Flagstone

Inspectors wroteBased on interview and document review, the facility failed to obtain and document informed consent, including an explanation of risks and benefits, for 1 of 5 residents (R43) reviewed for the use of psychotropic medications.

Inspectors wroteBased on interview and document review, the facility failed to ensure instructions for use of multiple as-needed (PRN) psychotropic medications were included, to ensure appropriate administration and minimize the risk of unnecessary medication usage for 1 of 5 residents (R43) reviewed for unnecessary medications.

Inspectors wroteBased on interview and document review, the facility failed to ensure complete and comprehensive Minimum Data Set(s) (MDS) were completed for 1 of 5 residents (R4) reviewed for assessment accuracy.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure routine personal hygiene care (i.e., facial hair removal) was provided for 1 of 1 resident (R39) reviewed who was dependent of staff for activities of daily living (ADLs).

Inspectors wroteBased on observation, interview, and document review, the facility failed to comprehensively assess and, if needed, determine or develop proactive interventions to help address pressure injury risk and prevent skin alteration worsening, after a pressure-induced skin alteration was identified for 1 of 3 residents (R19) reviewed for pressure injuries.

Inspectors wroteBased on interview and document review, the facility failed to ensure safety measure were put in place to prevent accidents for one of two resident (R25) reviewed for accidents who had known fainting episodes, often while on the toilet.

Inspectors wroteBased on observation, interview and document review the facility failed to ensure residents using a continuous positive airway pressure (CPAP) machine had appropriate orders for use to include equipment settings for 1 of 2 residents (R19) reviewed for respiratory care.

Inspectors wroteBased on interview and document review, the facility failed to ensure the consulting pharmacist (CP) identified and acted upon 1 of 5 residents (R5) reviewed who had psychotropic medications without an adequate medical diagnosis for ongoing use.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure medications were administered at the ordered time resulting in worsened pain for 1 of 1 resident (R25) resulting in a significant medication error.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure enhanced barrier precautions (EBP) were followed for 3 of 6 residents (R26, R51, R4) and failed to perform hand hygiene to reduce the risk of the spread of infection to others for 1 of 6 residents (R51) reviewed for infection control practices.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased on observation, interview and document review, the facility failed to provide assistance with personal hygiene for 4 of 4 residents ( R7, R33, R267) reviewed for activities of daily living (ADL)'s.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure the resident's ability to self-administration of medications (SAM) was assessed prior to leaving medications with the resident for 3 of 3 residents (R33, R267, R9) reviewed who had medications in their rooms. R33 R33's admission Minimum Data Set (MDS) dated [DATE], identified R33 had no cognitive impairment and diagnoses which included: muscle weakness, depression, and diabetes. R33 required moderate assistance with personal hygiene such as combing hair and shaving. R33's care plan dated 12/26/24, revealed R33 had an activity of daily living (ADL) self-care performance deficits due to encephalopathy, aspiration, urinary tract infection (UTI) dysphasia, and cognitive impairment. R33 wanted to be clean and well-dressed. R33 required one assist for dressing, grooming, and hygiene. [...]

Inspectors wroteBased on interview and document review, the facility failed to follow the comprehensive care plan for 1 of 1 residents (R62) whose care plan was reviewed.

Inspectors wroteBased on observation, interview and document review, the facility failed to provide meaningful and engaging activities for 1 of 1 residents (R62) reviewed for activities.

Inspectors wroteBased on observation, interview and document review, the facility failed to implement interventions for 1 of 1 residents (R17) who had a recent fall with a significant injury in the facility and remained at high risk for falls.

Inspectors wroteBased on interview and document review, the facility failed to ensure newly admitted residents received 30 day physician visits for the first 90 days for 1 of 1 residents (R30) reviewed for 30 day physician visits.

Inspectors wroteBased on interview and document review, the facility failed to implement a system to ensure medications were available to administer as ordered for 2 of 2 residents (R61, R57) identified who did not receive medications as ordered. Findings Include: R61 R61's admission Minimum Data Set (MDS) dated [DATE], identified R61 had moderate cognitive impairment and diagnoses which included: Crohn's disease (chronic condition that causes inflammation of gastrointestinal tract), heart failure and chronic kidney disease. During an observation on 1/27/25 at 4:38 p.m., trained medication aide (TMA)-A set up R61's medications. TMA-A indicated R61 was to receive Creon (medication that replaces digestive enzymes in body) however it was not available to administer, so would contact the pharmacy to order it again. R61's Discharge Orders And Information hospital form dated 12/30/24, included the following: [...]

Inspectors wroteBased on observation, interview and document review, the facility had a 7% percent medication error rate for 2 of 4 residents( R61, R44) observed during medication administration. Findings Include: R61 R61's admission Minimum Data Set (MDS) dated [DATE], identified R61 had moderate cognitive impairment and diagnoses which included: Crohn's disease (chronic condition that causes inflammation of gastrointestinal tract), heart failure and chronic kidney disease. R61's Discharge Orders And Information hospital form dated 12/30/24, included the following: -Creon 24000-76000 units oral capsule, take one capsule by mouth three times daily. During an observation on 1/27/25 at 4:38 p.m. trained medication aide (TMA)-A set up R61's medications. [...]

Inspectors wroteBased on interview, observation, and document review, the facility failed to ensure resident room walls were in good repair to create a home-like environment for 1 of 1 resident (R26) reviewed for room environment.

Inspectors wroteBased on observation, interview and document review, the facility failed to develop a comprehensive care plan for psychotropic medications that included resident-specific interventions for 1 or 4 residents (R54) reviewed for psychotropic medications.

Inspectors wroteBased on observation, interview and document review, the facility failed to provide grooming and shaving for 1 of 1 residents (R22) reviewed for activities of daily living (ADLs) and who were dependent on staff for their care.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure interventions were in place for 1 of 2 residents (R26) reviewed for pressure ulcers.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure adequate monitoring of orthostatic blood pressures for antipsychotic drug use for 1 of 4 residents (R22) reviewed for psychotropic drug use. Additionally, the facility facility failed to ensure adequate monitoring of weights and fluid status for 1 of 5 residents (R22) reviewed for unnecessary medications.

Inspectors wroteBased on interview and document review, the facility failed to implement a system to ensure appropriate follow up on wound culture results to prevent potential inappropriate use of antibiotics and determine whether to use special precautions for 1 of 1 resident (R1).