Average — CMS composite of the measures below.
The next survey window likely opens around January 2027
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 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.
Two residents had inaccurate Entry MDS coding. One resident with serious mental illness diagnoses was coded as not currently considered under Level II PASRR despite being approved by Level II authority for temporary admission, and another resident was coded as entering from an Intermediate Care Facility even though the record showed admission from an LTAC hospital. S3CCC and the DON confirmed both MDS entries were incorrect.
Call Light Not Kept Within Reach: A resident with Parkinson's disease, osteoarthritis, and unsteady gait was observed sitting in a wheelchair with the call light placed in the bed under the covers and out of reach. The resident stated he needed help getting back into bed but could not reach the call light. A PT and the DON confirmed the resident required assistance and that the call light should have been within reach.
A resident with dementia and moderate cognitive impairment was not protected from verbal abuse by another resident with schizophrenia and moderate cognitive impairment. The other resident was yelling, screaming, and cursing, stood over the resident in a wheelchair, and staff confirmed the behavior was verbal abuse; the resident also reported being hit and called a b****.
Failure to Timely Report Abuse Allegation: The facility did not report an abuse allegation to the State Survey Agency within the required timeframe after an incident in which one resident yelled, cursed, stood over another resident, and hit the resident on the lips. Both residents were moderately cognitively impaired, and staff interviews confirmed the behaviors met the definitions of verbal and physical abuse. The DON and ADM acknowledged responsibility for reporting, but the ADM stated the incident was not reportable because the resident had no injuries.
Failure to Provide Required Nail Care: A resident with ADL assistance needs had long, dirty fingernails that extended about 1 cm past the nailbeds on all 10 fingers, with debris under each nail. The resident said the nails had not been cut in a while and wanted them trimmed. Staff confirmed the resident was not diabetic, had not refused care, and that CNAs were responsible for weekly nail care during baths/showers, but the nails remained untrimmed and unclean.
Failure to Use Required PPE During PEG Tube Care: A resident on EBP for feeding tube care had PEG tube placement and residual checks plus a water flush performed by an LPN without a gown, despite the posted EBP instructions requiring gloves and a gown for feeding tube-related high-contact care. The LPN confirmed the omission, and the DON confirmed staff should have worn a gown during the PEG tube care.
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.
MDS Coding Errors for PASRR and Entry Source
Penalty
Summary
Ensure each resident receives an accurate assessment was not met when the facility failed to code the Entry MDS accurately for 2 residents out of 28 in the final sample. For Resident #37, the clinical record showed diagnoses including Schizoaffective Disorder, Bipolar Type, Dementia Psychotic Disturbance, Catatonic Disorder, Depressive Disorders, and Mental Disorder. Her Entry MDS with an ARD of 04/17/2025 coded Section A1500, PASRR, as "no" for whether the resident was currently considered by the state level II PASRR process to have a serious mental illness and/or intellectual disability or related condition, even though her Behavioral Health State Form 142 showed she had been approved for admission by Level II authority for a temporary period effective 03/18/2025 through 03/17/2026. For Resident #71, the Entry MDS with an ARD of 01/30/2026 coded Section A1805, Entered From, as "08. Intermediate Care Facility," while the clinical record showed she entered the facility from a Long Term Acute Care hospital. During interviews, S3CCC and S2DON reviewed the records and confirmed that Resident #37's PASRR coding and Resident #71's entry source coding were incorrect.
Call Light Not Kept Within Reach
Penalty
Summary
The facility failed to ensure that Resident #76's call light was within reach. The resident was admitted with diagnoses including unsteadiness on feet, Parkinson's disease, and primary generalized osteoarthritis. The entry MDS dated 01/28/2026 indicated the resident required substantial assistance for transfers, and the care plan identified the resident as high risk for falls related to gait instability secondary to Parkinson's disease and osteoarthritis to the knees, with an intervention to keep the call light in reach and encourage the resident to call for assistance. During observation on 02/09/2026 at 9:15 a.m., Resident #76 was sitting in a wheelchair in the room, and the call light was observed in the bed under the covers and out of reach. The resident stated he needed assistance getting back into bed but could not reach the call light. A later observation at 9:40 a.m. again found the resident in the wheelchair with the call light out of reach. S9PT confirmed the resident could not reach the call light and required assistance to transfer to the bed, and also confirmed the call light should always be within reach but was not. S2DON later confirmed the call light should be within reach at all times.
Failure to Protect Resident from Verbal Abuse by Another Resident
Penalty
Summary
The facility failed to protect Resident #33 from verbal abuse by Resident #11. Resident #33 had diagnoses including dementia, mood disturbance, and anxiety, and her MDS showed a BIMS of 8, indicating moderate cognitive impairment. Resident #11 had diagnoses including schizophrenia, generalized anxiety disorder, and an intellectual disability, and her MDS showed a BIMS of 9, also indicating moderate cognitive impairment. The facility’s abuse policy stated residents must be free from verbal abuse by anyone, including other residents. According to the incident report and staff interviews, Resident #11 was yelling, screaming, cursing at staff, and threw a meal tray across the room. Resident #33 rolled to Resident #11’s doorway to ask if she was okay, and Resident #11 exited her room, stood over Resident #33 in her wheelchair, and continued yelling and cursing. Staff reported that Resident #11 cursed at Resident #33 and that Resident #33 stated Resident #11 hit her and called her a b****. Staff separated the residents and assessed Resident #33, who had no visible facial markings, but the report and interviews confirmed that Resident #11’s screaming, cursing, and standing over Resident #33 constituted verbal abuse.
Failure to Timely Report Abuse Allegation
Penalty
Summary
The facility failed to report allegations of physical and verbal abuse to the State Survey Agency immediately, but no later than 2 hours, for one resident reviewed for abuse. The facility’s Abuse-Neglect Prevention Manual stated that abuse allegations are to be reported per Federal and State law, no later than 2 hours to health standards when the incident or allegation involves abuse with or without serious bodily harm. The report identified verbal abuse as oral, written, or gestured communication, or sounds to residents within hearing distance, and physical abuse as hitting, slapping, pinching, biting, and kicking. Resident #33 had diagnoses including dementia, mood disturbance, and anxiety, and was moderately cognitively impaired with a BIMS of 8. Resident #11 had diagnoses including schizophrenia, generalized anxiety disorder, and other genetic related intellectual disability, and was also moderately cognitively impaired with a BIMS of 9. The incident report stated that Resident #11 yelled, screamed, cursed staff, threw a meal tray, exited the room, cursed Resident #33, stood over Resident #33, and then hit Resident #33 on the lips. Staff separated the residents and assessed Resident #33, and the physician was notified. Interviews confirmed that standing over a resident while screaming and cursing was verbal abuse and hitting a resident was physical abuse. The DON and ADM stated they were responsible for reporting abuse allegations to the state agency, but the ADM said the incident did not require reporting because Resident #33 had no injuries. The facility’s State Agency Reported Incidents showed no report for either resident.
Failure to Provide Required Nail Care
Penalty
Summary
The facility failed to ensure a resident who was unable to carry out ADLs received the necessary services to maintain good grooming and personal hygiene. Resident #24 was admitted with diagnoses including muscle wasting and atrophy of the right and left shoulder and need for assistance with personal care. The resident’s physician orders directed staff to check, clean, and/or trim fingernails and toenails weekly by CNA every Wednesday evening shift, and the care plan directed staff to assist with hygiene, dressing, and grooming as needed, with fingernails cleaned and trimmed as needed. During observations, Resident #24’s fingernails were noted to be long and dirty, extending approximately 1 centimeter past the nailbeds on all 10 fingers, with a brown/red substance under each nail. The same condition was observed again the next day. The resident stated his fingernails were too long and had not been cut in a while, and he wanted them cut. Staff interviews confirmed that CNAs were responsible for cleaning and trimming fingernails for non-diabetic residents, that nail care should have been performed during baths/showers, and that Resident #24 was not diabetic and had not refused baths or nail trimming. The DON also confirmed that the resident’s nails should have been kept clean and trimmed.
Failure to Use Required PPE During PEG Tube Care
Penalty
Summary
The facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary environment to help prevent the development and transmission of infection for 1 of 5 residents reviewed on Enhanced Barrier Precautions (EBP). Resident #68 had a physician’s order dated 11/06/2025 for EBP to be used when performing high-contact resident care activities related to a feeding tube every shift. The facility’s EBP policy stated that gown and glove use were required during high-contact resident care activities, including device care or use for a feeding tube. On 02/10/2026 at 3:26 p.m., an observation showed the EBP sign posted on Resident #68’s door stating that staff must wear gloves and a gown for high-contact resident care activities, including feeding tube care. During the same observation, S5LPN performed a PEG tube placement check, residual check, and water flush without wearing a gown. In an interview at 3:33 p.m., S5LPN confirmed Resident #68 was on EBP and stated she should have worn a gown while performing the PEG tube procedure but had not. On 02/11/2026 at 3:00 p.m., S2DON confirmed staff should have worn a gown while performing Resident #68’s PEG tube care.
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.
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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.
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Nursing homes near Zachary
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Lodge At Lane | 0.3 mi | ★★★★★ | 0 | 0 |
| River Oaks Nursing & Rehabilitation Center Llc | 4.1 mi | ★★★★★ | 2 | 0 |
| Grace Nursing Home | 5.3 mi | ★★★★★ | 4 | 0 |
| Baton Rouge Health Care Center | 6.3 mi | ★★★★★ | 3 | 0 |
| Central Guest House Healthcare & Rehabilitation Ce | 8.8 mi | ★★★★★ | 6 | 0 |
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