Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Flanagan Rehabilitation And Health Care Center during CMS and state inspections, most recent first.
A resident with cognitive impairment and anxiety had their Ativan 1mg TID stopped abruptly without physician notification or tapering, contrary to care plan and facility policy. After the medication was discontinued and wasted, the resident was found unresponsive and was hospitalized with benzodiazepine withdrawal, delirium, and syncope. Staff and the medical director confirmed that the medication should not have been stopped suddenly and that required notifications and documentation were not completed.
Two residents receiving medications for seizures and opioid pain management did not have care plans that addressed their diagnoses or medication use. The care plans lacked problems, goals, and interventions for seizure disorder and opioid monitoring, including risk for constipation, as confirmed by the DON.
A resident with severe cognitive impairment and dependent on staff for toileting was prescribed Tramadol, but did not have a care plan addressing opioid-induced constipation or receive scheduled bowel medications. Despite documented periods of no bowel movements for several days, there was no evidence of assessment or intervention for constipation, and staff confirmed the absence of a standardized bowel protocol.
A resident did not receive treatment and care in accordance with physician orders and their own preferences and goals, resulting in a deficiency for not following required care protocols.
Staff did not immediately inform a resident, the resident's doctor, and a family member about situations such as injury, decline, or room changes that affected the resident, as required. This deficiency was identified through review of facility practices and records.
A Social Services Director did not conduct or document required follow-up visits with a resident who reported abuse by two CNAs, despite the resident's history of PTSD and facility policy mandating such follow-up after abuse allegations. The omission was acknowledged by the Social Services Director and confirmed by the Administrator.
The facility failed to safeguard resident trust funds, affecting 19 residents, due to improper handling by the Business Office Manager (BOM). The BOM, responsible for managing the funds, discovered a discrepancy of $489.82 and was terminated for not following facility policy. The policy required separate individuals for handling transactions and reconciling accounts, which was not adhered to, leading to unaccounted funds.
The facility failed to convey a deceased resident's funds to the estate within the required 30 days. The resident had a balance of $125.00, and the administrator was unsure how to transfer the funds due to being new to the role after the termination of the Business Office Manager.
A resident with severe cognitive impairment and behavioral disturbances physically abused two other residents in the facility. Despite the facility's policy to prevent abuse, the resident's aggressive actions, including punching and kicking, were not adequately monitored or managed, leading to substantiated abuse allegations.
The facility failed to ensure that the Medical Director and DON attended the QA meetings, as required by their policy. The sign-in sheets for a meeting did not include their signatures, and the Administrator in Training confirmed their absence. This failure has the potential to affect all 27 residents in the facility.
The facility failed to identify resident-specific targeted behaviors and implement non-pharmacological interventions before using and increasing psychotropic medications for two residents. One resident's record lacked specific behaviors and interventions, while another resident's record did not document behaviors or non-pharmacological attempts before increasing Risperdal dosage.
The facility failed to implement Enhanced Barrier Precautions and perform proper hand hygiene during incontinence care for four residents. Staff did not wear gowns while providing catheter and wound care, and a CNA did not perform hand hygiene after incontinence care, contrary to the facility's infection control policies.
The facility failed to ensure a resident's call light was within reach, despite the resident's care plan indicating impaired physical mobility and the need for the call light to be accessible. The call light was tied to a water jug on an over bed table, out of the resident's reach, and a CNA confirmed the issue.
The facility failed to provide quarterly financial statements to a cognitively intact resident whose money is managed by the facility. The Business Office Manager confirmed that statements have not been provided since a data breach in October 2023.
The facility failed to document care plans including resident-centered interventions for respiratory care for a resident with Chronic Respiratory Failure with Hypoxia. Physician orders indicated the use of oxygen and Albuterol nebulizer, but the care plan did not document any respiratory problems or needs. The resident was observed without oxygen and stated they use oxygen in bed and the nebulizer daily for shortness of breath.
The facility failed to notify the physician of significant weight changes for a resident, despite documented fluctuations in weight. The resident's progress notes did not show any physician notification or re-weighs, contrary to the facility's stated protocol.
The facility failed to administer medications correctly for three residents, resulting in a 14.28% medication error rate. Errors included administering insulin after a meal, giving Lactaid without food, and providing Vascepa and Metformin before dinner without ensuring the resident had eaten.
Abrupt Discontinuation of Benzodiazepine Without Physician Notification
Penalty
Summary
A deficiency occurred when a resident with moderate cognitive impairment and diagnoses including developmental intellectual disability, depression, and anxiety disorder had their prescribed Ativan (a benzodiazepine) 1mg three times daily stopped abruptly without physician notification or a tapering process. The resident's care plan required medications to be given as ordered and for staff to monitor and document side effects and effectiveness. Pharmacy records confirmed the medication was being filled and administered as ordered until it was discontinued. On the date of discontinuation, 32 Ativan pills were wasted with two nurse witnesses, and the medication order was removed from the Medication Administration Record (MAR) without contacting the physician or the resident's Power of Attorney. Following the abrupt cessation of Ativan, the resident was found unresponsive on the floor, with cool and clammy skin and high blood pressure, requiring emergency medical services and hospital transfer. The hospital diagnosed the resident with benzodiazepine withdrawal, delirium, and syncope. Interviews with facility staff and the medical director confirmed that the physician was not notified of the discontinuation, and the medical director stated that any controlled medication, especially at a high dose, should be tapered gradually to prevent withdrawal symptoms. The facility's medication administration policy required documentation of any medication changes and up-to-date MARs, which was not followed in this case.
Care Plans Lacking for Seizure and Opioid Medication Management
Penalty
Summary
The facility failed to ensure that care plans included problems, goals, and interventions to address specific diagnoses and medication use for two residents. One resident with a diagnosis of epileptic seizures was receiving Lamotrigine and Phenytoin Sodium for seizure management, but their active care plan did not address the seizure disorder or the use of these medications. Another resident was receiving Tramadol, an opioid, but their care plan did not include a problem, goal, or interventions related to opioid use or monitoring for associated risks such as constipation. These omissions were confirmed by the Director of Nursing, who acknowledged that the care plans did not address these issues.
Failure to Implement Bowel Program for Resident on Opioid Medication
Penalty
Summary
The facility failed to implement an appropriate bowel program for a resident who was prescribed Tramadol, an opioid known to increase the risk of constipation. The resident, who has severe cognitive impairment and is dependent on staff for toileting, had no scheduled bowel medications and did not receive any doses of as-needed Milk of Magnesia, despite documented periods of no bowel movements for several consecutive days. The resident's care plan did not address opioid use or the associated risk for constipation, and there was no evidence in the nursing notes that the resident was assessed for constipation or offered bowel interventions during these periods. Staff interviews confirmed that the electronic medical record system only triggered alerts after three days without a bowel movement, and the facility did not have a standardized bowel protocol, instead relying on individual assessment. The DON and nursing staff acknowledged the lack of a care plan addressing opioid-induced constipation and confirmed that the resident experienced occasional constipation, with no routine bowel medications ordered or administered. Documentation showed multiple instances of three or more days without a bowel movement, with no corresponding interventions recorded.
Failure to Provide Care According to Orders and Resident Preferences
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders, as well as the resident's preferences and goals. This deficiency indicates that care delivered did not align with the established plan or the expressed wishes and objectives of the resident, as required by regulations.
Failure to Promptly Notify Resident, Physician, and Family of Significant Events
Penalty
Summary
Facility staff failed to immediately notify the resident, the resident's physician, and a family member about situations that affected the resident, such as injury, decline, or changes in room assignment. This lack of timely communication was observed and documented by surveyors during the review of facility practices and records. The deficiency centers on the facility's failure to ensure that all required parties were promptly informed when significant events impacting the resident occurred.
Failure to Provide and Document Social Services Follow-Up After Abuse Allegation
Penalty
Summary
The facility Social Services Director failed to conduct required follow-up visits and document interactions with a resident following an abuse allegation, as mandated by the facility's Abuse policy. The policy specifies that Social Services must follow up with any resident after an allegation and document the visit in the resident's chart. In this case, the resident, who is cognitively intact and has a history of PTSD, reported two Certified Nursing Assistants for alleged abuse. Although the investigation concluded the allegation was unfounded, the Social Services Director did not meet with the resident or document any follow-up, despite a report stating that social services would meet with the resident twice a week for four weeks. The Social Services Director acknowledged not speaking with the resident or documenting the required follow-up, attributing the omission to forgetfulness. The Administrator confirmed that the follow-up and documentation should have occurred according to policy and the report related to the allegation.
Failure to Safeguard Resident Trust Funds
Penalty
Summary
The facility failed to safeguard and account for resident monies held in the resident trust fund cash box, affecting 19 residents. The issue was identified when the Business Office Manager (BOM), who was responsible for handling the resident trust fund cash, discovered a discrepancy of $489.82. The BOM was not following the facility's policy, which required that the person handling day-to-day transactions should not be the same person reconciling the accounts. The BOM was terminated for not adhering to these procedures. The facility's policy outlined a process where the Activity Designee would collect a list of desired items from residents, obtain funds from the BOM, and have residents sign for withdrawals. Upon returning from shopping, the Activity Designee was supposed to have residents sign receipts and return the change to the BOM, who would then deposit it back into the bank. However, the BOM was handling the cash during shopping trips and not obtaining resident signatures for the change, leading to the discrepancy. This failure to follow protocol resulted in the unaccounted funds.
Failure to Convey Deceased Resident's Funds Timely
Penalty
Summary
The facility failed to convey a deceased resident's funds to the resident's estate or probate within the required 30 days after death. This deficiency affected one resident, identified as R7, out of a sample of 25 residents reviewed for resident funds. R7's records, including the Electronic Medical Record Resident Listing, Minimum Data Set, and Nurses Notes, documented that R7 expired on a specific date. The Individual Resident Trust Fund Ledger showed that R7 had a balance of $125.00 as of another specific date. The facility's policy required that resident personal funds be refunded within 30 days of discharge or death, with a final accounting to the resident's estate or the person administering the estate. However, the administrator, V1, acknowledged that R7 still had a balance and was unsure how to convey the funds to the appropriate party due to being new to the role after the termination of the Business Office Manager.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect residents from physical abuse by another resident, affecting three residents in the sample. The facility's Abuse Prevention and Prohibition Policy emphasizes the right of residents to be free from abuse and mistreatment. However, incidents involving a resident with severe cognitive impairment and diagnosed with Dementia with Behavioral Disturbance and Delusional Disorder were reported. This resident, referred to as R1, exhibited aggressive behaviors, including punching another resident, R5, and kicking a third resident, R2, without provocation. These actions were witnessed by staff members and confirmed through interviews and facility investigations. R1's aggressive behaviors were documented in a psychosocial evaluation, which noted new behaviors such as physical aggression and agitation. Despite this, R1 was not adequately monitored, leading to incidents of abuse. R2, who has moderate cognitive impairment and is diagnosed with Depression, Schizoaffective Disorder, and Anxiety, was kicked by R1. R5, with severe cognitive impairment and diagnosed with Cerebral Palsy, Schizoaffective Disorder, Depression, and Explosive Disorder, was punched by R1. The facility's failure to monitor and manage R1's behavior resulted in substantiated allegations of abuse, as confirmed by the facility administrator.
Failure to Ensure Required Attendance at QA Meetings
Penalty
Summary
The facility failed to ensure that the Medical Director and Director of Nursing (DON) attended the Quality Assurance (QA) meetings, as required by their Quality Assurance policy. The facility's policy, dated 2022, mandates monthly and quarterly QA meetings, but the sign-in sheets for the meeting on 10/26/23 did not include signatures from the DON or the Medical Director. During an interview on 05/06/24, the Administrator in Training confirmed that the facility did not have a DON at the time of the meeting and that the Medical Director was not in attendance. This failure has the potential to affect all 27 residents residing in the facility, as documented in the facility's Application for Medicaid and Medicare dated 5/6/24.
Failure to Implement Non-Pharmacological Interventions Before Psychotropic Medication Use
Penalty
Summary
The facility failed to identify resident-specific targeted behaviors and implement non-pharmacological interventions prior to the use and increase of psychotropic medications for two residents. For one resident, the electronic health record documented current orders for Geodon and Sertraline, but did not contain resident-specific targeted behaviors or interventions. The facility used a preprinted behavior tracking list that was not specific to the resident. The Director of Nursing confirmed that the same computer-generated list of behaviors and interventions was used for all residents requiring behavior tracking. For another resident with a diagnosis of unspecified dementia with behavioral disturbance, the physician's order sheet documented an increase in Risperdal dosage. However, the medical record did not document any behaviors after a specific date, nor did it document that non-pharmacological interventions were attempted prior to the medication increase. A registered nurse familiar with the resident stated that the behaviors were inconsistent and triggered by another resident. The Director of Nursing confirmed there was no documentation of increased behaviors prior to the medication increase and acknowledged that psychotropic medications were not being monitored appropriately before the new company took over.
Failure to Implement Enhanced Barrier Precautions and Perform Hand Hygiene
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions and perform proper hand hygiene during incontinence care for four residents. Specifically, the facility did not ensure that staff wore gowns while providing catheter care and wound care for residents with indwelling medical devices and chronic wounds. For instance, two CNAs provided catheter care to a resident with an indwelling catheter without wearing gowns, and there was no sign indicating the need for enhanced barrier precautions. Another resident with a venous ulcer on the left foot did not have enhanced barrier precautions implemented until several days after the survey began, despite having a history of wound infection. Additionally, a resident with a chronic wound on the ischial tuberosity did not have enhanced barrier precautions applied because the wound was mistakenly considered acute by the staff. Furthermore, the facility failed to ensure proper hand hygiene during incontinence care. A CNA changed gloves but did not perform hand hygiene after providing incontinence care to a resident who had been incontinent of a bowel movement. This action was contrary to the facility's Infection Prevention and Control Manual, which emphasizes the importance of hand hygiene as the primary means of preventing infection transmission. The failure to adhere to these protocols was confirmed by the Director of Nursing during the survey.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure the call light was within reach for one of the residents reviewed for call lights. On 5/06/24 at 1:20 PM, the resident was observed sitting in a reclining chair in their room, with the call light tied to a water jug on the over bed table, which was out of the resident's reach. The resident attempted to reach the call light but was unable to do so. A CNA confirmed the call light was not within reach and expressed confusion about the situation. The resident's care plan, dated 3/18/24, documented impaired physical mobility and included an intervention to keep the call light within reach.
Failure to Provide Quarterly Financial Statements
Penalty
Summary
The facility failed to provide quarterly financial statements to a resident who is cognitively intact and has her money managed by the facility. The resident expressed that she does not receive these statements and would be interested in seeing them. The Business Office Manager confirmed that quarterly statements have not been provided since a data breach occurred in October 2023, affecting the third quarter of last year and the first and second quarters of this year.
Failure to Document Respiratory Care in Care Plan
Penalty
Summary
The facility failed to document care plans including resident-centered interventions for respiratory care for one resident reviewed for care plans. The resident, who is alert and oriented, has a diagnosis of Chronic Respiratory Failure with Hypoxia. Physician orders indicate the use of oxygen at 2-4 liters per nasal cannula to maintain oxygen saturation levels above 92% and Albuterol nebulizer every four hours as needed for shortness of breath and wheezing. However, the resident's care plan did not document any respiratory problems or needs. During an observation, the resident was seen sitting in a wheelchair without wearing oxygen and stated that they wear oxygen all the time when in bed and use the nebulizer on average once a day for shortness of breath.
Failure to Notify Physician of Significant Weight Changes
Penalty
Summary
The facility failed to update the physician on significant weight changes for a resident (R29) reviewed for weight changes. R29's Minimum Data Set (MDS) assessment indicated that the resident is alert and oriented. The weight log for R29 documented significant fluctuations: a weight gain of 9.26% in one month, a weight loss of 3.67% in the following month, and another weight gain of 14.96% in the subsequent month. Despite these significant changes, there was no documentation in R29's progress notes indicating that the physician was notified or that re-weighs were conducted. The Director of Nursing (V2) stated that the facility would typically re-weigh residents and notify the physician, but this was not reflected in the records for R29.
Medication Administration Errors
Penalty
Summary
The facility failed to administer medications in accordance with physician orders and manufacturer's instructions for three residents. One resident received fast-acting insulin (Lispro) after breakfast, contrary to the manufacturer's instructions to administer it within fifteen minutes before or immediately after a meal. Another resident was given Lactaid without food, despite the package insert indicating it should be taken with the first bite of dairy food. A third resident was administered Vascepa and Metformin before dinner, but had not received dinner by the time the medications were given, contrary to the instructions to take both medications with food. These actions resulted in a 14.28% medication error rate, exceeding the acceptable threshold of 5% or less.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Flanagan
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| El Paso Rehabilitation And Health Care Center | 9.8 mi | — | 8 | 0 |
| Arc At El Paso | 10.3 mi | ★★★★★ | 5 | 0 |
| Goldwater Pontiac Nursing Home | 12.2 mi | ★★★★★ | 7 | 0 |
| Accolade Healthcare Of Pontiac | 14.6 mi | ★★★★★ | 4 | 0 |
| Evenglow Lodge | 14.8 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.