Flannery Oaks Guest House

In the surveyor’s words

From the most serious findings on record at Flannery Oaks Guest House, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF812Jul 2, 2025

  Based 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. Findings: Review of the facility's policy, titled, Food Storage Labeling, with a revised date of 10/2018, revealed, in part: The facility will store and label all foods to ensure safety and quality. 7. […]

• No harm, potential for more than minimal, widespreadF865Jul 2, 2025

  Based 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. Findings: Review of the facility's policy, Quality Meeting Policy and Procedure, dated 04/28/2025 revealed, in part, the following: Purpose: To identify, respond, track and trend, and monitor for improvement of facility potential quality deficiencies. The overall goal is to improve the quality of care for the residents of the facility. Policy: II. […]

• No harm, potential for more than minimal, patternF880Jul 29, 2026

  Based on observations, interviews and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe and sanitary environment to help prevent the development and transmission of infection by failing to ensure staff wore appropriate Personal Protective Equipment (PPE) while providing care to 2 (#15 and #62) of 6 residents on Enhanced Barrier Precautions reviewed in the final sample. Findings: Review of the provider policy titled Enhanced Barrier Precautions Policy & Procedure with a revision date of 04/01/2024 revealed the following, in part: Policy: Enhanced Barrier Precautions (EBP) refers to an infection control intervention designed to reduce transmission of multidrug resistant organisms that employs targeted gown and glove use… […]

• No harm, potential for more than minimal, patternF558Jul 2, 2025

  Based 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. Findings: Review of the facility's policy, Resident Call Light System, dated 09/14/2022, revealed the following, in part: Purpose: To provide a communication system with audible or visual signals to allow residents to call for staff assistance . Procedure 6. When providing care to residents, be sure to positon the call light conveniently within reach for the resident to use. Resident #201 Review of Resident #201's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses which included, Transient Ischemic Attack and chronic pain. […]

• No harm, potential for more than minimal, patternF656Jul 2, 2025

  Based 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. […]