The Centers for Medicare and Medicaid Services (CMS) categorize problematic nursing homes as Special Focus Facilities (SFF) until the Centers have taken appropriate measures to correct serious issues while providing care to their residents. The federal agency utilizes their “progressive enforcement” policies and procedures and monitors each facility to check for improvements.
When the Home’s quality of care has been elevated to appropriate levels, the facility can be removed from the SFF designation. Until then, State surveyors will often show up unannounced multiple times throughout the year or arrive unexpectedly to investigate a formal complaint.
Flagship Health Care Center was recently designated a special focus facility. It has not yet had its first scheduled survey and investigation to determine if appropriate measures have been taken, developed and enforced to ensure the residents are receiving the least minimal amount of care as required by federal and state laws.
If found in compliance, the facility will be monitored for some time to ensure the positive changes made at the Center are permanent. If not, their contract to provide care to Medicare and Medicaid patients may be terminated.
The Special Focus Facility Flagship Health Care Center is a Medicare/Medicaid participating 167-certified bed for-profit nursing home providing cares and services to residents of Newport Beach and Orange County, California.
466 Flagship Rd.
Newport Beach, CA 92663
(949) 642-8044
The Sava Senior Care-affiliated facility provides rehabilitation care, intravenous therapy, dementia care, respiratory therapy and bariatric care.
The federal government and the State of California routinely rank the services, care and assistance every nursing facility provides its residents using a star rating system. The publicly available information is listed on their Medicare.gov website. Currently, Flagship Healthcare Center maintains an overall two out of five-star rating compared to all other facilities in the United States.
This ranking includes two out of five stars for health inspections, five out of five stars for quality measures, and two out of five stars for staffing. Other safety concerns that have harmed or has the potential to harm one or all residents at the facility include:
Failure to Provide Residents an Environment Free of Accident Hazards and a Failure to Provide Adequate Supervision to Prevent Avoidable Accidents
In a summary statement of deficiencies dated August 23, 2017, the state investigator noted the facility’s failure to “provide the necessary cares and services to ensure adequate supervision one place to prevent fall.” This failure “resulted in injuries of [one resident who] fell to the floor while [a Certified Nursing Aide]] was providing incontinence care.” As a result of the fall, the resident had a “skin tear to the upper lip, right frontal scalp hematoma (abnormal collection of blood outside of a blood vessel), and a fracture of the left distal femoral shaft (thigh bone above the knee joint).
Failure to Develop Policies That Prevent Mistreatment, Neglect, or Abusive Residents
In a summary statement of deficiencies dated August 23, 2017, an additional notation was made of the facility’s failure to “implement their own policies and procedures and investigate an incident for [one resident] who was found lying in bed naked from the waist down” in another resident’s bedroom. The investigators noted that this failure “to investigate the allegation of abuse had the potential to place [multiple] residents at increased risk of abuse and [and potentially could cause all residents to] not be protected against abuse.”
As a part of the investigation, the surveyors reviewed the facility’s policies and procedures titled Abuse & Neglect Prohibition that reads in part:
“The facility will timely conduct an investigation of any alleged abuse in accordance with the state law.” “The facility will complete an incident/accident report on occurrences of abuse. The facility shall report all allegations of substantiated occurrence of abuse in accordance with state law.”
A review of a document dated August 3, 2017, revealed that a resident’s “hands were allegedly found inside [another resident’s] shirt touching her breasts.” Another incident was recorded in an August 6, 2017, document revealing that the same resident “allegedly hit” a different resident.
Failure to Protect Each Resident from All Abuse, Physical Punishment, and Being Separated from Others
In a summary statement of deficiencies dated July 21, 2017, the State surveyors noted a failure the facility “to ensure one resident was free from verbal mistreatment.” The resident was provided assistance with eating by a Certified Nursing Assistant when the resident “spit out his milk onto the CNA’s clothing.” The Certified Nursing Assistant “reacted by calling [the resident] a pig in Spanish.” The surveyors noted that the actions of the nursing staff failed to ensure that the resident “was free from verbal abuse and had the potential for humiliation and a negative impact on [the resident’s] psychosocial well-being.”
Failure to Provide Residents and Environment Free of Mice, Insects and Other Pests
In a summary statement of deficiencies dated April 11, 2017, the State surveyors noted the facility’s failure to “ensure the pest control company’s recommendations were followed for [a resident’s] bathroom.” The failure by the administration “had the potential for pests to be harboring underneath the lifted tiles.”
The State surveyor inspected the resident’s bathroom just before noon on March 29, 2017, in the presence of the Maintenance Supervisor who “verified the bathroom floor tile inside the resident’s room was lifted.” A review of the Customer Service Report dated March 16, 2017, revealed that “the pest control company showed the loose floor tiles needed to be repaired to eliminate a potential pest harboring/breeding site.” During an interview with the facility administrator, it was acknowledged that “the pest control company’s recommendations were not followed.”
Failure to Provide Residents an Environment Free of Accident Hazards
In a summary statement of deficiencies dated November 7, 2016, the state investigator noted the facility’s failure “to provide assistive devices and adequate staff assistance to ensure transfers to and from the bed for [a resident] was completed in a manner which minimizes the risk for false or injury.” This failure to provide adequate supervision to a prevent avoidable accidents “increases the risk for the resident to sustain avoidable injuries….”
A review of the resident’s medical records showed that the resident “had a pathologic fracture of his left humerus is likely due to … a contracture of his shoulders and osteoporosis in the humerus. The resident was being transferred to a chair by his caretakers [who supported] his weight under his arms, which is likely the mechanism of injury in the [physician assistant’s] opinion as there was stress placed on the bone during transfers.
Investigator interviewed the Director of Nursing on August 1, 2017, who defined the technique used for transferring that might have led to the resident’s injury. The Director stated that the nursing staff “stood the resident up, put his arms under the resident’s arms, hugged the resident, then lifted and turned the resident into the chair.” The investigator asked the Director if a gait belt was used to assist in the transfer and minimize the potential for injury. The response was “No, the facility did not have [gait belts] and had to order them.”
Failure to Provide Every Resident a Clean, Safe, Comfortable Home-like Environment
In a summary statement of deficiencies dated December 15, 2016, state investigator noted the facility’s failure “to ensure a safe, clean, and home-like environment into resident bathrooms.” The surveyor noted that the facility “failed to label residents’ personal items [which] posed the potential risk of cross-contamination.” The investigator toured one bathroom and made an observation of two unlabeled portable urinals and one unlabeled bedpan “hanging on the wall next to the toilet.”
The State investigator interviewed a Certified Nursing Assistant stated that the specific bathroom observed by the surveyor “was shared by four residents.” The investigator asked the CNA “how they knew who the urinals in bedpan belonged to,” to which the CNA replied, “she did not know.”
Failure to Assist Residents Who Require Help with Eating, Drinking, Grooming, and Personal an Oral Hygiene
In a summary statement of deficiencies dated December 15, 2016, state investigator noted the facility’s failure to “ensure ADL (assistance of daily living) and incontinence care was provided to the residents throughout the facility due to insufficient nursing staff to obtain and maintain the basic physical and psychosocial needs of each resident.” It was also noted that this failure to provide appropriate care “had the potential to cause negative psychosocial and physical effects, including the development of skin irritations, pressure ulcers and worsening of pressure ulcers, and increasing the risk of accidents due to falls.”
The investigator reviewed the facility’s November 30, 2016, Daily Nursing Signing Sheet for the 11 – 7 shift where 5 of 10 Certified Nursing Assistants “called in” and did not attend work that day. The reduced number of staff members left six CNAs to provide all of the care to 153 residents throughout the facility. During an interview conducted with residents at the facility on December 1, 2016, seven residents stated that “staff did not answer the call lights in a timely manner.” Two residents at the facility “had to wait up to 25 to 30 minutes and had accidents in their beds.” Another resident “had his light turned off and had to wait for over two hours before he received his pain medication.”
Two other residents stated that “staff took a long time to answer the call lights [and] sometimes turned [the light] off without addressing their needs.” One Certified Nursing Assistant stated that a resident pressed their “call light and asked for assistance to go to the toilet [because they] could not wait long.” The Certified Nursing Assistant also stated that “she was very busy helping other residents [and] sometimes she helped other residents in the restroom, so she could not go to [other residents calling for assistance] right away. As a result, one resident got up and went to the toilet unassisted.”
Failure to Take Preventive Measures to Avoid the Development of Pressure Ulcers or Treatment for Existing Bedsores
In a summary statement of deficiencies dated December 15, 2016, the state investigator noted the facility’s failure “to ensure the necessary care and services were provided to prevent the development and promote healing of pressure ulcers [for a resident at the facility].” In one incident, a resident had “informed staff of pain to the right heel for a week before the staff identified that the resident had developed a DTI (deep tissue injury) to the right heel. This resulted in the resident requiring further treatment to attempt to heal the pressure ulcer, or the discomfort due to having to wear a special boot, imposing the risk of possible infection.”
Another resident was admitted to the facility with the Stage IV pressure ulcer to their Sacro-coccyx area. The pressure ulcer was observed to be covered with loose stool. There is no documentation revealing that “the staff had turned, reposition, checked every two hours, and provided the resident’s peri care after each incontinence episode as Care Planned.” The surveyor noted that the facility did not “have enough nursing staff to provide proper care for the residents throughout the facility.
Failure to Ensure That Every Resident Entering the Nursing Facility without a Catheter Is Not Given Catheter
In a summary statement of deficiencies dated December 15, 2016, the surveyor noted that the facility had failed to “ensure one resident received appropriate cares and services for an indwelling urinary catheter (a tube placed in the bladder to drain urine).” The staff “failed to ensure [that the resident] was provided daily catheter care [which] posed the risk of [the resident] developing recurring urinary tract infections.”
If your loved one has suffered serious mistreatment, ongoing poor care or neglect while residing at Flagship Healthcare Center or any other nursing facility, a personal injury attorney can provide immediate assistance to stop the abuse now.
Contact us today! With legal representation, you can take appropriate measures to ensure your loved one receives the highest level of care by being transferred to a better facility and holding those responsible for your loved ones harm financially accountable for your damages.
Attorney Anthony Lanzone
Licensed in California
Newport Beach Nursing Home Injury Lawyer Nursing Home Law Center LLC Home