-01-24 | 2024-02-20 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-07-20 | 2023-11-29 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2023-10-24 | 2023-11-14 | Y |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2023-09-03 | 2023-11-04 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2023-09-03 | 2023-10-17 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-09-03 | 2023-10-17 | Y |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-07-20 | 2023-09-05 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2023-07-20 | 2023-08-12 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2023-07-20 | 2023-08-12 | N |
| Develop a communication plan. | Fire Safety | 2023-07-20 | 2023-08-12 | N |
| Establish emergency prep training and testing. | Fire Safety | 2023-07-20 | 2023-08-12 | N |
| Establish staff and initial training requirements. | Fire Safety | 2023-07-20 | 2023-08-12 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-07-20 | 2023-08-12 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-07-20 | 2023-08-12 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2023-07-19 | 2023-08-11 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2023-07-19 | 2023-08-11 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-07-19 | 2023-08-11 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-07-19 | 2023-08-11 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-07-19 | 2023-08-11 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-07-19 | 2023-08-11 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-07-19 | 2023-08-11 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-07-19 | 2023-08-11 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2023-07-19 | 2023-08-11 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2023-07-19 | 2023-08-11 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-07-19 | 2023-08-11 | N |
| Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility. | Health | 2023-07-19 | 2023-08-11 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-07-19 | 2023-08-11 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2023-07-19 | 2023-08-11 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-07-19 | 2023-08-11 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2023-07-19 | 2023-08-11 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-07-19 | 2023-08-11 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2023-07-19 | 2023-08-11 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-03-08 | 2023-03-27 | Y |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2023-03-08 | 2023-03-27 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-11-30 | 2022-12-15 | Y |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-06-27 | 2022-08-15 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-06-27 | 2022-07-15 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-06-27 | 2022-07-15 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-06-27 | 2022-07-15 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2022-06-27 | 2022-07-15 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2022-06-09 | 2022-06-24 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-06-09 | 2022-06-24 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2022-06-09 | 2022-06-20 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-04-05 | 2022-04-15 | Y |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2022-04-05 | 2022-04-06 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-03-23 | 2022-04-05 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-03-23 | 2022-04-05 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-03-23 | 2022-04-05 | Y |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2022-03-23 | 2022-04-05 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-01-05 | 2022-01-13 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-01-05 | 2022-01-13 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-01-05 | 2022-01-13 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-11-04 | 2021-11-15 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-10-07 | 2021-10-20 | Y |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-06-03 | 2021-07-16 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-06-10 | 2021-06-24 | Y |
| Establish staff and initial training requirements. | Fire Safety | 2021-06-03 | 2021-06-21 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-06-03 | 2021-06-21 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2021-06-03 | 2021-06-20 | N |
| Provide emergency officials' contact information. | Fire Safety | 2021-06-03 | 2021-06-20 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2021-06-03 | 2021-06-20 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2021-06-03 | 2021-06-20 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-06-03 | 2021-06-20 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-06-10 | 2021-06-15 | Y |
| Implement emergency and standby power systems. | Fire Safety | 2021-06-03 | 2021-06-14 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2021-06-03 | 2021-06-10 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2021-05-13 | 2021-05-27 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2021-05-13 | 2021-05-24 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2021-05-13 | 2021-05-17 | N |
| Post nurse staffing information every day. | Health | 2021-05-13 | 2021-05-17 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2021-05-13 | 2021-05-17 | N |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2021-05-13 | 2021-05-14 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2021-05-13 | 2021-05-14 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2021-05-13 | 2021-05-14 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-05-13 | 2021-05-14 | N |
| Report COVID19 data to residents and families. | Health | 2021-05-13 | 2021-05-14 | N |
| Perform COVID19 testing on residents and staff. | Health | 2021-05-13 | 2021-05-14 | N |
| Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame. | Health | 2021-05-13 | 2021-05-14 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2021-05-13 | 2021-05-13 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2021-05-13 | 2021-05-13 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-05-13 | 2021-05-13 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2021-05-13 | 2021-05-13 | N |
