Below average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
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 Flannery Oaks Guest House during CMS and state inspections, most recent first.
The facility failed to complete quarterly MDS assessments for two residents within the required timeframe. According to the facility's policy, all MDS assessments should be completed and transmitted according to the most current RAI manual. One resident's assessment was not completed by the required date, and another resident's assessment was also delayed. Interviews with staff confirmed that the assessments were not completed in a timely manner.
A resident with cognitive intactness was involved in a physical altercation with a CNA after becoming upset over a missing breakfast item. The resident hit the CNA, who retaliated by hitting the resident, leading to the CNA's termination. The incident was reported, and no injuries were noted on the resident.
The facility failed to ensure accurate resident assessments, including PASRR evaluations, discharge statuses, and the presence of pressure ulcers. Staff interviews confirmed discrepancies in the MDS documentation for multiple residents.
The facility failed to refer a resident with a newly identified mental health diagnosis for a PASRR Level II Evaluation as required. The resident had a diagnosis of Psychosis not due to a substance or known physiological condition, and the facility did not resubmit a new Level I PASRR Screen and Determination after the new diagnosis was identified.
The facility failed to maintain a Level 1 PASRR form for a resident with Schizophrenia. The resident was admitted with this diagnosis, but the facility did not have or submit the required PASRR documentation, as confirmed by the administrator.
The facility failed to develop and implement comprehensive care plans for two residents. One resident's urinalysis results were not reported to the consulting provider as ordered, and another resident's frequent refusals and behaviors were not addressed in the care plan. Staff interviews confirmed lapses in communication and documentation processes.
The facility failed to provide two residents with the therapeutic diets prescribed by their healthcare providers, resulting in missing dietary supplements on their meal trays. Observations and interviews confirmed that staff were unaware of the dietary requirements, and meal tickets did not reflect the necessary supplements due to a communication lapse between the DON and dietary supervisor.
The facility failed to identify and address a resident's PTSD diagnosis, resulting in a lack of appropriate care planning and interventions. Staff members were either unaware of the diagnosis or did not take necessary actions to address it, leading to inadequate care for the resident's condition.
The facility failed to limit PRN orders for psychotropic medications to 14 days for two residents receiving hospice services. Both residents had orders for Ativan without stop dates, which was confirmed by the Director of Nursing.
The facility failed to ensure accurate documentation of medical records for a resident receiving Risperdal. The medication was prescribed for Major Depressive Disorder in the physician's orders and MAR, but the Pharmaceutical Consultant Report indicated it was for Delusional Disorder. Interviews revealed a lack of clarity regarding responsibility for updating diagnoses linked to psychotropic medications.
The facility failed to ensure documentation of pneumococcal immunization status for two residents. The responsible staff member confirmed that the documentation and administration of the vaccine were incomplete for all residents during the specified period.
The facility failed to report an alleged incident of physical abuse within the required 2-hour timeframe. A resident with severe cognitive impairment was observed hitting another resident. The incident was reported to the administrator, who did not consider it abuse and did not report it to the state agency as required by policy.
The facility failed to obtain physician's orders for medications delivered for a resident, resulting in a delay in administering prescribed antibiotics. The resident, with multiple diagnoses including Chronic Kidney Disease and Acute Kidney Failure, did not receive her medications until several days after they were delivered.
A resident with severe cognitive impairment and muscle wasting had a physician's order to be fed all meals, but staff failed to provide the necessary feeding assistance. Observations and interviews confirmed that the resident was left to feed himself, contrary to the hospice plan of care and physician's orders, leading to a deficiency in care.
The facility failed to ensure drugs and biologicals were labeled according to professional principles. Two tubes in a specimen refrigerator were found without a resident's name, date and time collected, or a second identifier. Staff confirmed this was against policy and professional standards.
The facility failed to maintain an infection control program for a resident with an indwelling catheter. The resident, who had severe cognitive impairment and multiple diagnoses, was observed with the catheter bag improperly placed on several occasions. Both an LPN and the DON confirmed the improper placement and the increased risk of infection it posed.
The facility failed to electronically transmit discharge MDS assessments for two residents upon their discharge. Staff confirmed that the assessments should have been completed and transmitted on the respective discharge dates.
Failure to Complete Quarterly MDS Assessments Timely
Penalty
Summary
The facility failed to complete quarterly assessments for two of the three residents reviewed for Resident Assessment. According to the facility's MDS Policy and Procedure, all Minimal Data Set (MDS) assessments are to be completed and transmitted according to the most current Resident Assessment Instrument (RAI) manual. Resident #1 had a Quarterly MDS with an Assessment Reference Date (ARD) of 12/18/2024, which was not completed by the required date of 01/01/2025. Similarly, Resident #3 had a Quarterly MDS with an ARD of 12/11/2024, which was not completed by 12/25/2024. Interviews with S4MDS and S2DON confirmed that the Quarterly Assessments should be completed within 14 days of the ARD, and both residents' assessments were not completed in a timely manner.
Resident Abuse Incident Involving CNA
Penalty
Summary
The facility failed to protect a resident's right to be free from physical abuse. The incident involved a resident who was cognitively intact, as indicated by a Brief Interview for Mental Status (BIMS) score of 14. The resident, who had diagnoses including Vascular Dementia, Depression, and Anxiety Disorder, was involved in a physical altercation with a Certified Nursing Assistant (CNA). The altercation occurred when the resident became upset over not receiving coffee with breakfast and threatened to hit the CNA. The resident then hit the CNA, who retaliated by hitting the resident. The incident was documented in the facility's Self-Reported Incident Report and was corroborated by witness statements and interviews. A housekeeper witnessed the altercation and confirmed that the CNA hit the resident on the forehead after being struck by the resident. The Director of Nursing (DON) and the Administrator were notified immediately, and the CNA was terminated following the incident. The facility's policy on abuse prevention and prohibition clearly states that any form of physical abuse, including hitting or slapping, is not tolerated. Interviews with staff and the resident confirmed the sequence of events. The resident acknowledged hitting the CNA and being hit in return. The DON assessed the resident for injuries, and no injuries were noted. The facility's policy dictates that any staff member hitting a resident constitutes abuse, and this was acknowledged by multiple staff members during interviews. The incident was reported to the police, and the resident's responsible party was notified.
Inaccurate Resident Assessments
Penalty
Summary
The facility failed to ensure resident assessments accurately reflected the residents' status in several instances. For two residents, the facility did not correctly mark that they had been evaluated for PASRR, despite their clinical records showing Level II PASRR approvals. Interviews with staff confirmed that the MDS assessments for these residents were inaccurate. Additionally, the facility failed to accurately reflect the discharge status of another resident, who was discharged to home but was incorrectly documented as discharged to a short-term general hospital. Staff interviews confirmed the discrepancy in the discharge documentation. Furthermore, the facility did not accurately document the presence of pressure ulcers for a resident who had a Stage 3 pressure ulcer on the right buttock and an unstageable ulcer on the right heel. The resident's Admission MDS did not indicate the presence of these pressure ulcers, despite active diagnoses and ongoing wound care orders. Staff interviews confirmed that the MDS should have reflected the resident's current wound care status. These inaccuracies in resident assessments indicate a failure to ensure that the MDS accurately captured the residents' conditions and statuses.
Failure to Refer Resident for PASRR Level II Evaluation
Penalty
Summary
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. Resident #36 was admitted with a diagnosis of Psychosis not due to a substance or known physiological condition, with the onset date of 08/25/2017. The most recent Level I PASRR Screening and Determination for this resident was performed on 08/18/2017, prior to the new diagnosis. There was no documentation available to show that a new Level I PASRR Screen and Determination was submitted following the addition of the new mental illness diagnosis on 08/25/2017. An interview with the facility administrator confirmed that the resident's Pre-admission Level I PASRR Screen and Determination was last submitted on 08/18/2017 and that the facility did not resubmit a new Level I PASRR Screen and Determination after the new diagnosis was identified. The resident's most recent Minimum Data Set (MDS) indicated significant cognitive impairment with a Brief Interview of Mental Status (BIMS) score of 0, and included the diagnosis of Psychotic Disorder and Unspecified Psychosis not due to a substance or known physiological condition.
Failure to Maintain PASRR Documentation for Resident with Schizophrenia
Penalty
Summary
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 one resident reviewed for PASRR. The resident was admitted with a diagnosis of Schizophrenia, which is a relevant mental illness listed on the Level I PASRR Screen and Determination. Despite this, the facility did not have a copy of the resident's most recent Level 1 PASRR Screen and Determination and had not submitted one upon the resident's admission. This was confirmed by the facility administrator during an interview.
Failure to Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for two residents. For Resident #23, the facility did not report the urinalysis results to the consulting provider as ordered. The resident had multiple diagnoses, including chronic kidney disease and urinary tract infection, and was at risk for infection. Despite an order to fax the urinalysis results to the urologist, the results were not sent, as confirmed by the Director of Nursing (DON) and the urologist's medical assistant. The DON admitted to not sending the results and explained the process for handling lab orders, which was not followed in this case. For Resident #86, the facility did not ensure the care plan was comprehensive and individualized, particularly regarding the resident's frequent refusals and behaviors. The resident, who was severely cognitively impaired and had multiple diagnoses including chronic kidney disease and a feeding tube, frequently refused tube feedings and care related to his catheter. Despite documentation of these refusals and behaviors in nurse's notes and the 24-hour Communication Report log, the care plan was not updated to address these issues. The MDS coordinator, responsible for care plans, was unaware of the resident's frequent refusals and behaviors, indicating a breakdown in communication and documentation processes. Interviews with staff, including the LPN and DON, confirmed that refusals of care and behaviors should be documented and communicated to the MDS coordinator for care plan updates. However, this process was not followed for Resident #86, resulting in a lack of appropriate interventions in the care plan. The DON confirmed that the care plan should have been updated to reflect the resident's needs and behaviors, but this was not done, leading to a deficiency in providing person-centered care.
Failure to Provide Therapeutic Diets as Ordered
Penalty
Summary
The facility failed to ensure that two residents, who were prescribed therapeutic diets, received the necessary dietary supplements as ordered by their healthcare providers. Resident #9, who had severe cognitive impairment and a history of significant weight loss, was not provided with protein juice, pudding, or ice cream as per her physician's orders. Observations on multiple occasions confirmed that these items were missing from her meal trays, and staff were unaware of the dietary requirements. The resident's care plan and meal tickets did not reflect the prescribed dietary supplements, contributing to her continued weight loss. Similarly, Resident #78, who was under hospice care with a diagnosis of muscle wasting and atrophy, did not receive the prescribed protein juice, pureed soup, or ice cream with his meals. Observations and interviews with staff confirmed that these items were consistently missing from his meal trays. The hospice nurse and dietary staff were unaware of the resident's dietary orders, and the meal tickets did not include the necessary supplements. This oversight was attributed to a communication lapse between the Director of Nursing (DON) and the dietary supervisor during their weekly meetings. Interviews with the DON and dietary supervisor revealed that the failure to implement the dietary orders was due to missed communication during their weekly discussions about residents at high risk for weight loss. The DON admitted to not providing the dietary supervisor with the updated orders for Residents #9 and #78, resulting in the dietary staff being unaware of the necessary additions to the residents' meal trays. This deficiency highlights a critical gap in the facility's process for ensuring that dietary orders are accurately communicated and implemented.
Failure to Address Resident's PTSD Diagnosis
Penalty
Summary
The facility failed to identify and address a resident's past history of trauma and triggers related to PTSD. Resident #86 was admitted with multiple diagnoses, including PTSD, but the care plan did not include any interventions for PTSD. The social assessment conducted upon admission did not identify the PTSD diagnosis, and the CNA assigned to the resident was unaware of the PTSD condition. The LPN was aware of the diagnosis but confirmed that no interventions were in place to address it. The Director of Nursing stated that a routine social assessment should be completed for residents with PTSD, but this was not done in this case. The Social Worker who completed the assessment was not aware of the PTSD diagnosis at the time of the assessment. The Psychiatric Nurse Practitioner also confirmed that a PTSD evaluation should have been completed but was not. Interviews with the resident's responsible party and various staff members revealed a lack of communication and awareness regarding the resident's PTSD diagnosis. The responsible party stated that no one at the facility had discussed the PTSD diagnosis with her. The Psychiatric Nurse Practitioner acknowledged that the facility staff should have been aware of the PTSD diagnosis and that a PTSD evaluation should have been conducted. The failure to identify and address the resident's PTSD resulted in a lack of appropriate care planning and interventions for the resident's condition.
Failure to Limit PRN Orders for Psychotropic Medications
Penalty
Summary
The facility failed to ensure PRN orders for psychotropic medications were limited to 14 days and indicated the duration for two residents receiving hospice services. Resident #63 was admitted with diagnoses including Anxiety Disorder, Delusional Disorders, Major Depressive Disorder, and Restlessness and Agitation. The resident had a physician's order for Ativan 1 mg tablet every 4 hours as needed (PRN) for anxiety/agitation, written on 03/13/2024, without a stop date. This order was reflected in the May 2024 Medication Administration Record (MAR) without a stop date. Similarly, Resident #78, who was admitted to the facility and a local hospice agency, had a physician's order for Ativan 1 mg tablet every 4 hours PRN for anxiousness, written on 05/08/2024, also without a stop date. The Director of Nursing (S2DON) confirmed that Ativan is a psychotropic medication and acknowledged that both residents had PRN orders for Ativan without stop dates, which is a violation of the requirement to limit PRN orders for psychotropic medications to 14 days and indicate the duration.
Inaccurate Documentation of Medical Records for Psychotropic Medication
Penalty
Summary
The facility failed to ensure accurate documentation of medical records for a resident receiving unnecessary medications. Resident #24 was admitted with diagnoses including Delusional Disorders and Major Depressive Disorder. The physician's orders and the Medication Administration Record (MAR) for May 2024 indicated that Risperdal was prescribed for Major Depressive Disorder. However, the Pharmaceutical Consultant Report dated May 2, 2023, documented that Risperdal was prescribed for Delusional Disorder. This discrepancy was confirmed by the Director of Nursing (S2DON) during an interview, who acknowledged that the records were inaccurate. Interviews with the Director of Nursing (S2DON) and the Medical Records staff (S5MR) revealed a lack of clarity regarding responsibility for updating diagnoses linked to psychotropic medications. S2DON stated that medical records should review pharmaceutical consultant reports and adjust diagnoses accordingly, while S5MR indicated that she was not responsible for this task. This miscommunication and lack of proper documentation led to the inaccurate medical records for Resident #24.
Failure to Document Pneumococcal Immunization Status
Penalty
Summary
The facility failed to develop procedures to ensure documentation indicating whether residents received the pneumococcal immunization or did not receive it due to medical contraindication or refusal. Specifically, the records for two residents lacked documentation of their pneumococcal immunization status from 10/01/2023 to 05/13/2024. The facility's policy required that each resident's immunization status be determined upon admission and documented accordingly. However, the responsible staff member confirmed that the documentation and administration of the pneumococcal vaccine were incomplete for all residents during the specified period.
Failure to Report Physical Abuse Incident
Penalty
Summary
The facility failed to report an alleged incident of physical abuse within the required 2-hour timeframe to the State Survey Agency. The incident involved a resident with severe cognitive impairment, who was observed hitting another resident in the face. The incident was witnessed by a CNA, who immediately separated the residents and reported the event to her supervisor. However, the administrator, who was informed of the incident around 12:30 p.m. on the same day, did not consider it to be physical abuse and therefore did not report it to the state agency as required by the facility's policy. The facility's policy mandates that any suspected physical abuse must be reported to the state agency and local law enforcement within 2 hours. Despite this, the incident was not documented in the facility's incident log or reported to the state agency. Interviews with the CNA and the administrator confirmed the timeline of events and the failure to report the incident as required. The resident involved had a history of dementia and traumatic subdural hemorrhage, which contributed to her severe cognitive impairment.
Failure to Obtain Physician's Orders for Delivered Medications
Penalty
Summary
The facility failed to ensure services were provided to meet professional standards of quality by not obtaining physician's orders when medications were received from the pharmacy for a resident. Resident #23, who was admitted with multiple diagnoses including Stage 3 Chronic Kidney Disease and Acute Kidney Failure, did not receive prescribed antibiotics in a timely manner. The resident had an appointment with her urologist and was prescribed Levaquin, Pyridium, and Macrobid, which were delivered to the facility on 05/10/2024. However, the medications were not administered until 05/13/2024 because the facility did not have the necessary physician's orders. Interviews revealed that the facility's staff, including the Infection Preventionist and Nurse Practitioner, were unaware of the medication delivery without orders until 05/13/2024. The Director of Nursing stated that nursing staff should have obtained the orders as quickly as possible. The delay in obtaining the physician's orders resulted in the resident not receiving her prescribed antibiotics for several days, despite the medications being delivered to the facility on time.
Failure to Follow Feeding Assistance Orders
Penalty
Summary
The facility failed to provide care and services in accordance with the orders written for dining for a resident who required feeding assistance. Resident #78, who was admitted to the facility and later to a local hospice agency with a diagnosis of Muscle Wasting and Atrophy, had a physician's order to be fed all meals due to diminished nutrition and hydration from disease progression. Despite this, observations on multiple occasions revealed that the resident was left to feed himself without staff assistance, contrary to the hospice plan of care and physician's orders. Interviews with staff, including a CNA and an LPN, confirmed that the resident had an active order to be fed all meals, but this order was not being followed. The resident's weight log indicated a decline in weight over a two-month period, further emphasizing the need for adherence to the feeding assistance order. The hospice nurse also confirmed that the resident required feeding assistance to ensure he ate adequately. The Director of Nursing acknowledged the active order and the expectation for staff to implement it as written. The failure to follow the feeding assistance order represents a deficiency in the care provided to the resident, potentially impacting his nutritional status and overall well-being.
Failure to Properly Label Specimens
Penalty
Summary
The facility failed to ensure drugs and biologicals were labeled in accordance with currently accepted professional principles. During an observation of a medication storage room, two tubes filled with yellow fluid were found in a refrigerator labeled 'Specimens.' These tubes did not have a resident's name, date and time collected, or a second identifier. This was confirmed by S3IP during the observation and by S2DON and S1ADM during subsequent interviews. All three staff members acknowledged that specimens should be labeled with the resident's name, date and time collected, and a second identifier as per common professional standards and the lab provider's policy. The lab provider's policy, reviewed in January 2024, specifically requires that urinalysis and culture and susceptibility tubes be labeled with the patient's first and last name, a second identifier, and the date and time of specimen collection. The failure to adhere to this policy was observed on May 14, 2024, at 8:27 a.m. in MR1. This deficiency was confirmed through interviews with S3IP, S2DON, and S1ADM, who all stated that they would expect all specimens collected to be properly labeled according to the policy and professional standards.
Failure to Maintain Infection Control for Resident with Indwelling Catheter
Penalty
Summary
The facility failed to maintain an infection control program for a resident with an indwelling catheter. Resident #86, who was readmitted to the facility with multiple diagnoses including Bacteremia, Benign Prostate Hyperplasia, Urinary Tract Infection, Retention of Urine, Chronic Kidney Disease, and Cystitis, was observed with improper catheter management. The resident, who had severe cognitive impairment as indicated by a BIMS score of 7, was seen on multiple occasions with the catheter bag improperly placed. On one occasion, the catheter bag was hooked to a trash can, and on another, it was being dragged on the floor. Additionally, the catheter bag was observed in the resident's bed, not below the level of the bladder, and half full of urine flowing back into the bladder. These observations were confirmed by both an LPN and the Director of Nursing, who acknowledged the improper placement of the catheter bag and the increased risk of infection it posed. The observations and interviews revealed that the facility did not ensure the indwelling catheter bag was kept below the level of the bladder, out of the trash can, and off the floor. The LPN and DON both confirmed the correct procedures for catheter management, indicating a lapse in adherence to infection control protocols. This deficiency highlights a failure in maintaining a safe and sanitary environment to prevent the development and transmission of infections, particularly for residents with indwelling catheters.
Failure to Transmit Discharge MDS Assessments
Penalty
Summary
The facility failed to electronically transmit a subset of items upon a resident's discharge for two of the five residents reviewed for discharge. Resident #38 was admitted to the facility and later discharged, but did not have an electronically transmitted discharge MDS assessment. Similarly, Resident #84 was admitted and discharged without an electronically transmitted discharge MDS assessment. During interviews, S6MDS confirmed that discharge assessments for both residents should have been completed and transmitted on their respective discharge dates. S2DON also confirmed that MDS staff should have completed and transmitted the discharge assessments after the residents were discharged from the facility.
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Illustrative
What surveyors actually found near you
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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.
Illustrative
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Nursing homes near Baton Rouge
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Woodleigh Of Baton Rouge | 1.1 mi | ★★★★★ | 1 | 0 |
| Pines Retirement Center Of Baton Rouge | 1.1 mi | ★★★★★ | 10 | 0 |
| Capitol House Nursing And Rehab Center | 1.3 mi | ★★★★★ | 0 | 0 |
| The Guest House Care Center | 2.2 mi | ★★★★★ | 0 | 0 |
| White Oak Post Acute Care | 3 mi | — | 12 | 1 |
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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.