Deficiencies (last 3 years)
Deficiencies (over 3 years)
11.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
183% worse than Louisiana average
Louisiana average: 4 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Routine
Deficiencies: 11
Date: Jul 2, 2025
Visit Reason
The inspection was conducted as a routine regulatory survey of Flannery Oaks Guest House to assess compliance with healthcare facility regulations and standards.
Findings
The facility was found deficient in multiple areas including call light accessibility, accurate documentation of resident code status, resident assessments, care planning, nursing services quality, bladder and bowel care, nurse staffing posting, food storage safety, medication administration documentation, and quality assurance program implementation.
Deficiencies (11)
Failed to ensure residents' call lights were within reach for 2 residents (#201 and #401).
Failed to ensure all medical records reflected resident's code status for 1 resident (#201).
Failed to ensure resident assessments accurately reflected status; incorrect discharge location coded for 1 resident (#99).
Failed to ensure accurate PASARR screening for mental disorders for 1 resident (#16).
Failed to develop comprehensive care plans meeting resident needs for 2 residents (#29 and #56).
Failed to ensure nursing staff conducted full body skin assessments and communicated changes in resident status for 1 resident (#202).
Failed to provide appropriate bladder and bowel care and training for 1 resident (#351).
Failed to post nurse staffing data daily including resident census.
Failed to store food properly sealed, dated, and stored in kitchen.
Failed to accurately document medication administration for 1 resident (#202).
Failed to maintain documentation and evidence of ongoing QAPI program activities.
Report Facts
Residents affected: 2
Residents reviewed for advance directives: 32
Residents reviewed for closed records: 3
Residents reviewed for PASARR: 1
Residents reviewed for care plans: 20
Residents reviewed for skin injury: 2
Residents reviewed for pain: 2
Residents reviewed for bladder and bowel incontinence: 2
Residents affected by staffing posting deficiency: 100
Residents affected by food storage deficiency: 100
Residents affected by QAPI deficiency: 100
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S22CNA | Certified Nursing Assistant | Confirmed call light not within reach of Resident #201 |
| S7CNA | Certified Nursing Assistant | Confirmed call light not within reach of Resident #401 |
| S2DON | Director of Nursing | Confirmed call light should be within reach; confirmed code status documentation requirements; confirmed care plan requirements; confirmed skin audit and reporting requirements; confirmed staffing form requirements; confirmed medication documentation requirements; confirmed QAPI program deficiencies |
| S19LPN | Licensed Practical Nurse | Confirmed no code status in physical chart for Resident #201 |
| S6LPN | Licensed Practical Nurse | Confirmed incorrect discharge coding for Resident #99 |
| S17SW | Social Worker | Confirmed PASARR screening deficiency for Resident #16 |
| S3ADON | Assistant Director of Nursing | Confirmed care plan deficiencies for Residents #29 and #56; confirmed Resident #351 bladder/bowel training deficiency |
| S8LPN | Licensed Practical Nurse | Confirmed care plan deficiency for Resident #56 |
| S21LPN | Licensed Practical Nurse | Conducted skin audits; confirmed failure to report pain and bruising for Resident #202; confirmed medication administration without documentation for Resident #202 |
| S20LPN | Licensed Practical Nurse | Observed skin issues on Resident #202; confirmed medication administration without order for Resident #202 |
| S24LPN | Licensed Practical Nurse | Confirmed failure to receive report on Resident #202's foot pain and x-ray results |
| S25LPN | Licensed Practical Nurse | Confirmed failure to report Resident #202's foot pain and x-ray results to oncoming staff |
| S23LPN | Licensed Practical Nurse | Confirmed Resident #351 incontinent and not assisted with toilet transfers |
| S5LPN | Licensed Practical Nurse | Responsible for assessing Resident #351's bowel and bladder continence |
| S16UC | Unit Clerk | Responsible for posting Daily Staffing Reporting Form on weekends |
| S9UC | Unit Clerk | Responsible for posting Daily Staffing Reporting Form on weekdays |
| S11HR | Human Resources | Responsible for collecting Daily Staffing Reporting Forms |
| S18CO | Cook | Confirmed food storage deficiencies in kitchen |
| S15DM | Dietary Manager | Confirmed food storage deficiencies in kitchen |
| S1ADM | Administrator | Responsible for QAPI program; confirmed deficiencies in monitoring and documentation |
| S4CNAS | Certified Nursing Assistant Supervisor | Responsible for call light monitoring; confirmed lack of documentation and ongoing deficiencies |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Jan 2, 2025
Visit Reason
The inspection was conducted following a complaint investigation related to an alleged physical abuse incident involving Resident #2 and a staff member (S5CNA) on 12/22/2024.
Complaint Details
The complaint involved an incident on 12/22/2024 where Resident #2 and staff member S5CNA engaged in a physical altercation. Resident #2 hit S5CNA in the face after being upset about not receiving coffee, and S5CNA responded by hitting Resident #2 on the forehead. The facility investigated, terminated S5CNA, notified police and responsible parties, and provided staff training. Resident #2 was monitored for injuries and psychological impact with no injuries noted and no further abuse allegations identified.
Findings
The facility failed to protect Resident #2 from physical abuse by staff member S5CNA. The incident involved a physical altercation where Resident #2 hit S5CNA and S5CNA hit Resident #2. The facility took corrective actions including terminating the staff member, notifying authorities, conducting assessments, and providing staff in-service training on abuse prevention. Additionally, the facility failed to complete timely quarterly assessments for Residents #1 and #3.
Deficiencies (2)
Failure to protect Resident #2 from physical abuse by staff member S5CNA.
Failure to complete quarterly assessments timely for Residents #1 and #3.
Report Facts
Residents reviewed for abuse: 3
Residents affected by abuse deficiency: 1
Residents reviewed for Resident Assessment: 3
Residents affected by Resident Assessment deficiency: 2
Completion deadline days for Quarterly MDS: 14
In-service completion rate: 100
Resident #2 social worker interviews: 6
Resident #2 nurse assessments: 3
Random resident interviews: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S5CNA | Certified Nursing Assistant | Accused staff member involved in physical abuse incident with Resident #2 |
| S7HK | Witnessed physical altercation between Resident #2 and S5CNA and stated S5CNA hitting Resident #2 was abuse | |
| S2DON | Director of Nursing | Assessed Resident #2 post-incident, provided in-service training, and monitored residents for abuse allegations |
| S1ADM | Administrator | Notified of incident, reviewed camera footage, terminated S5CNA, and conducted follow-up monitoring |
| S8SSD | Notified by S2DON about incident and confirmed abuse and staff termination | |
| S3RN | Registered Nurse | Received in-service training on abuse prevention and completed posttest |
| S6RN | Registered Nurse | Received in-service training on abuse prevention and completed posttest |
| S4MDS | Confirmed quarterly MDS assessments should be completed timely and confirmed delays for Residents #1 and #3 |
Inspection Report
Complaint Investigation
Deficiencies: 13
Date: May 16, 2024
Visit Reason
The inspection was conducted due to complaints regarding failure to timely report suspected abuse, failure to transmit resident assessments, inaccurate resident assessments, failure to refer for PASRR evaluations, failure to develop comprehensive care plans, medication administration issues, feeding assistance, dietary order implementation, trauma-informed care, psychotropic medication orders, medication labeling, and vaccination documentation.
Complaint Details
The complaint investigation was substantiated with findings of failure to timely report abuse, failure to transmit assessments, inaccurate assessments, failure to refer for PASRR, incomplete care plans, medication administration issues, feeding assistance failures, dietary order failures, trauma-informed care failures, psychotropic medication order issues, specimen labeling issues, and vaccination documentation failures.
Findings
The facility was found deficient in multiple areas including failure to timely report suspected physical abuse, failure to electronically transmit discharge assessments, inaccurate resident assessments, failure to refer residents for PASRR Level II evaluations, incomplete care plans for residents with refusals and behaviors, failure to obtain physician orders for delivered medications, failure to provide feeding assistance as ordered, failure to provide therapeutic diets as ordered, failure to identify and address PTSD in a resident, failure to limit PRN psychotropic medication orders to 14 days, failure to label urine specimens properly, and failure to document pneumococcal vaccination status.
Deficiencies (13)
Failure to timely report suspected physical abuse within 2 hours to the State Survey Agency.
Failure to electronically transmit a subset of resident assessment items upon discharge.
Failure to ensure resident assessments accurately reflected resident status including PASRR evaluation, discharge status, and pressure ulcers.
Failure to refer a resident with a newly identified mental health diagnosis for PASRR Level II evaluation.
Failure to maintain a record of the Level 1 PASRR form in the resident's record.
Failure to develop and implement a comprehensive person-centered care plan to meet resident needs including reporting lab results and care planning for refusals and behaviors.
Failure to obtain physician orders when medications were delivered from pharmacy.
Failure to provide feeding assistance as ordered for a resident.
Failure to ensure residents were offered therapeutic diets as ordered.
Failure to identify and address a resident's PTSD diagnosis in care planning and assessments.
Failure to limit PRN orders for psychotropic medications to 14 days and indicate duration.
Failure to label urine specimens with resident's name, date and time collected, and second identifier.
Failure to document pneumococcal immunization status or refusal for residents.
Report Facts
Residents reviewed for abuse: 3
Residents reviewed for discharge: 5
Residents reviewed for PASRR: 4
Residents reviewed for medication administration: 5
Residents reviewed for feeding assistance: 2
Residents reviewed for nutritional status: 3
Residents reviewed for psychotropic medication: 3
Residents reviewed for unnecessary medications: 5
Residents reviewed for vaccination documentation: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S15CNA | Witnessed physical abuse incident between residents #295 and #80 | |
| S1ADM | Administrator | Did not report alleged physical abuse incident to state agency |
| S6MDS | Confirmed failure to transmit discharge assessments and inaccurate MDS assessments | |
| S2DON | Director of Nursing | Confirmed expectations for accurate assessments, care planning, and medication orders |
| S7MDS | Confirmed PASRR evaluation inaccuracies | |
| S3IP | Discussed medication delivery without physician orders and specimen labeling issues | |
| S13LPN | Licensed Practical Nurse | Provided information on resident refusals, catheter care, and PTSD diagnosis awareness |
| S20CNA | Unaware of resident's PTSD diagnosis | |
| S21SW | Social Worker | Completed social assessment unaware of resident's PTSD diagnosis |
| S4NP | Nurse Practitioner | Confirmed medication orders and dietary needs |
| S11DS | Dietary Supervisor | Discussed meal ticket inaccuracies and dietary order communication |
| S10CNA | Observed feeding assistance and meal tray issues | |
| S12CNAS | Confirmed dietary staff responsibilities and meal tray contents | |
| S9LPN | Confirmed feeding assistance orders | |
| S14LPN | Observed unlabeled specimens and missing lab results | |
| S3IP | Discussed specimen labeling and medication order issues | |
| S5MR | Not responsible for reviewing pharmaceutical consultant reports |
Inspection Report
Routine
Census: 93
Deficiencies: 4
Date: Apr 27, 2023
Visit Reason
The inspection was conducted to evaluate the facility's compliance with professional standards of quality in nursing care, pressure ulcer prevention, and food service safety.
Findings
The facility failed to ensure timely neurological checks after an unwitnessed fall for one resident, failed to monitor urinary retention after catheter removal for another resident, failed to prevent pressure ulcers caused by a heel offloading device for a resident, and failed to maintain proper cleaning of kitchen equipment including a can opener and juice machine.
Deficiencies (4)
Failure to initiate neurological checks immediately following an unwitnessed fall for Resident #21.
Failure to monitor urinary retention after discontinuation of urinary catheter for Resident #103.
Failure to prevent pressure ulcers caused by heel offloading device for Resident #80.
Failure to properly clean kitchen equipment including can opener and juice machine, resulting in presence of sticky black and brownish substances.
Report Facts
Residents served meals: 93
Urine volume collected: 600
Neurological checks initiation delay: 6
Pressure ulcer measurements: 4.5
Pressure ulcer measurements: 1.7
Pressure ulcer measurements: 6
Pressure ulcer measurements: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S11 LPN | Licensed Practical Nurse | Prepared incident report and failed to initiate neurological checks for Resident #21 |
| S12 CNA | Certified Nursing Assistant | Found Resident #21 on floor and reported incident |
| S7 LPN | Licensed Practical Nurse | Confirmed failure to initiate neurological checks for Resident #21 |
| S3 DON | Director of Nursing | Verified failure to initiate neurological checks and lack of monitoring for urinary retention |
| S6 NP | Nurse Practitioner | Ordered catheter removal and confirmed expectations for monitoring Resident #103 |
| S13 LPN | Licensed Practical Nurse | Performed in and out catheter and reported urine volume for Resident #103 |
| S12 CNA | Certified Nursing Assistant | Documented Resident #103 did not void after catheter removal |
| S14 CNA | Certified Nursing Assistant | Documented Resident #103 did not void after catheter removal |
| S8 CNA | Certified Nursing Assistant | Reported Resident #80 used heel offloading device continuously |
| S9 CNA | Certified Nursing Assistant | Reported Resident #80 used heel offloading device continuously |
| S4 LPN | Licensed Practical Nurse | Provided care to Resident #80 and confirmed pressure ulcers caused by heel offloading device |
| S5 LPN | Licensed Practical Nurse | Assessed Resident #80 and confirmed pressure ulcers caused by heel offloading device |
| S16 DS | Dietary Supervisor | Confirmed kitchen equipment cleanliness issues |
| S2 ADM | Administrator | Confirmed Resident #80 sustained pressure ulcers from heel offloading device |
Inspection Report
Routine
Deficiencies: 2
Date: Apr 27, 2023
Visit Reason
The inspection was conducted to evaluate compliance with professional standards of quality in the nursing facility, specifically reviewing residents for falls and catheter care.
Findings
The facility failed to ensure neurological checks were initiated immediately following an unwitnessed fall for Resident #21, and failed to monitor Resident #103 for urinary retention after discontinuation of a urinary catheter. Documentation and timely interventions were lacking in both cases.
Deficiencies (2)
Failure to initiate neurological checks immediately following an unwitnessed fall for Resident #21.
Failure to monitor Resident #103 for urinary retention after removal of urinary catheter and lack of documentation regarding voiding status.
Report Facts
Residents reviewed for falls: 3
Residents reviewed for catheters: 2
Urine collected during in and out catheterization: 600
Time neurological checks were delayed: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S11LPN | Prepared incident report and failed to initiate neurological checks for Resident #21 | |
| S12CNA | Found Resident #21 on floor after fall and reported incident | |
| S7LPN | Confirmed failure to initiate neurological checks for Resident #21 and worked with Resident #103 | |
| S3DON | Director of Nursing who verified proper procedures and deficiencies | |
| S13LPN | Performed in and out catheterization on Resident #103 and reported urine output | |
| S14CNA | Documented Resident #103 did not void during shift | |
| S6NP | Nurse Practitioner who gave orders regarding catheter removal and monitoring | |
| S15LPN | Worked with Resident #103 and confirmed catheter removal and lack of monitoring |
Inspection Report
Annual Inspection
Deficiencies: 2
Date: Feb 23, 2023
Visit Reason
The inspection was conducted to evaluate the nursing facility's compliance with professional standards of quality, infection prevention, and wound care management.
Findings
The facility failed to ensure accurate documentation and treatment of wounds for Resident #2, including lack of physician orders and wound assessments for multiple toe wounds. Additionally, the facility failed to implement proper infection control practices during wound care, as staff did not change gloves or perform hand hygiene appropriately.
Deficiencies (2)
Failure to ensure accurate documentation and completion of Resident #2's wound assessments and treatments, including lack of physician orders for wounds on multiple toes.
Failure to implement appropriate infection control practices during wound care, including not changing gloves or performing hand hygiene when gloves were soiled.
Report Facts
Residents affected: 3
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S3LPNWC | Performed wound care for Resident #2 and Resident #1; confirmed lack of documentation and improper infection control practices | |
| S5RN | Performed wound care on weekends; unaware of toe wounds and lack of orders | |
| S4NP | Received wound reports weekly; confirmed missing documentation of toe wounds | |
| S6LPN | Resident #2's nurse; confirmed no treatment orders for toe wounds | |
| S1ADM | Assessed Resident #2's wounds on 01/17/2023; confirmed wounds on foot and toes | |
| S2CN | Confirmed no physician orders for toe wounds and expected weekly wound assessments; stated staff should change gloves and perform hand hygiene during wound care |
Viewing
Loading inspection reports...
