Zachary Manor Nursing and Rehabilitation Center

Inspectors wroteBased on interviews and record reviews, the facility failed to implement a person centered care plan by failing to ensure nursing staff followed the physician's order to notify the MD of an elevated blood glucose level for 1 (#2) of 3 residents reviewed with Type 2 Diabetes Mellitus.

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure residents' Medication Administration Record (MAR) were accurately documented for 2 (#3 and #4) of 4 sampled residents reviewed for accurate documentation. Review of the facility's undated policy titled Insulin Guidelines revealed the following, in part: Policy: Insulin is utilized to control blood sugar levels in residents with diabetes mellitus. Insulin therapy may include various regimens, which are carried out per doctor's orders. Insulin lowers the blood glucose by decreasing the release of glucose from the liver and increasing the utilization of glucose by muscle and fat cells. Guidelines: Whenever a physician orders Regular insulin on a sliding scale, care must be taken to document finger stick blood sugar and administration of insulin as ordered. Charting on MAR and/or nurses' notes should include the following: [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure the MDS assessment accurately reflected the resident's status for 2 (#37 and #71) out of 28 residents in the final sample. The facility failed to ensure Resident #37 and #71 were coded accurately on the Entry Minimum Data Set (MDS) assessment. Resident #37 Review of Resident #37's Clinical Record revealed she was admitted to the facility on [DATE] with diagnosis which included Schizoaffective Disorder, Bipolar Type, Dementia Psychotic Disturbance, Catatonic Disorder Depressive Disorders, and Mental Disorder. Review of Resident #37's Entry MDS with an ARD of 04/17/2025 revealed the following, in part: [...]

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure a resident's call light was within reach for 1 (#76) of 29 residents reviewed during the initial pool.

Inspectors wroteBased on interviews and record reviews, the facility failed to protect each residents' right to be free from verbal abuse for 1 (#33) of 29 residents reviewed for abuse in the initial pool. The facility failed to protect Resident #33 from verbal abuse by Resident #11.

Inspectors wroteBased on record reviews and interviews, the facility failed to report allegations of physical and verbal abuse to the State Survey Agency immediately, but no later than 2 hours, for 1 (#33) of 29 residents reviewed for abuse in the initial pool.

Inspectors wroteBased on observations, interviews, and record review, 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 for 1 (#24) of 2 residents reviewed for ADL's. The facility failed to trim and clean Resident #24's fingernails.

Inspectors wroteBased on observations, interviews, and record review, 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 (#68) of 5 residents reviewed on Enhanced Barrier Precautions (EBP). The facility failed to ensure staff wore proper Personal Protective Equipment (PPE) while providing direct care for Resident #68 who was on EBP.

Inspectors wroteBased on record review and interview the facility failed to have sufficient Certified Nursing Assistant (CNA) staff to provide direct care and related services to maintain the highest practicable physical, mental, and psychosocial well-being of each resident based on the facility assessment. This deficiency had the potential to affect the facility's total census of 68 residents.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure a resident's call light was within reach for 1 (#R1) of 7 (#1, #2, #3, #4, #5, #6, and #R1 ) residents reviewed.

Inspectors wroteBased on record review and interviews, the facility failed to electronically submit accurate payroll information for direct care staffing as required. This deficient practice had the potential to affect any of the 67 residents residing in the facility.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure the MDS assessment accurately reflected the resident's status for 3 (#12, #54 and #66) residents out of a total of 21 sampled residents. The facility failed to ensure: 1. Resident #12 was coded correctly for PASRR (Pre-admission Screening and Resident Review); 2. Resident #54 was coded correctly for vision; and 3. Resident #66 was coded correctly for discharge.

Inspectors wroteBased on record review and interviews the facility failed to ensure a resident's plan of care was revised by failing to update vision interventions for 1 (#54) of 19 residents reviewed in the final sample for Care Plans.

Inspectors wroteBased on an observation, interviews, and record review, the facility failed to ensure there was a system in place for facility residents to receive routine dental care by an outside dentist as requested for 1 of 1 (#16) resident reviewed for dental services. This deficient practice had the potential to affect any of the 67 residents residing in the facility.

Inspectors wroteBased on record review and interviews, the facility failed to maintain accurate records in accordance with accepted professional standards and practices for 2 (#14 and #65 ) of 2 (#14 and #65 ) residents reviewed for accurate documentation. The facility failed to ensure: 1. The medical record of Resident #65 contained accurate documentation of Coroner Notification with Permission to Release the Body; and 2. The medical record of Resident #14 contained a documented nurse assessment upon return from dialysis. This deficient practice had the potential to affect a current census of 67 residents.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to maintain an infection prevention and control program to help prevent the development and transmission of infection for 1 (#167) of 19 resident's reviewed in the final sample. The facility failed to ensure: 1. Staff wore proper Personal Protective Equipment (PPE) while providing catheter care; and 2. Staff performed proper hand hygiene while providing catheter care.

Inspectors wroteBased on observation, record review and interview, the provider failed to ensure the care plan was implemented for 1 ( #2) of 3 (#1, #2, and #3) residents sampled for ADL care had incontinence care provided with the required amount of staff assistance.

Inspectors wroteBased on interviews and record review, the facility failed to ensure residents remained free of accident hazards by failing to ensure residents were transferred with proper transfer assistance and devices for 2 (#2 and #3) of 3 (#1, #2, and #3) residents reviewed for transfer assistance. The facility failed to ensure: 1. Resident #2 was transferred with 2 person assistance; and 2. Resident #3 was transferred with a mechanical lift.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide necessary care and services for the provision of respiratory care in accordance with professional standards of practice. The facility failed to ensure the oxygen tubing and humidification bottles were properly labeled for 3 (#23, #266, and #267) of 3 (#23, #266, and #267) residents reviewed for oxygen therapy.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to store, prepare, and distribute foods under sanitary conditions. The facility failed to ensure: 1. Food was properly sealed and dated after opening; and 2. Dietary staff wore a hair restraint while the kitchen. There were a total of 56 out of 60 facility residents who were provided meals and beverages from the facility's kitchen.

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure resident rights by failing to initiate resident grievances received during monthly resident council meetings for 1 (#53) of 8 (#31, #46, #51, #52, #53, #58, #61, and #62) residents present for the resident council meeting.

Inspectors wroteBased on interviews and record review, the facility failed to ensure resident assessments accurately reflected the resident's status for 1 (#14) of 4 (#14, #22, #28, and #35) residents reviewed for falls.