Zachary Manor Nursing And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Zachary, Louisiana.
- Location
- 6161 Main Street, Zachary, Louisiana 70791
- CMS Provider Number
- 195362
- Inspections on file
- 27
- Latest survey
- March 11, 2026
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at Zachary Manor Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with Type 2 DM, diabetic polyneuropathy, severe protein-calorie malnutrition, and long-term insulin use had care plan problems and MD orders requiring insulin per sliding scale and provider notification when blood glucose exceeded specified thresholds. MAR review showed multiple elevated blood glucose readings in the high 300s on several occasions without any documented MD notification or related nursing notes. In interviews, involved LPNs admitted they did not notify the provider despite the orders, and leadership (ADON, DON, NP) confirmed that staff were expected to notify the MD for such values and document the notification and any new orders, which did not occur.
The facility failed to accurately document sliding scale insulin administration and blood glucose monitoring on the MARs for two residents with type 2 DM and complex medical conditions, despite physician orders and facility insulin guidelines requiring detailed charting of finger-stick results, insulin doses, injection sites, and nurse identification. On multiple occasions, scheduled before-meal and bedtime insulin doses and corresponding blood glucose checks were left blank on the MARs, with no indication of administration or refusal. The LPNs assigned to these residents during the relevant shifts acknowledged responsibility for the medication passes, confirmed the MAR blanks, and admitted they did not document the insulin administrations or refusals, while the ADON confirmed that all such care should have been recorded.
The facility did not provide enough CNA staff to meet its own minimum staffing requirements, with only two CNAs covering the entire building during some evening and night shifts. Multiple staff, including CNAs and an LPN, confirmed frequent short staffing, especially on certain halls and weekends, resulting in staff being unable to complete their tasks on time and sometimes working alone. The administrator acknowledged that staffing levels were insufficient based on census and resident acuity.
A resident with a history of falls, dementia, and limited mobility was repeatedly observed in bed with her call light placed out of reach, despite facility policy and her care plan requiring it to be accessible. Staff confirmed the call light was not within reach and acknowledged it should have been.
The facility failed to submit accurate payroll information for direct care staffing, resulting in a one-star staffing rating, low weekend staffing, no RN hours, and lack of 24-hour licensed nursing coverage. The inaccuracies were identified by a contract company responsible for data submission, and both the responsible staff member and the administrator acknowledged the need for complete and accurate data.
The facility failed to ensure accurate MDS assessments for three residents, leading to discrepancies in their records. A resident was not correctly coded for PASRR despite having a serious mental illness. Another resident, who was legally blind, was inaccurately coded as having adequate vision. Additionally, a resident transferred to a hospital for shortness of breath was incorrectly coded for discharge status as being sent to an inpatient rehabilitation facility.
A resident with legal blindness had a care plan that was not updated to reflect her current condition, which included being non-ambulatory and not using corrective lenses. The care plan contained inappropriate interventions such as maintaining eyeglasses and providing ambulation assistance. Staff interviews confirmed the care plan did not match the resident's needs, and the MDS staff failed to revise it as required.
A resident with mild cognitive impairment and malnutrition requested to see an outside dentist instead of the in-house dentist. Despite multiple documented refusals of in-house services and a clear preference for an outside dentist, the facility failed to schedule an appointment. Staff interviews revealed communication breakdowns and a lack of documentation, resulting in the resident not receiving the requested dental care.
The facility failed to maintain accurate medical records for two residents. One resident's record lacked documentation of coroner notification and permission to release the body after death. Another resident's record did not include a nurse's assessment upon return from dialysis, despite it being standard practice. These deficiencies were confirmed through staff interviews and policy reviews.
A facility failed to maintain proper infection control during catheter care for a resident with a UTI. A CNA did not wear a gown or perform hand hygiene as required by Enhanced Barrier Precautions. The DON confirmed these lapses in infection control practices.
A resident requiring two-person assistance for incontinence care did not receive the necessary support, as a CNA performed the care alone. The facility's care plan, which was clearly communicated through the Resident Wall Care Plan Sheet, was not followed, leading to a deficiency in care. Interviews with the DON and Administrator confirmed the oversight.
Two residents were not transferred according to their care plans, leading to incidents where one resident fell and another was lowered to the floor. The CNAs involved did not check the wall care plan sheets, which specified the need for two-person assistance and the use of a mechanical lift.
Failure to Follow MD Orders for Elevated Blood Glucose Notifications
Penalty
Summary
The deficiency involves the facility’s failure to implement a person-centered care plan and follow physician orders for blood glucose monitoring and MD notification for a resident with Type 2 Diabetes Mellitus and related complications. The resident had diagnoses including Type 2 Diabetes Mellitus with diabetic polyneuropathy, other hypoglycemia, unspecified severe protein-calorie malnutrition, and long-term use of insulin. The resident’s care plan included problems related to following MD orders and diabetes management, with interventions such as administration of Humalog insulin per sliding scale and diabetes medications as ordered, and monitoring for side effects and effectiveness. Physician orders directed staff to administer Humalog per sliding scale and to notify the MD when blood glucose levels were above specified thresholds (greater than 350 or 351 mg/dL), and later to monitor blood glucose four times daily and call the MD if levels were less than 70 mg/dL or greater than 350 mg/dL. Record review of the MARs and nursing notes showed multiple documented elevated blood glucose readings above the ordered notification thresholds on several dates, with no corresponding documentation that the physician was notified. Specific readings included values in the 370s and 390s on multiple occasions, and later readings of 367 mg/dL, all without evidence of MD notification in the MAR or nurses’ notes. In interviews, the involved LPNs acknowledged that they did not notify the physician despite the orders to do so and confirmed that such notifications should have been documented. The ADON, DON, and NP each confirmed that, based on the physician orders, nursing staff were expected to notify the provider when blood glucose exceeded the ordered thresholds and to document the blood glucose value, the notification, and any new orders, and that this was not done for the elevated readings identified in the resident’s record.
Failure to Accurately Document Sliding Scale Insulin and Blood Glucose on MARs
Penalty
Summary
The deficiency involves the facility’s failure to accurately document insulin administration and blood glucose monitoring on the Medication Administration Record (MAR) in accordance with its own insulin guidelines and accepted professional standards. The facility’s policy required that when a physician ordered regular insulin on a sliding scale, staff must document the date, time, and results of finger-stick blood sugar testing, the insulin dose given per sliding scale, the injection site, and the nurse administering the insulin. The policy also required charting on the MAR and/or nurses’ notes for these elements. Resident #3, admitted with diagnoses including obesity due to excess calories, cognitive communication deficit, dysphagia following cerebral infarction, and type 2 diabetes mellitus, had a physician’s order for NovoLog insulin via sliding scale to be given subcutaneously before meals and at bedtime, with blood glucose checks and documentation. Review of this resident’s February 2026 MAR showed no documented evidence that the ordered sliding scale insulin or blood glucose checks were administered or refused on multiple specified dates and times. The March 2026 MAR similarly lacked documentation for an ordered 11:00 a.m. administration and blood glucose check. The LPN assigned to this resident during the relevant shifts confirmed that the MAR entries were blank, acknowledged responsibility for the 11:00 a.m. medications, and stated there should not be any blanks on a MAR, admitting she did not document the administration or refusal of the insulin and blood glucose checks. Resident #4, admitted with diagnoses including type 2 diabetes mellitus, mild protein-calorie malnutrition, gastrostomy status, long-term insulin use, and cognitive communication deficit, also had a physician’s order for NovoLog insulin via sliding scale with specific instructions for hypoglycemia management and to administer the insulin subcutaneously before meals and at bedtime. Review of this resident’s February 2026 MAR revealed no documentation that the ordered insulin or blood glucose checks were administered or refused at the scheduled afternoon and evening times on a specified date. The March 2026 MAR showed the same lack of documentation for the same scheduled times on another date. The LPN responsible for this resident’s care on those shifts confirmed she was responsible for the 4:45 p.m. and 8:00 p.m. medications, acknowledged the MAR blanks, and admitted she did not document the administration or refusal of the sliding scale insulin and blood glucose checks. The ADON further confirmed that all medication administrations and glucose checks should have been documented and were not.
Insufficient CNA Staffing Fails to Meet Facility Assessment Requirements
Penalty
Summary
The facility failed to provide sufficient Certified Nursing Assistant (CNA) staffing to meet the needs of all residents, as required by their own minimum staffing assessment. The facility's assessment specified the required number of CNAs per shift for each hall, but on 03/04/2025, staffing records showed only 2 CNAs were present for the entire facility during both the evening and night shifts, which was below the minimum required. Multiple staff interviews confirmed that staffing was often inadequate, particularly on Hall B and Hall C, and that CNAs were frequently required to work alone or cover more residents than appropriate for safe care. Staff reported being unable to complete their tasks on time due to insufficient staffing levels. The administrator acknowledged that the facility's staffing on the evening and night shifts did not meet the minimum requirements based on census and resident acuity. Staff interviews consistently described frequent short staffing, especially on weekends and certain shifts, with CNAs being asked to pick up extra shifts and sometimes working entire halls alone. This deficiency had the potential to affect the entire facility census of 68 residents, as the lack of adequate CNA coverage could impact the ability to provide necessary direct care and related services.
Call Light Not Kept Within Reach for Resident at Risk for Falls
Penalty
Summary
The facility failed to ensure that a resident's call light was within reach, as required by facility policy and the resident's care plan. The resident, who had a history of muscle wasting and atrophy, chronic pain syndrome, unsteadiness, history of falls, dementia, lack of coordination, and Alzheimer's disease, was identified as being at risk for falls and required encouragement to call for assistance. On multiple occasions, observations revealed the resident lying in bed with the call light placed on a table at the foot of the bed, out of her reach. When asked, the resident was unable to locate or access the call light. Staff interviews confirmed that the call light was not within reach and acknowledged that it should have been accessible to the resident.
Inaccurate Payroll Data Submission for Direct Care Staffing
Penalty
Summary
The facility failed to electronically submit accurate payroll information for direct care staffing as required by CMS. A review of the Payroll Based Journal (PBJ) Staffing Data Report for Fiscal Year 2024 Quarter 4 revealed several deficiencies, including a one-star staffing rating, excessively low weekend staffing, no Registered Nurse hours, and a failure to maintain licensed nursing coverage 24 hours a day. During interviews, the staff responsible for submitting payroll data acknowledged that the contract company hired to submit the facility's payroll data identified inaccuracies in the September 2024 payroll data for direct care staffing. Both the staff member responsible for data submission and the administrator confirmed that all quarters for payroll data submission should be complete and accurate.
Inaccurate MDS Assessments for Three Residents
Penalty
Summary
The facility failed to ensure accurate MDS assessments for three residents, leading to discrepancies in their records. Resident #12 was not correctly coded for PASRR, despite having a serious mental illness as indicated in her OBH-Level II Evaluation Summary. Both the MDS coordinator and the Director of Nursing confirmed the error upon review. Resident #54, who was legally blind, was inaccurately coded as having adequate vision in her Quarterly MDS. This mistake was acknowledged by the MDS coordinator and the Director of Nursing after reviewing the resident's records and diagnosis. Resident #66 was incorrectly coded for discharge status. Although she was transferred to a hospital for shortness of breath, her Discharge MDS inaccurately indicated that she was sent to an inpatient rehabilitation facility. The error was confirmed by the MDS coordinator and the Director of Nursing after reviewing the nurse's notes and physician's orders, which clearly stated that the resident was sent to the emergency room for evaluation and treatment.
Failure to Update Care Plan for Legally Blind Resident
Penalty
Summary
The facility failed to revise a resident's care plan to accurately reflect her current condition and needs. The resident, who was admitted with a diagnosis of legal blindness, was found to have a care plan that included interventions for maintaining eyeglasses, ensuring adequate lighting, and providing ambulation assistance. However, these interventions were not appropriate for her condition, as she was unable to distinguish light from dark, did not wear corrective lenses, and was non-ambulatory and bed-bound. Interviews with the resident and staff confirmed these discrepancies, indicating that the care plan did not reflect the resident's status at admission or currently. The care plan, dated over a year prior, had not been updated despite the resident's condition and needs being clearly different from what was documented. The MDS staff, responsible for conducting assessments and updating care plans, failed to revise the plan as required. Interviews with the CNA, LPN, and DON confirmed the oversight, acknowledging that the care plan should have been updated with each assessment conducted by the MDS staff. This failure to update the care plan resulted in interventions that were not applicable to the resident's actual needs.
Failure to Schedule Outside Dental Care for Resident
Penalty
Summary
The facility failed to ensure a system was in place for residents to receive routine dental care by an outside dentist as requested, affecting Resident #16. Resident #16, who was moderately cognitively impaired and diagnosed with mild protein-calorie malnutrition, expressed a preference to see an outside dentist rather than the in-house dentist. Despite this request being documented on multiple occasions, no appointment was scheduled with the outside dentist. The resident's last appointment with the outside dentist was over two years prior, and the facility staff did not communicate effectively to ensure the resident's request was fulfilled. Interviews with various staff members revealed a breakdown in communication and responsibility. S11MR documented the resident's request but did not inform the nurse, assuming S3ADON would review the notes. S12ST, responsible for scheduling outside appointments, was unaware of the resident's request. S14SW and S2DON believed an appointment had been scheduled and refused by the resident, but they could not provide documentation to support this. This lack of coordination and documentation led to the failure to provide the requested dental care for Resident #16.
Deficiencies in Documentation for Coroner Notification and Post-Dialysis Assessment
Penalty
Summary
The facility failed to maintain accurate medical records for two residents, leading to deficiencies in documentation. For one resident, the facility did not accurately document the notification of the coroner and the permission to release the body after the resident's death. The Assistant Director of Nursing (ADON) initiated a medical order to call the coroner but failed to document the time of the call, the person spoken to, and the permission to release the body. The coroner's office confirmed they did not receive a call from the facility, which was required, and only became aware of the death when contacted by the funeral home. For another resident, the facility did not document a nurse's assessment upon the resident's return from dialysis. The resident, who was dependent on renal dialysis, attended dialysis three times a week, but there was no documented evidence of an assessment being conducted upon their return to the facility on specific dates. Interviews with the LPN and the Director of Nursing (DON) confirmed that assessments were standard practice and should have been documented in the resident's medical record, but they were not. These documentation failures were identified during a review of the facility's policies and interviews with staff members. The lack of accurate documentation in both cases was not in accordance with accepted professional standards and practices, potentially affecting the care and communication regarding the residents' conditions.
Inadequate Infection Control During Catheter Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the improper use of Personal Protective Equipment (PPE) and inadequate hand hygiene during catheter care for a resident. The resident, who was admitted with a diagnosis of a Urinary Tract Infection, had specific physician orders for Enhanced Barrier Precautions during high-contact care activities, including the use of gloves and a gown. However, during an observation, a Certified Nursing Assistant (CNA) was seen performing catheter care without wearing a gown, which was contrary to the posted Enhanced Barrier Precautions sign on the resident's door. Additionally, the CNA did not change gloves or perform hand hygiene between cleansing the resident's genitalia, catheter tubing, and applying a new, clean brief. This was confirmed during an interview with the CNA, who acknowledged the failure to adhere to the required infection control practices. The Director of Nursing (DON) also confirmed that the CNA should have worn a gown and performed proper hand hygiene during the catheter care process.
Failure to Implement Care Plan for Incontinence Care
Penalty
Summary
The provider failed to ensure the care plan was implemented for a resident who required incontinence care with the assistance of two staff members. The facility uses Resident Wall Care Plan Sheets and Turning Schedules to communicate important individualized information about residents to CNAs. These sheets are supposed to be prominently displayed in each resident's room and include details such as transfer status and the number of staff required for assistance. Resident #2, who had diagnoses including lack of coordination, muscle wasting and atrophy, and hemiplegia and hemiparesis, required extensive two-person physical assistance with bed mobility, toileting, and transfers, as indicated in their care plan. An observation on July 29, 2024, revealed that a CNA performed incontinence care for Resident #2 without the required assistance from another staff member, despite the care plan specifying two-person assistance. The CNA confirmed that she performed the care alone and acknowledged that she should have had another staff member present. Interviews with the Director of Nursing and the Administrator confirmed that peri-care/incontinence care is included in bed mobility and that the care plan should have been followed, requiring two staff members to be present during incontinence care.
Failure to Follow Transfer Assistance Protocols
Penalty
Summary
The facility failed to ensure that residents were transferred with the appropriate assistance and devices, leading to two incidents involving residents who were not transferred according to their care plans. Resident #2, who has a history of hemiplegia and requires two-person assistance for transfers, was transferred by a single CNA, resulting in the resident falling to the floor. The CNA admitted to not checking the wall care plan sheet, which clearly indicated the need for two-person assistance. Similarly, Resident #3, who requires a mechanical lift and two-person assistance due to conditions such as hemiplegia and a history of falls, was transferred without the use of a mechanical lift. Two CNAs attempted to transfer the resident manually, which led to the resident being lowered to the floor when his legs gave out. Both CNAs involved confirmed they did not check the wall care plan sheet before proceeding with the transfer. Interviews with the Director of Nursing (DON) and the Administrator confirmed that the CNAs are trained to follow the wall care plans, which are derived from the residents' care plans. The DON acknowledged that if the CNAs had adhered to the specified transfer assistance requirements, the incidents could have been avoided. The Administrator also confirmed that the wall communication sheets are intended to guide staff in providing care according to the residents' needs.
Latest citations in Louisiana
A resident with Parkinson’s disease, essential tremor, dementia, and legal blindness, who was care planned as being at risk for burns from hot liquids and to receive hot beverages in lidded cups at temperatures not exceeding 130°F, sustained 2nd and 3rd degree burns to the left thigh after spilling coffee during a group activity. The facility’s policy required hot beverages to be cooled to 120–130°F and mandated temperature monitoring, but the coffee served at the time of the incident was reported by dietary staff to be 140°F, and the coffee temperature log did not include documentation for the 10:00 a.m. service when the spill occurred. This failure to adhere to the hot beverage policy and to consistently monitor and document beverage temperatures resulted in actual harm to the resident.
A resident with severe cognitive impairment, multiple chronic conditions, and hospice services required extensive assistance for transfers. During a transfer from wheelchair to bed performed by a CNA, the resident’s left lower leg rubbed against an enabler bar that had a missing end cap, creating a sharp edge. An LPN observed a large laceration on the leg and identified the defective enabler bar as the source of injury. The resident was sent to the ED, where a deep, 25.5 cm stellate laceration required extensive cleaning, internal and external sutures, a tetanus shot, and subsequent daily wound care and antibiotics due to delayed healing. The incident occurred despite facility policies and the Maintenance Supervisor’s responsibilities requiring regular inspection of bed rails and enabler bars for hazards.
The facility did not maintain the required 8 consecutive hours of daily RN coverage on multiple days, as time card records showed that the only scheduled RN worked less than 8 hours on several occasions. The administrator confirmed that this RN was the sole RN scheduled during the period reviewed and acknowledged that full daily RN coverage was not provided on the identified days.
The facility failed to maintain adequate supplies of clean bath towels and bed linens despite its own assessment identifying the need to keep sufficient PAR levels for these items. A resident with a history of traumatic brain injury and another with type 2 DM and asthma, both cognitively intact, reported that towels and linens were often unavailable, with one resident’s family providing personal linens due to frequent shortages. The grievance log documented a complaint about missing personal towels and sheets, and staff, including laundry personnel, a CNA, and the ADON, confirmed that clean towels and bed linens were frequently unavailable during multiple weeks, affecting all residents in the facility.
A resident with severe cognitive impairment, dementia, and multiple comorbidities, assessed as high risk for elopement due to prior exit-seeking and wandering, was found alone outside near the front entrance in a flower bed by an oncoming LPN. The LPN assisted the resident and notified staff inside, and the responsible party later reported the same event. Despite a written wandering and elopement policy requiring notification of regulatory agencies after such incidents, the Administrator acknowledged that this elopement was not reported to the State Survey Agency as required by state law.
A resident with multiple conditions, including type 2 DM, dementia with behavioral symptoms, gait abnormalities, and an anxiety disorder, was documented in progress notes as having eloped and been found outside in a flower bed, and later was found to have a diabetic ulcer on the right heel. Review of the comprehensive care plan showed it was not revised to address either the elopement or the new diabetic ulcer, and the MDS coordinator acknowledged that the care plan should have been updated to reflect these changes in condition.
A resident with type 2 DM, dementia, mobility impairments, and other comorbidities was admitted with a documented deep tissue injury on the right heel, but no corresponding MD wound care orders or treatments were recorded for approximately one month despite a care plan directive to assess for skin breakdown and treat as ordered. A NP note referenced treatment with gentian violet and foam, yet this was not supported by physician orders or the TAR. Later, a wound care nurse identified a diabetic ulcer on the same heel and initiated gentian violet and foam dressings after an order was finally obtained, with treatments documented on only a few dates. The resident was later seen in the ED for cellulitis related to the diabetic heel ulcer and discharged with antibiotics, and both the wound care nurse and NP confirmed gaps in assessment, ordering, and follow-up of the heel wound.
Staff failed to follow infection control protocols during incontinence care for two residents, including not performing required hand hygiene between glove changes and after contact with stool, and placing soiled items on clean linens. CNAs provided perineal care, handled residents’ clean clothing, body surfaces, wheelchairs, and room surfaces, and managed soiled briefs and pads without appropriate glove changes or hand sanitizing, contrary to facility policy. Both CNAs later acknowledged they should have performed hand hygiene and changed gloves correctly, and the DON confirmed that staff are expected to follow these infection prevention practices.
Two residents were not treated in a manner that promoted dignity and quality of life. One resident with left-sided weakness and a flaccid arm following a stroke requested a bedpan, but a CNA told her she was wearing a diaper and could use it instead, despite therapy having recommended bedpan use and the resident not wanting to use a diaper. Another resident with vascular dementia, a history of C. diff enterocolitis, heart failure, and depression, and a moderately impaired BIMS score continued to receive meals on disposable dishware in the dining room even though contact isolation precautions had been discontinued, and nursing leadership confirmed this should not have occurred.
A resident with paraplegia, severe cognitive impairment (BIMS 6), and dependence for mobility and hygiene was repeatedly observed in bed and in a Geri chair without access to a call light, despite facility policy requiring call lights to be within easy reach when residents are in bed or confined to a chair. On multiple occasions throughout the day, the call light was found on the floor or hanging on the side of the bed, out of the resident’s reach. The resident reported being unable to reach the call light, and both a CNA and the DON acknowledged that the call light was not within reach and should have been accessible.
Resident Burn from Overheated Coffee and Failure to Follow Hot Beverage Policy
Penalty
Summary
The deficiency involves the facility’s failure to ensure the environment was free from accident hazards and that residents received adequate supervision to prevent accidents, specifically related to serving hot beverages. The facility had a written policy titled “Serving Hot Beverages and Soup,” revised in 07/2007, which required the Food Service Department to monitor the temperature of all hot liquids to prevent burns if they contacted skin. The policy specified that coffee should be chilled to 120–130°F before being served and that the Food Service Department was responsible for ensuring all hot beverages, including those for activities, left the kitchen at the proper temperature. However, the coffee temperature log for March only included entries for 6:00 a.m. and 2:00 p.m., with no slot or documentation for 10:00 a.m. coffee temperatures, despite coffee being served at that time. Resident #1 was admitted with diagnoses including Parkinson’s disease, unspecified dementia, essential tremor, and legal blindness. A quarterly MDS with an ARD of 12/31/2025 showed a BIMS score of 13, indicating the resident was cognitively intact, and Section GG indicated no functional limitation in upper extremity range of motion. The resident’s care plan included a focus that the resident was at risk for burns from hot liquids, with interventions such as encouraging consumption of hot liquids while sitting at a table, requiring use of a cup with a lid for all hot beverages, and specifying that the temperature of hot liquids should not exceed 130°F. Another care plan focus addressed impaired visual function related to legal blindness, with interventions to provide activities adjusted to the resident’s visual disability. During a 10:00 a.m. group activity, Resident #1 spilled hot coffee on her lap. The dietary manager later confirmed that coffee was served at 6:30 a.m., 10:00 a.m., and 2:00 p.m., and that the dietary aide who prepared the coffee for the incident reported the coffee temperature as 140°F, which exceeded the facility’s policy limit of 130°F. Resident #1 reported that she spilled coffee on herself while sitting at a table in the activity room and that the coffee was hot and burned when it was spilled. Subsequent nursing and NP assessments documented two in-house–acquired wounds on the resident’s left upper thigh: one described as a blister and one as a burn, later characterized by the NP as a full-thickness (3rd degree) burn and a partial-thickness (2nd degree) burn. These findings, combined with the lack of documented 10:00 a.m. temperature monitoring and the reported serving temperature of 140°F, demonstrate that the facility did not follow its hot beverage policy and failed to protect the resident from an avoidable burn hazard.
Failure to Maintain Safe Enabler Bar Results in Severe Leg Laceration
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident’s enabler bar was free from accident hazards, resulting in an actual injury. The facility’s own Bed and Side Rails policy required a designee to inspect all bed frames, mattresses, and bed rails, including grab bars and assist bars, as part of a regular maintenance program. The Maintenance Supervisor job description also required daily tours of the property to identify and correct hazardous conditions and liability hazards. Despite these requirements, the enabler bar on one resident’s bed had a missing end cap, creating a sharp edge that was not identified or corrected prior to use. The affected resident had been admitted with multiple diagnoses, including Peripheral Vascular Disease, Malnutrition, Chronic Kidney Disease, Depression, and Alzheimer’s Disease, and had a BIMS score of 5, indicating severe cognitive impairment. The resident was receiving hospice services and required extensive assistance of one staff person with transfers, as documented in the care plan. On the date of the incident, a CNA assisted the resident with a transfer from a wheelchair to the bed. During this transfer, the resident’s left lower leg rubbed against the enabler bar that had the missing end cap and sharp edge. Nursing documentation recorded that the CNA called an LPN to the room and the LPN observed a large laceration on the resident’s left lower leg with bleeding, which the CNA reported had occurred during the transfer. The LPN noted that the enabler bar had a missing end cap, resulting in a sharp edge, and that the resident’s leg had contacted this area during the transfer. The resident was sent to the emergency department, where records described a very large stellate laceration measuring 25.5 cm on the lateral left lower leg, extending deep to the fascia and requiring extensive cleaning and a complicated repair with internal and external sutures, as well as a tetanus vaccination. Subsequent physician notes documented that the wound required ongoing assessment, daily wound care, and two courses of Bactrim DS due to the extent and depth of the laceration and delayed healing, with sutures removed in stages over several weeks.
Failure to Maintain Required Daily RN Coverage
Penalty
Summary
The facility failed to ensure that a registered nurse (RN) was on duty for 8 consecutive hours per day, 7 days a week, as required. Review of the time card report for staff member S5RN from 02/22/2026 through 03/24/2026 showed that on five specific dates—02/25/2026, 02/26/2026, 02/27/2026, 02/28/2026, and 03/01/2026—there were fewer than 8 consecutive hours of RN coverage, with recorded work times of 6.50, 7.48, 6.48, 7.50, and 7.50 hours respectively. During an interview on 03/25/2026 at 9:35 a.m., the Administrator (S1) confirmed that S5RN was the only RN scheduled between 02/22/2026 and 03/21/2026 and acknowledged that the facility did not have 8 consecutive hours of RN coverage on the identified dates. No additional information was provided in the report regarding specific residents, their medical conditions, or any clinical events occurring during the periods without full RN coverage.
Failure to Maintain Adequate Supply of Clean Towels and Bed Linens
Penalty
Summary
The facility failed to provide residents with a safe, functional, sanitary, and comfortable environment by not ensuring the consistent availability of clean bath towels and bed linens. The facility’s own Facility Assessment Tool, updated on 03/23/2026, identified bed and bath linen as non-medical supplies for which PAR levels must be maintained at all times to ensure adequate supplies. Despite this, multiple interviews and record reviews showed that clean linens and towels were often unavailable. One resident, admitted on 12/05/2022 with diagnoses including diffuse traumatic brain injury and allergic rhinitis and a BIMS score of 15 (no cognitive impairment), reported that bath towels and bed linens were often unavailable, most recently during the week of 03/15/2026 through 03/21/2026. Another resident, admitted on 07/12/2023 with diagnoses including type 2 diabetes mellitus and asthma and a BIMS score of 15, had filed a grievance on 01/10/2026 reporting that personal bath towels and sheets were missing from the laundry and later reported that family had to provide personal linens because the facility frequently lacked bath towels and bed linens. Staff interviews corroborated these reports: a laundry staff member stated the facility frequently did not have clean bath towels and bed linens available for residents; a CNA reported that clean bath towels and bed linens were unavailable for residents during the week of 03/08/2026 through 03/14/2026; and the ADON confirmed that the facility did not have clean bath towels and bed linens available for residents on 03/23/2026. This pattern of unavailability affected the facility’s census of 58 residents.
Failure to Report Resident Elopement to State Survey Agency
Penalty
Summary
The deficiency involves the facility’s failure to report a resident elopement to the State Survey Agency as required by state law and by the facility’s own Wandering and Elopement Policy dated 11/15/2023. That policy directs that when a resident returns after an elopement, the DON or charge nurse must examine the resident, notify the attending physician, complete an incident/accident report, document the event in the medical record, and notify regulatory agencies per state guidelines. Record review showed that one resident, admitted on 01/09/2026, had multiple diagnoses including type 2 diabetes mellitus, cognitive communication deficit, aphasia, muscle wasting and atrophy, gait and mobility abnormalities, disorientation, unspecified dementia with anxiety, psychotic and mood disturbance, anxiety disorder, and essential hypertension. A Quarterly MDS documented a BIMS score of 4, indicating severely impaired cognition, and the resident was assessed as an elopement risk level 3 due to a history of attempted elopement at home, wandering with purpose in the facility, and exit-seeking behavior. Progress notes and interviews confirmed that on 02/08/2026 the resident was found outside the facility alone in the flower bed at the front of the building, bent over with hands in the dirt, by an oncoming nurse arriving for her shift. The LPN reported she parked her car, went to assist the resident, and alerted staff inside that the resident was outside alone. The resident’s responsible party similarly reported that the resident had been found outside alone in front of the facility on that date. During interview, the Administrator confirmed that the resident, who had dementia and a BIMS score of 4, had been found outside in the flower bed in front of the facility and acknowledged that this incident was not reported to the State Survey Agency, constituting a failure to report the elopement in accordance with state law and facility policy.
Failure to Revise Care Plan After Elopement and Development of Diabetic Ulcer
Penalty
Summary
The deficiency involves the facility’s failure to revise a resident’s comprehensive care plan following significant changes in condition, specifically an elopement and the development of a diabetic ulcer. The resident was admitted with multiple diagnoses, including type 2 diabetes mellitus, cognitive communication deficit, aphasia, muscle wasting and atrophy at multiple sites, gait and mobility abnormalities, disorientation, unspecified dementia with associated anxiety, psychotic and mood disturbances, an anxiety disorder, and essential hypertension. Progress notes documented that the resident was found outside the facility in a flower bed, bent over with hands in the dirt, after having eloped from the building. Further review of the resident’s progress notes showed that a diabetic ulcer was identified on the resident’s right heel the day after the elopement. Despite these documented changes in condition, review of the resident’s comprehensive care plan revealed no revisions to address the actual elopement event or the new diabetic ulcer on the right heel. During an interview, the MDS Coordinator confirmed that the resident’s care plan should have been revised to reflect both the elopement and the development of the diabetic ulcer, but it was not.
Failure to Implement and Document Diabetic Foot and Heel Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with professional standards of practice and the comprehensive care plan for a resident with diabetes and multiple comorbidities. The resident was admitted with type 2 diabetes mellitus, cognitive communication deficit, aphasia, muscle wasting and atrophy, gait and mobility abnormalities, disorientation, unspecified dementia with associated psychiatric symptoms, anxiety disorder, and hypertension. On admission, the Minimum Data Set and skin assessment documented a deep tissue injury on the right heel. A nurse practitioner’s progress note dated shortly after admission described a deep tissue injury on the right heel being treated with gentian violet and foam and noted the heel was tender to touch. However, there were no corresponding physician’s orders for wound care treatment on the January and early February physician order sheets, and the treatment administration records for that same period showed no wound care treatments provided. The resident’s care plan for diabetes included an approach to check the body for breaks in the skin and treat promptly as ordered by the physician, but the facility did not develop and implement specific approaches addressing the documented right heel injury. A wound care nurse’s progress note later identified a diabetic ulcer on the right heel, described as tender and spongy, and documented application of gentian violet–soaked gauze and foam dressing. Only then was a physician’s order written to monitor the right heel and apply gentian violet dampened gauze and a protective dressing on specified days, with the treatment administration record showing documentation of these treatments on only three dates. The resident’s responsible party reported that the resident was discharged and subsequently required emergency department treatment for cellulitis due to a diabetic ulcer on the right heel, for which antibiotics were prescribed. The wound care nurse confirmed the initial documentation of a deep tissue injury without any physician’s orders for treatment and that the diabetic ulcer was not identified until nearly a month after admission, and the nurse practitioner confirmed he examined the right heel only once during that period.
Failure to Follow Hand Hygiene and Glove Protocols During Incontinence Care
Penalty
Summary
The deficiency involves the facility’s failure to maintain an infection prevention and control program during incontinence care, specifically related to hand hygiene, glove use, and handling of soiled linens. The facility’s own policy for bladder incontinence care requires staff to perform handwashing or use alcohol gel, don disposable gloves, cleanse the perineal and anal areas, then remove and discard gloves and perform hand hygiene before proceeding. During observed incontinence care for one resident, a CNA donned clean gloves and used perineal wipes to remove bowel movement from the resident’s buttocks, then, without changing gloves or performing hand hygiene, placed a clean incontinence pad and brief under the resident. The CNA placed a soiled brief and urine-soaked bed pad at the foot of the bed on top of the resident’s clean comforter, then disposed of the soiled brief in the trash, spread a clean incontinence pad on the bed, and secured a clean brief, all without changing gloves or performing hand hygiene. The same CNA continued to touch the resident’s clean clothing, body, wheelchair armrests, and room door, transferred the resident to the wheelchair, and moved the resident into the hallway, then returned to retrieve the soiled incontinence pad and carried it down the hall to the soiled linen barrel before finally disposing of gloves, again without any observed hand hygiene during the entire episode of care. In a separate observation involving another resident, two CNAs provided incontinence care without performing hand hygiene before donning gloves. One CNA removed bowel movement from the resident’s buttocks, discarded the soiled brief, removed soiled gloves, and donned clean gloves without hand hygiene, then touched the resident’s extremities, bed linens, and applied a clean brief and incontinence pad. The CNA again changed gloves and dressed the resident in a clean gown, touching multiple body areas, without hand hygiene. The second CNA unfastened the brief, confirmed the resident remained soiled, wiped remaining stool, and helped secure the clean brief without changing soiled gloves or performing hand hygiene. Both CNAs later confirmed in interviews that they should have performed hand hygiene and changed gloves appropriately, and the DON confirmed staff are expected to change gloves when soiled or moving from contaminated to clean areas, sanitize hands between glove changes and between residents, and avoid placing soiled linen on clean linen.
Failure to Honor Resident Dignity and Discontinue Unnecessary Isolation Practices
Penalty
Summary
The deficiency involves failure to honor residents' rights to dignity and self-determination. One resident, who was lying in bed and requested a bedpan, was observed on 03/25/2026 at 8:59 a.m. using the call light with surveyor assistance. When the CNA entered the room, she stated the resident was wearing a diaper, could not get up due to left-sided weakness from a stroke, and said the resident "can go in her diaper" instead of providing a bedpan as requested. A COTA later reported that therapy had recommended the resident use a bedpan and had removed the bedside commode the previous day, and that the resident did not want to use a diaper. The COTA also stated the resident’s left arm was flaccid and that she required maximum assistance of two people. A second deficiency involved another resident who continued to receive meals on disposable dishware in the dining room after contact isolation precautions had been discontinued. This resident had diagnoses including vascular dementia, enterocolitis due to Clostridium difficile, hyperlipidemia, heart failure, and depression, and had a BIMS score of 9, indicating moderately impaired cognition. A physician order for single room isolation with contact precautions had been discontinued on 02/17/2026, yet on 03/23/2026 at 11:20 a.m., the resident was observed receiving a lunch tray on disposable dishware while seated in the dining room. The ADON confirmed the resident was no longer on contact precautions and should not have been receiving meals on disposable dishware.
Failure to Keep Call Light Within Reach for Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s call light was accessible as required by facility policy and necessary to reasonably accommodate the resident’s needs. The facility’s policy on answering call lights, dated 01/16/2026, states that when a resident is in bed or confined to a chair, the call light must be within easy reach. Resident #3 was admitted on 12/07/2023 with diagnoses including mononeural disorder, paraplegia, epilepsy, and peripheral vascular disease. A quarterly MDS with an ARD of 03/03/2026 documented a BIMS score of 6, indicating severe cognitive impairment, and showed the resident required setup assistance with eating, was dependent for toileting and personal hygiene, and needed substantial/maximal assistance to roll left to right. On multiple observations on 03/24/2026, surveyors found the resident’s call bell out of reach despite the resident’s reliance on it to express needs. At 10:12 a.m., the resident was lying in bed with eyes closed and the call bell was on the floor on the right side of the bed, not within reach. At 12:24 p.m., the resident was awake and alert in bed, and again the call bell was on the floor and not reachable; the resident stated he could not reach it. During an interview at 12:45 p.m., a CNA familiar with the resident confirmed the resident could express needs with short responses and used the call bell. At 12:48 p.m., with the CNA present, the call bell was still on the floor and not within reach, and the CNA acknowledged it should have been accessible. Later observations at 1:41 p.m. and 3:00 p.m. found the resident awake and alert in a reclined position in a Geri chair, with the call bell hanging on the side of the bed and again out of reach; the DON, present at 3:00 p.m., confirmed the call bell was not within reach and should have been.
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