Zachary Manor Nursing and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Zachary Manor Nursing and Rehabilitation Center, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF851Jan 8, 2025

  Based 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. Findings: Review of the PBJ (Payroll Based Journal) Staffing Data Report for Fiscal Year 2024 Quarter 4 (July 1- September 30) revealed the following: -One star staffing rating, triggered. -Excessively low weekend staffing, triggered. -No Registered Nurse hours, triggered. -Failed to have licensed nursing coverage 24 hours/day, triggered. An interview was conducted on 01/08/2025 at 10:40 a.m. with S10CHR. She stated she was responsible for submitting payroll data to a contract company who was hired to submit the facility's payroll data. […]

• No harm, potential for more than minimal, patternF641Feb 11, 2026

  Based 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. […]

• No harm, potential for more than minimal, patternF725Apr 8, 2025

  Based 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. Findings: Review of the facility's Minimum Staffing Requirements assessment revealed the following: Hall A Days: 1-2 CNA Evenings: 1 CNA Nights: 1 CNA Hall B Days: 2 CNA Evenings: 2 CNA Nights: 1 CNA Hall C Days: 2 CNA Evenings: 2 CNA Nights: 1 CNA Review of the facility's Staffing Pattern dated 03/04/2025 revealed the following: Staff assigned: Day shift - 7 CNA; Evening shift- 2-CNA; Night shift- 2 CNA On… […]

• No harm, potential for more than minimal, patternF641Jan 8, 2025

  Based 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. Findings: Resident #12 Review of Resident #12's Clinical Record revealed she was admitted to the facility on [DATE]. Review of Resident #12's OBH-Level II Evaluation Summary & Determination Notice dated 08/02/2024 revealed under recommendations: The individual has a serious mental illness and nursing home admission was recommended. […]

• No harm, potential for more than minimal, patternF695Feb 21, 2024

  Based 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. Findings: Resident #23 Review of the Clinical Record for Resident #23 revealed she was admitted to the facility on [DATE] and had diagnoses which included Shortness of Breath. Review of Resident #23's Quarterly MDS with an ARD of 11/08/2023 revealed she had a BIMS of 10, which indicated she had moderate cognitive impairment. […]