8 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
1 fire-safety deficiencies
Top issue: Services (1 deficiency)
Zachary, LA
4-star overall rating with 4-star inspections with 8 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
6161 Main Street, Zachary, LA
(225) 654-6893
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Beds
110
Certified beds
Average residents
70
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Central Management Company
Operator or chain grouping
Approved since
1996-05-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
21 facilities
Chain averages 3 overall / 3 health / 3 staffing / 2 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
RN hours / resident day
0.33
Registered nurse staffing · state 0.32 · national 0.68
LPN hours / resident day
1.29
Licensed practical nurse staffing · state 1.18 · national 0.87
Aide hours / resident day
2.20
Nurse aide staffing · state 2.33 · national 2.35
Total nurse hours
3.82
All reported nurse hours · state 3.81 · national 3.89
Licensed hours
1.62
RN + LPN hours · state 1.49 · national 1.54
Weekend hours
3.26
Weekend nurse staffing · state 3.26 · national 3.43
Weekend RN hours
0.18
Weekend registered nurse coverage · state 0.22 · national 0.47
Physical therapist
0.07
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.36
CMS adjusted RN staffing hours
Adjusted total hours
4.13
CMS adjusted total nurse staffing hours
Case-mix index
1.27
Higher values indicate more complex resident acuity
RN turnover
44%
Annual RN turnover · state 44% · national 45%
Total nurse turnover
51%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Program rank
9,240
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
24.33
Composite VBP score used to determine payment impact.
Payment multiplier
0.9834
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
0
Baseline 19.28% · Performance 21.94% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
4.97
Baseline 7.30% · Performance 6.35% · Measure score 4.97 · Achievement 4.97 · Improvement 3.62
Total nurse turnover
2.67
Baseline 46.55% · Performance 52.78% · Measure score 2.67 · Achievement 2.67 · Improvement 0
Adjusted total nurse staffing
2.10
Baseline 3.16 hours · Performance 3.67 hours · Measure score 2.10 · Achievement 2.10 · Improvement 1.45
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.77% |
10.72%
About the same
|
No Different than the National Rate · Eligible stays 60 · Observed rate 11.67% · Lower 95% interval 7.51% |
| Discharge to community | 50.74% |
50.57%
0.2 pts better
|
No Different than the National Rate · Eligible stays 49 · Observed rate 40.82% · Lower 95% interval 34.22% |
| Medicare spending per beneficiary | 1.03 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 94.12% |
95.27%
1.1 pts worse
|
Numerator 32 · Denominator 34 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 34 |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | 2.94% |
2.29%
0.6 pts worse
|
Numerator 1 · Denominator 34 · Adjusted rate 3.51% |
| Healthcare-associated infections requiring hospitalization | 6.35% |
7.12%
0.8 pts better
|
No Different than the National Rate · Eligible stays 32 · Observed rate 3.13% · Lower 95% interval 3.25% |
| Staff COVID-19 vaccination coverage | 17.52% |
8.2%
9.3 pts better
|
Numerator 24 · Denominator 137 |
| Staff flu vaccination coverage | 21.17% |
42%
20.8 pts worse
|
Numerator 29 · Denominator 137 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | 95.24% |
95.95%
0.7 pts worse
|
Numerator 20 · Denominator 21 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.9 |
2.6
0.7 pts better
|
1.9
About the same
|
Long Stay · 20240701-20250630 · Adjusted 1.9 · Observed 1.6 · Expected 1.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.8 |
2.8
1 pts better
|
1.8
About the same
|
Long Stay · 20240701-20250630 · Adjusted 1.8 · Observed 1.5 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
92.0%
8 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
94.9%
5.1 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.9% |
3.4%
0.5 pts better
|
3.3%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.5% · Q2 3.5% · Q3 1.6% · Q4 1.6% · 4Q avg 2.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
1.8%
1.8 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 5.2% |
5.2%
About the same
|
5.4%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 5.8% · Q3 5.4% · Q4 7.4% · 4Q avg 5.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 23.6% |
23.1%
0.5 pts worse
|
19.6%
4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.5% · Q2 25.0% · Q3 25.9% · Q4 20.0% · 4Q avg 23.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 5.6% |
24.4%
18.8 pts better
|
16.7%
11.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.3% · Q2 7.5% · Q3 0.0% · Q4 9.5% · 4Q avg 5.6% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.2%
0.2 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 24.1% |
22.2%
1.9 pts worse
|
16.3%
7.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 24.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 15.5% |
20.1%
4.6 pts better
|
14.9%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 14.0% · Q2 14.3% · Q3 17.0% · Q4 16.7% · 4Q avg 15.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.8% |
1.6%
0.2 pts worse
|
1.0%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 4.4% · Q4 2.3% · 4Q avg 1.8% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.1% |
2.6%
0.5 pts better
|
1.7%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 0.0% · Q3 3.2% · Q4 3.3% · 4Q avg 2.1% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 21.2% |
16.9%
4.3 pts worse
|
19.8%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.0% · Q2 28.6% · Q3 11.1% · Q4 18.0% · 4Q avg 21.2% |
| Percentage of long-stay residents with pressure ulcers | 3.8% |
6.2%
2.4 pts better
|
5.1%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 5.4% · Q3 4.4% · Q4 3.6% · 4Q avg 3.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.1% |
83.6%
15.5 pts better
|
81.7%
17.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 98.9% · Q3 98.5% · Q4 98.8% · 4Q avg 99.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 18.4% |
14.7%
3.7 pts worse
|
12.0%
6.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 18.4% · Observed 21.4% · Expected 13.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.8% |
3.3%
1.5 pts better
|
1.6%
0.2 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 3.3% · Q3 2.1% · Q4 0.0% · 4Q avg 1.8% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 75.3% |
76.2%
0.9 pts worse
|
79.7%
4.4 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 75.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 28.4% |
27.8%
0.6 pts worse
|
23.9%
4.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 28.4% · Observed 35.7% · Expected 30.0% · Used in QM five-star |
Survey summary
Top issue: Resident Assessment and Care Planning (3 deficiencies)
1 fire-safety deficiencies
Top issue: Services (1 deficiency)
Top issue: Quality of Life and Care (2 deficiencies)
2 fire-safety deficiencies
Top issue: Services (1 deficiency)
No concentrated health issue counts in this cycle.
1 fire-safety deficiencies
Top issue: Services (1 deficiency)
Fire safety
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Not marked corrected
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-03-05
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-03-26
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Not marked corrected
Inspection history
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2025-05-16
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-05-16
Health
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Corrected 2025-02-07
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-02-07
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2025-02-07
Health
Provide or obtain dental services for each resident.
Corrected 2025-02-07
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-02-07
Health
Provide and implement an infection prevention and control program.
Corrected 2025-02-07
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-08-30
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-08-30
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-04-01
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-04-01
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2024-04-01
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-04-01
Penalties and ownership
5% Or Greater Indirect Ownership Interest · Individual
5% Or Greater Direct Ownership Interest · Organization
5% Or Greater Direct Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Individual
5% Or Greater Indirect Ownership Interest · Individual
Operational/Managerial Control · Organization
Operational/Managerial Control · Individual
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