Flannery Oaks Guest House

Inspectors wroteBased on observations, interviews and record review, the facility failed to store food in accordance with professional standards for food service safety. The facility failed to ensure food was properly sealed, stored, and dated in the refrigerator and dry storage area of the facility's kitchen. This had the potential to affect 100 residents who were served from the kitchen.

Inspectors wroteBased on interviews and record review, the facility failed to maintain documentation and demonstrate evidence of its ongoing Quality Assurance and Performance Improvement (QAPI) program demonstrating the development, implementation, and evaluation of corrective actions or performance improvement activities. This deficient practice had the potential to affect a census of 100 residents.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure a resident's call light was within reach for 2 of 2 (#201 and #401) residents reviewed for accommodation of needs.

Inspectors wroteBased on record reviews and interviews, the facility failed to develop a Comprehensive Person Centered Care Plan, which met the needs of 2 (#29 and #56) of 20 residents Care Plans reviewed in the final sample. The facility failed to ensure the Comprehensive Care Plan included the following: 1. Resident #29's discharge goals; and 2. Resident #56's physical need for a Mechanical Lift for transfers. 1. Review of Resident #29's Clinical Record revealed she was admitted to the facility on [DATE] with a diagnosis, which included Rheumatoid Arthritis. Review of Resident #29's most recent Care Plan revealed no documented evidence of discharge plans. 2. Review of Resident #56's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses, which included Hemiplegia, Hemiparesis, Muscle Wasting to Multiple Sites, and Lack of Coordination. [...]

Inspectors wroteBased on interviews, and record reviews, the facility failed to ensure services provided by the facility met professional standards of quality. The facility failed to ensure: 1. Nursing staff adequately conducted full body skin assessments for 1 (#202) of 2 (#75 and #202) residents reviewed for skin injury and; 2. Nursing staff communicated changes in resident status to oncoming nursing staff for 1 (#202) of 2 (#51 and #202) residents reviewed for pain.

Inspectors wroteBased on interviews, observations, and record review, the facility failed to ensure that a resident was provided services to restore as much normal bladder and bowel function as possible for 1 (#351) of 2 (#45, and #351) residents reviewed for Bladder and Bowel Incontinence.

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure all medical records regarding the resident's code status reflected the resident's wishes for 1 (#201) of 32 residents reviewed in the initial screening for advance directives. This deficient practice had the potential to affect the100 residents that resided in the facility.

Inspectors wroteBased on interviews and record review, the facility failed to ensure resident assessments accurately reflected the resident's status. The facility failed to ensure staff accurately coded the correct discharge location for 1 (#99) of 3 (#98, #99, #100) residents reviewed for closed records.

Inspectors wroteBased on record review and interviews, the facility failed to ensure a resident with a mental disorder had an accurate Pre-admission Screening and Resident Review (PASARR) for 1 (#16) of 1 (#16) resident reviewed for PASARR.

Inspectors wroteBased on record review and interviews, the facility failed to ensure medication administration was accurately documented for 1 (#202) of 2 (#51 and #202) residents reviewed for pain.

Inspectors wroteBased on observation, record review and interviews, the facility failed to post nurse staffing data on a daily basis which included the total resident census. This deficient practice had the potential to affect the 100 residents residing in the facility.

Inspectors wroteBased on record review and interviews, the facility failed to complete quarterly assessments for 2 (#1, #3) of 3 (#1, #2, and #3) residents reviewed for Resident Assessment.

Inspectors wroteBased on interviews and record review, the facility failed to protect the residents' right to be free from physical abuse for 1 (#2) of 3 (#1, #2, and #3) residents reviewed for abuse. The facility failed to ensure Resident #2 was free from physical abuse by S5CNA. The facility implemented corrective actions, which were completed prior to the State Agency's investigation, thus it was determined to be a Past Noncompliance citation.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure the resident assessments accurately reflected the resident's status. The facility failed to ensure: 1. Staff accurately marked a resident was evaluated for PASRR on 2 (#62, #66) of 4 (#8, #36, #62, #66) resident's reviewed for PASRR; and 2. Staff accurately reflected the discharge status for 1 (#91) of 5 (#38, #84, #88, #91, #92) residents reviewed for discharge; and 3. Staff accurately reflected a resident had pressure ulcers for 1 of 1 (#43) resident reviewed for pressure ulcers. 1. Resident #62 Review of Resident #62's clinical record revealed the resident was admitted to the facility on [DATE] with diagnoses which included Bipolar Disorder and Borderline Personality Disorder. Review of Resident #62's clinical record revealed a Level II PASRR with approval dates of 04/03/2024 through 04/02/2024. [...]

Inspectors wroteBased on interview and record reviews, the facility failed to ensure a resident with a newly identified mental health diagnosis was referred for a Preadmission Screening and Resident Review (PASRR) Level II Evaluation as required for 1 (#36) of 4 (#8, #36, #62 and #66) residents reviewed for PASRR.

Inspectors wroteBased on interview and record reviews, the facility failed to ensure a record of the Level 1 Preadmission Screening Resident Review (PASRR) form was maintained in the resident's record for 1 (#8) of 4 (#8, #36, #62 and #66) residents reviewed for PASRR.

Inspectors wroteBased on observations, interviews and record review, the facility failed to develop and implement a comprehensive person-centered care plan to meet the needs of 2 (#23, #86) residents out of a 25 total sampled residents. The facility failed to: 1. Report Resident #23's urinalysis results to the consulting provider as ordered; and 2. Ensure care plan was comprehensive and individualized for Resident #86 whom exhibited frequent refusals and behaviors.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure a resident was offered a therapeutic diet when the health care provider ordered a therapeutic diet for 2 (#9 and #78) of 3 (#9, #70 and #78) residents reviewed for nutritional status.

Inspectors wroteBased on interviews and record reviews the facility failed to identify a resident's past history of trauma, and/or triggers which may cause re-traumatization for 1of 1(#86) resident reviewed for Post-Traumatic Stress Disorder (PTSD).

Inspectors wroteBased on interviews and record review, the facility failed to ensure PRN orders for psychotropic medications were limited to 14 days and indicated the duration for 2 (#63, #78) of 3 (#63, #80, and #78) residents reviewed receiving hospice services.

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure medical records were accurately documented for 1 (#24) of 5 (#23, #24, #47, #62, #80) resident's reviewed for unnecessary medications.

Inspectors wroteBased on record reviews and interviews, the facility failed to develop procedures to ensure 2 (#51 and #62) of 5 (#9, #51, #62, #70 and #90) resident's records had documentation indicating resident either received the pneumococcal immunization or did not receive the pneumococcal immunization due to medical contraindication or refusal.

Inspectors wroteBased on interviews and record review, the facility failed to ensure an alleged violation of physical abuse was reported within 2 hours to the State Survey Agency after an allegation was made for 1 (#295) of 3 (#5, #294, and #295) residents reviewed for abuse.

Inspectors wroteBased on interviews and record review, the facility failed to ensure services were provided by the facility to meet quality of professional standards. The facility failed to obtain physician's orders when the facility received medications from the pharmacy for 1 (#23) of 5 (#23, #51, #26, #294, and #47) residents reviewed for medication administration.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide care and services in accordance with orders written for dining for 1 (#78) of 2 (#9 and #78) residents reviewed for requiring feeding assistance.

Inspectors wroteBased on observation, record review, and interviews, the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles for 1 (MR1) of 2 (MR1 and MR2) medication storage rooms observed. The facility failed to ensure a urine specimen was labeled with resident's first and last name, include a second identifier, and include the date and time of specimen collection.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary environment, and to help prevent the development and transmission of communicable diseases and infections for 1 of 1 (Resident #86) residents observed with an indwelling catheter.

Inspectors wroteBased on record reviews and interviews, the facility failed to electronically transmit a subset of items upon a resident's discharge for 2 (#38, #84) of 5 (#38, #84, #88, #91, and #92) residents reviewed for discharge. Resident #38 Review of Resident #38's clinical record revealed the resident was admitted to the facility on [DATE] and discharged on 01/31/2024. Further review revealed the resident did not have an electronically transmitted discharge MDS assessment. Resident #84 Review of Resident #84's clinical record revealed the resident was admitted to the facility on [DATE] and discharged on 01/23/2024. Further review revealed the resident did not have an electronically transmitted discharge MDS assessment. An interview was conducted with S6MDS on 05/15/2024 at 12:38 p.m. She reviewed Resident #38's clinical record. [...]

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure services were provided to meet quality professional standards. The facility failed to ensure: 1. 1 (#21) of 3 (#21, #59, and #91) residents reviewed for falls were assessed with neurological checks following an unwitnessed fall; and 2. 1 (#103) of 2 (#103 and #363) residents reviewed for catheters were monitored for urinary retention after a urinary catheter was discontinued.

Inspectors wroteBased on interviews and record review, the facility failed to ensure residents received care, consistent with professional standards of practice, to prevent pressure ulcers for 1 (#80) of 4 (#2, #80, #413, and #414) residents reviewed for pressure ulcers. The facility failed to ensure Resident #80 did not acquire a pressure ulcer while using a heel offloading device. Review of Resident #80's clinical record revealed the resident was admitted to the facility on [DATE] with diagnoses which included Essential Hypertension, Type 2 Diabetes Mellitus, and Unspecified Protein-Calorie Malnutrition. Further review revealed she had diagnoses of Pressure Induced Deep Tissue Damage of Other Site, Unspecified Soft Tissue Disorder Related to Use/Pressure, Left Lower Leg and Unspecified Soft Tissue Disorder Related to Use/Pressure, Right Lower Leg with an onset date of 04/14/2023. [...]

Inspectors wroteBased on observations and interview, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety by failing to ensure: 1. The can opener was properly cleaned and free of a sticky black substance; 2. The juice machine was properly cleaned and free of a brownish red substance; 3. The juice machine filter was properly cleaned and free of a brown and black substance; and 4. The juice machine connecters and tubing were properly cleaned and free of a black substance.