St. Helena Parish Nursing Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Greensburg, Louisiana.
- Location
- 32 North 2nd Street, Greensburg, Louisiana 70441
- CMS Provider Number
- 195610
- Inspections on file
- 21
- Latest survey
- February 19, 2026
- Citations (last 12 mo.)
- 9 (1 serious)
Citation history
Health deficiencies cited at St. Helena Parish Nursing Home during CMS and state inspections, most recent first.
Two residents with documented major depressive disorder and significant psychiatric events, including PEC placement and inpatient psychiatric hospitalization, did not have accurate or updated PASRR Level I forms or required Level II evaluations. One resident’s PASRR lacked any mental health diagnoses despite charted major depressive disorder, psychotropic medications, and IOP services, and the PASRR approval date was more than 30 days before admission and not renewed after a discharge longer than 30 days. Another resident’s PASRR also omitted a major depressive disorder diagnosis and was not resubmitted after a new psychiatric diagnosis or after an inpatient psychiatric stay for escalating behaviors. The SW, MDS staff, DON, and administrator reported there was no process to review or resubmit PASRRs after new mental illness diagnoses, significant changes, or psychiatric admissions, and several staff were unaware of the requirement to do so.
A resident was transferred to a hospital emergency room and returned, but the required transfer notice was not sent to the State LTC Ombudsman due to missing documentation in both the Emergency Transfer Log and Census Change Sheet. Staff interviews revealed that the responsible LPN was unaware of the requirement to document the transfer, resulting in the omission.
A resident was discharged to a hospital without the required discharge MDS assessment being opened, completed, or transmitted. Both an MDS nurse and the ADON confirmed that the assessment was not done as required.
A deficiency was cited when a resident was not protected from various forms of abuse and neglect, as the facility failed to ensure adequate safeguards against physical, mental, sexual abuse, physical punishment, and neglect by any individual.
Staff did not promptly inform a resident, the resident's doctor, and a family member about events such as injury, decline, or room changes that affected the resident, as required by regulation.
A resident with Bipolar Disorder and Depression was admitted under a PASRR Level II approval that required specific follow-up actions, including psychiatric evaluation, dementia testing, and community-based mental health services. Review of the clinical record and staff interview confirmed that none of these PASRR Level II recommendations were implemented after the determination notice.
A deficiency was cited when a resident's care plan did not include all necessary interventions, lacked measurable timetables, and failed to specify actions to address the resident's needs. Review of documentation showed incomplete planning for the resident's care.
The facility did not provide or document required QAPI training for multiple staff members, including LPNs and CNAs, as confirmed by personnel file reviews and administrator interview.
The facility did not complete the care plan within 7 days of the comprehensive assessment, and the plan was not prepared, reviewed, and revised by a team of health professionals as required.
Two residents suffered physical harm due to abuse—one was punched in the face by a CNA, resulting in a facial laceration and contusion, while another was struck on the head with a hand grabber by a fellow resident, causing a scalp laceration. Both incidents were witnessed or reported by staff, and both residents required emergency medical treatment for their injuries.
A resident with moderate cognitive impairment was struck on the forehead by another resident using a hand grabber, resulting in a laceration and transfer to the ED. The DON witnessed the incident, but the required report of alleged abuse was not submitted to the state survey agency as per facility policy, due to the Administrator being on medical leave.
A resident with a history of traumatic brain injury and chronic pain was found with a facial laceration and contusion. An LPN observed the injury but did not document the change in condition or notify the oncoming nurse, physician, or family, as required by policy. The oncoming nurse later discovered the injuries and arranged for emergency care.
The facility did not update its facility-wide assessment annually and failed to include necessary details about staffing levels for emergencies, weekends, and specific shifts. The DON confirmed these omissions, which had the potential to affect all residents.
Two residents who transferred hospice services did not have a Significant Change MDS Assessment completed within the required timeframe. Both residents, one with multiple myeloma and another with dysphagia post-cerebral infarction, changed hospice providers, but the facility did not submit the necessary MDS assessments as confirmed by hospice nurses and the DON.
Three residents with significant mental health diagnoses and current Level II PASRR determinations were inaccurately coded on their MDS assessments, with Section A1500 marked as 'No' for PASRR. The DON confirmed the discrepancy between the residents' care plans, clinical records, and the MDS documentation.
A resident with a stage 4 pressure ulcer received wound care from an LPN who, after cleaning the wound, failed to remove soiled gloves and perform hand hygiene before applying new dressings. The LPN acknowledged the lapse, and the DON confirmed that proper protocol requires glove change and hand hygiene between wound cleaning and redressing.
The facility did not make the most recent recertification survey results available for residents to review, as required by policy. During an observation, the Survey Results folder near the nurses' station was found to contain only outdated survey results, and the DON confirmed the absence of the latest survey documentation. This affected all current residents.
Nurse staffing data was not posted in a prominent location as required by facility policy. During a survey, no staffing data sheets were observed, and the DON confirmed the information had not been posted. This failure had the potential to affect all residents in the facility.
Failure to Resubmit and Update PASRR for Residents With Mental Illness and Psychiatric Hospitalizations
Penalty
Summary
The deficiency involves the facility’s failure to ensure required Preadmission Screening and Resident Review (PASRR) Level II evaluations and resubmissions for residents with identified or newly diagnosed mental illness, and for residents experiencing significant changes such as psychiatric hospitalization. For one resident, the clinical record showed admission with diagnoses including traumatic subdural hemorrhage, anxiety disorder, irritability and anger, and major depressive disorder. The resident’s PASRR Level I form, dated prior to admission, did not list any mental health diagnoses, despite the medical record and MAR documenting treatment with Seroquel and Sertraline for major depressive disorder, with the diagnosis onset and medication start dates clearly recorded. The DON confirmed that the admitting diagnoses included major depressive disorder, and care plan and IOP assessments documented depression, anxiety, hallucinations, delusions, withdrawal, and mood swings. Further review showed that this same resident’s PASRR Level I (142 form) approval date was more than 30 days before the actual admission date, and the resident had been discharged from the facility for more than 30 days before returning, which staff acknowledged should have triggered a new PASRR. Interviews with the social worker, MDS staff, and DON confirmed that no new PASRR was completed upon the resident’s return, despite the extended absence and subsequent significant changes, including a PEC (Physician’s Emergency Certificate) event and increased psychotropic medications. The DON and administrator also verified that they were not aware that a Resident Review form and PASRR review were required after such significant changes or the addition of IOP services. For another resident, the clinical record showed admission without psychiatric diagnoses initially, but later documentation reflected a diagnosis of major depressive disorder. The resident’s original Level I PASRR, completed by a local hospital, did not list any mental illness in the mental illness section. The social worker confirmed that there was no process to identify residents with new mental illness diagnoses who required a resubmitted Level I PASRR for possible Level II evaluation and stated she was unaware that resubmission was required after a new psychiatric diagnosis. This resident also had an unplanned discharge to an inpatient psychiatric facility under a PEC for escalating agitation and threatening behaviors, with documentation of severe major depressive disorder and increased Abilify for uncontrolled symptoms. Despite this inpatient psychiatric admission and diagnosis, there was no evidence of any subsequent Level I PASRR resubmission, and both the social worker and DON confirmed that the PASRR had not been updated and that there was no process in place to review PASRRs for accuracy when such events occurred.
Failure to Notify Ombudsman of Resident Hospital Transfer
Penalty
Summary
The facility failed to send a copy of the transfer notice to a representative of the Office of the State Long-Term Care Ombudsman for one of four residents reviewed for admission, transfer, and discharge requirements. Specifically, a resident was admitted to the facility and later transferred to a local hospital emergency room, then returned to the facility. There was no documentation of this transfer in the facility's Ombudsman Emergency Transfer Log or the Census Change Sheet for the relevant month. Interviews with facility staff revealed that the staff member responsible for updating the Emergency Transfer Log did not receive notification of the transfer because the assigned nurse did not complete the Census Change Sheet at the time of the resident's transfer. The assigned nurse confirmed she did not fill out the required documentation and was unaware of the requirement to do so. Facility leadership confirmed that the transfer was not documented as required and that the process for ensuring accurate notification to the Ombudsman was not followed.
Failure to Complete and Transmit Discharge MDS Assessment
Penalty
Summary
The facility failed to ensure that a discharge Minimum Data Set (MDS) assessment was completed and transmitted for one of five residents reviewed for resident assessment. Specifically, a resident was admitted to the facility and later discharged to a local hospital, but a review of the clinical record showed that no discharge MDS assessment was opened, completed, or transmitted as required. During interviews, an MDS nurse and the Assistant Director of Nursing both confirmed that the resident had been discharged and that the necessary discharge assessment had not been initiated or submitted, despite facility policy and regulatory requirements.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report documents that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's protective measures and oversight.
Failure to Immediately Notify Resident, Physician, and Family of Significant Events
Penalty
Summary
Facility staff failed to immediately notify the resident, the resident's physician, and a family member about situations that affected the resident, such as injury, decline, or changes in room assignment. This lack of timely communication was observed and documented by surveyors during the review of facility practices and records. The deficiency centers on the facility's failure to ensure that all required parties were promptly informed when significant events impacting the resident occurred, as mandated by regulations.
Failure to Implement PASRR Level II Recommendations for Resident with Mental Health Diagnoses
Penalty
Summary
The facility failed to coordinate assessments with the Pre-admission Screening and Resident Review (PASRR) Level II program by not incorporating the Level II determinations and recommendations into a resident's transitions of care. Specifically, a resident admitted with diagnoses of Bipolar Disorder and Depression was approved for a temporary nursing facility placement, contingent upon several PASRR Level II recommendations, including a psychiatric evaluation for assessment and medication management, referral for dementia testing by a neurologist or neuropsychologist, and community-based mental health services. Review of the clinical record showed that the last psychiatric evaluation occurred prior to the PASRR Level II determination, and none of the required recommendations had been completed since the determination notice was issued. The Director of Nursing confirmed during interview that these recommendations were not implemented as required.
Incomplete Care Plan Lacking Measurable Actions
Penalty
Summary
A deficiency was identified due to the facility's failure to develop and implement a complete care plan that addresses all of a resident's needs. The care plan lacked measurable timetables and specific actions, resulting in incomplete documentation and planning for the resident's care requirements. This deficiency was observed through review of the resident's records and care plans, which did not contain comprehensive or measurable interventions to meet the resident's identified needs.
Failure to Provide QAPI Training to Staff
Penalty
Summary
The facility failed to provide mandatory Quality Assurance and Performance Improvement (QAPI) training to all staff as required. Record reviews of five staff members' personnel files, including LPNs and CNAs, revealed no documented evidence that any of them had received QAPI training, regardless of their hire dates. During an interview, the administrator confirmed that there was no documentation indicating completion of QAPI training for any staff member. This lack of documentation and training was consistent across all reviewed personnel files.
Failure to Timely Develop and Review Care Plan
Penalty
Summary
The facility failed to develop the complete care plan within 7 days of the comprehensive assessment. The care plan was not prepared, reviewed, and revised by a team of health professionals as required. This deficiency was identified based on the review of facility records and documentation, which showed that the care planning process did not meet the specified timeline and team involvement requirements.
Failure to Protect Residents from Physical Abuse Resulting in Harm
Penalty
Summary
The facility failed to protect residents from physical abuse, resulting in two separate incidents involving harm to residents. In the first incident, a cognitively intact resident who was totally dependent on staff for all activities of daily living, including transfers and personal care, was physically assaulted by a CNA. The resident reported being punched twice in the face by the CNA after a verbal exchange regarding a snack. The resident sustained a 2.5 cm laceration to the left face, requiring four stitches, and a contusion to the left orbital area. The injury was discovered by morning staff, and the resident continued to experience significant pain when eating and drinking following the incident. Facility video surveillance confirmed the CNA's presence in the resident's room multiple times during the relevant time frame, and interviews with staff and the resident corroborated the account of physical abuse. In the second incident, a moderately cognitively impaired resident was injured by another resident with severe cognitive impairment. The event occurred in the facility's smoking area, where the aggressor struck the victim on the forehead with a hand grabber following a dispute over cigarette butts. The injured resident sustained a 1.5 cm laceration to the left scalp, which required staples. The incident was witnessed by the DON, who immediately separated the residents and observed blood oozing from the victim's forehead. The aggressor was subsequently sent for behavioral evaluation, and the injured resident was sent to the emergency room for treatment. Both incidents demonstrate a failure by the facility to ensure residents' right to be free from physical abuse, as required by policy and regulation. The first incident involved staff-to-resident abuse resulting in actual physical harm, while the second involved resident-to-resident abuse with injury. In both cases, the residents required emergency medical attention for their injuries, and the facility's policies for abuse recognition and reporting were referenced in the investigation.
Failure to Timely Report Alleged Physical Abuse to State Agency
Penalty
Summary
The facility failed to ensure that an allegation of physical abuse involving a resident was reported to the State Survey Agency within the required timeframe. According to the facility's policy, all suspected abuse must be reported immediately, but not later than two hours after the allegation is made. Documentation showed that a resident, who was moderately cognitively intact with a BIMS score of 9, was struck on the forehead by another resident using a hand grabber while on the smoker's patio. This incident resulted in a laceration that required the resident to be transferred to the emergency department for treatment. Despite the incident being witnessed by the DON, and the facility's policy requiring immediate reporting, there was no evidence that the alleged abuse was reported to the State Survey Agency. The DON confirmed during an interview that the incident was not reported as required, and that the responsibility for reporting lay with the Administrator, who was on medical leave at the time. No self-reported incident was filed for the resident involved.
Failure to Document and Report Change in Resident Condition
Penalty
Summary
The facility failed to ensure that nursing staff documented a resident's change in condition according to professional standards and facility policy. Specifically, a resident with a history of traumatic subdural hemorrhage and chronic pain was found with a laceration to the lip and a contusion to the left orbital area. The incident occurred early in the morning, and the resident reported to the nurse that he had bitten his lip. The nurse observed the injury but did not document the change in the resident's condition in the medical record, nor did she notify the oncoming nurse, the physician, or the resident's family as required by facility policy. Subsequently, the oncoming nurse was alerted to the resident's injuries by a CNA and, upon assessment, found a bleeding cut and a black eye, prompting immediate notification of the DON, physician, and family, and transfer of the resident to the emergency department. Review of the emergency department documentation confirmed the presence of a facial laceration requiring sutures and a contusion. Interviews with facility staff and review of records confirmed that the initial nurse did not follow the required procedures for documenting and reporting the change in the resident's condition.
Failure to Update Facility Assessment and Include Required Staffing Information
Penalty
Summary
The facility failed to update its facility-wide assessment at least annually and did not include required information regarding staffing levels needed for emergencies, weekends, or specific shifts such as day, evening, and night. Record review showed that the assessment was outdated and lacked details on necessary staffing for various operational periods. During an interview, the Director of Nursing confirmed that the assessment had not been updated annually and did not address staffing needs for weekends or different shifts. This deficiency had the potential to affect all 56 residents residing in the facility. No information was provided regarding the medical history or condition of individual residents at the time of the deficiency.
Failure to Complete Significant Change MDS Assessment After Hospice Transfer
Penalty
Summary
The facility failed to complete a Significant Change Minimum Data Set (MDS) Assessment within 14 days for two residents who transferred hospice services. One resident, admitted with multiple myeloma, transferred to a new hospice company on 03/18/2025, but no significant change MDS assessment was submitted at that time. Another resident, admitted with dysphagia following cerebral infarction, also transferred hospice companies on the same date, and similarly, no significant change MDS assessment was completed. Interviews with hospice nurses confirmed the transfer of hospice care for both residents, and the Director of Nursing acknowledged that the required assessments were not completed as mandated.
Inaccurate MDS Coding for PASRR Status
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments accurately reflected the PASRR (Preadmission Screening and Resident Review) status for three residents. Record reviews showed that each of these residents had diagnoses such as Bipolar Disorder, Depression, Dementia, Schizophrenia, Paranoid Schizophrenia, and Major Depressive Disorder, and all had current Level II PASRR determinations. Despite this, their annual MDS assessments incorrectly coded Section A1500 (PASRR) as 'No,' indicating that they did not have a Level II PASRR, when in fact they did. Interviews with the Director of Nursing (DON) confirmed that the facility was unable to locate the PASRR form for one resident, but acknowledged that all three residents should have been coded as having a Level II PASRR on their MDS assessments. The care plans for these residents also documented the presence of a Level II PASRR, further highlighting the inconsistency between the clinical records and the MDS documentation.
Failure to Follow Proper Infection Control During Wound Care
Penalty
Summary
The facility failed to implement and maintain an effective infection prevention and control program during wound care for one resident with a stage 4 pressure ulcer on the left hip. During an observed wound care procedure, an LPN cleaned the resident's wound while wearing gloves, but then, without removing the soiled gloves or performing hand hygiene, proceeded to apply silver alginate and cover the wound with a border foam dressing. The LPN only removed the soiled gloves and performed hand hygiene after completing the dressing. In interviews, the LPN acknowledged that gloves were soiled after cleaning the wound and confirmed that proper protocol would have been to remove gloves and perform hand hygiene before redressing the wound. The Director of Nursing also confirmed that staff are expected to change gloves and perform hand hygiene after cleaning a wound and before applying new dressings.
Failure to Post Most Recent Survey Results for Resident Access
Penalty
Summary
The facility failed to ensure that the results from the most recent recertification survey were readily available for residents to review. According to the facility's policy, the most recent survey should be posted in a location easily accessible to residents. However, during an observation near the nurses' station, the Survey Results folder was found to contain only survey results dated from the previous year, with no documentation of the most recent recertification survey. This was confirmed by the Director of Nursing, who acknowledged that the latest survey results were not present in the folder. This deficiency had the potential to affect all 56 residents currently residing in the facility.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that nurse staffing data was posted daily in a prominent location accessible to residents and visitors, as required by facility policy. During a tour and observation conducted at 9:30 a.m., no staffing data sheets were observed to be posted. An interview with the Director of Nursing (DON) confirmed that she was responsible for posting the staffing data and acknowledged that the information was not posted on the day of the survey. The facility's policy specifies that staffing information, including the facility name, current date, total number and actual hours worked, and resident census, should be posted at the beginning of each shift. This deficiency had the potential to affect all 56 residents in the facility.
Latest citations in Louisiana
The facility failed to maintain an effective pest control program when multiple live roaches, roach feces, and dead roach carcasses were observed in a room shared by two residents, including on and under a personal refrigerator and beneath items placed on top of it. Housekeeping, maintenance, and a CNA each reported seeing roaches in the room on the prior day, and subsequent observations by maintenance and the administrator confirmed ongoing roach activity in the same area.
A resident with end stage renal disease, bone density disorder, chronic pain, and osteoarthritis was care planned and assessed as totally dependent for chair/bed transfers, requiring a mechanical lift with two-person assist. On one occasion after dialysis, an LPN and a CNA brought a mechanical lift into the room but, after the resident reportedly expressed not wanting to use it, the CNA manually transferred the resident from wheelchair to bed by lifting under the resident’s arms while the resident held the CNA’s waist. During this non–care-planned manual transfer, a popping sound was heard from both shoulders and the resident complained of arm pain; subsequent x‑rays and hospital evaluation confirmed acute fractures of the left clavicle and right humerus. The facility’s investigation, including review of camera footage and staff interviews, established that the mechanical lift was not used as required by the resident’s care plan, and that the injury occurred during this improper manual transfer rather than during a clothing change as initially reported.
A staff member in Social Services routinely emailed detailed resident information, including face sheets and a full census listing names, dates of birth, payer sources, room numbers, diagnoses, allergies, and advance directive details, to a contracted outside provider so the provider could identify which residents were not receiving their services and then approach them. These disclosures involved all residents in the facility and were made without obtaining or documenting any resident or responsible party consent, despite a facility policy requiring protection and confidential handling of medical, financial, and social records.
A resident with an order for Glucerna 1.2 at a specified rate and duration was instead observed receiving Isosource at 60 ml/hour. Record review confirmed the physician’s order for Glucerna 1.2, while observation and interview with an LPN verified that Isosource, a different enteral formula, was being administered. The DON later stated that the LPN should have verified the physician’s order before administering the tube feeding.
Surveyors found that the facility failed to keep its medication error rate below 5%, identifying a 29% error rate during one observed medication pass. A resident had multiple medications ordered for 9:00 AM, including aspirin, calcium carbonate, vitamin C, carvedilol, furosemide, potassium chloride ER, thiamin, timolol ophthalmic drops, and docusate sodium. An LPN administered all of these medications at 11:24 AM, outside the facility’s policy window of one hour before to one hour after the scheduled time, and did so without a physician order to change the administration times. The DON confirmed that this timing did not comply with the facility’s medication administration policy.
A resident was readmitted from the hospital with handwritten physician orders for multiple medications, including acetaminophen, Eliquis, buspirone, losartan, mirtazapine, quetiapine, senna, and Vistaril, to be given on specific schedules and as needed. Review of the eMAR showed that none of these medications were administered for an extended period after readmission. In interviews, the DON stated that nurses are responsible for clarifying orders upon a resident’s return from the hospital, and an LPN acknowledged that the medications should have been restarted and administered as ordered but were not.
A resident with physician orders for Glucerna 1.2 via enteral feeding at a specified rate and duration did not have the administration of this feeding documented in the eMAR on two days, even though surveyors directly observed the feeding being administered at the ordered rate on both days. The DON acknowledged that nursing staff should have recorded the enteral feeding administration in the medication administration record, but this documentation was missing, resulting in incomplete medical records.
A treatment nurse performed wound care on a resident with a diabetic toe wound without following the facility’s hand hygiene policy. The facility’s policy required staff to wash hands after removing gloves and clarified that gloves do not replace handwashing. During the observed dressing change, the nurse removed the old dressing and gloves, did not perform hand hygiene, donned new gloves, cleansed the wound, then again removed gloves and applied new ones without hand hygiene before applying calcium alginate and a dry dressing. The nurse later stated she had not cleaned her hands between glove changes because there was no hand sanitizer available in the room and she did not wash her hands instead, and the DON confirmed that hand hygiene should have been performed between each glove change.
Surveyors found that a CNA’s personnel file lacked documentation of the required 12 hours of annual in-service education, including dementia care and abuse prevention. The CNA had been employed for over a year, and facility leadership confirmed there was no evidence that the mandated annual training had been completed.
A resident sustained burns after spilling hot coffee from a lidded Styrofoam cup while using an over-bed table. The incident review and interviews showed kitchen staff did not check coffee temperatures before sending it to the floor, and an observed canister of coffee measured 158.1 degrees F. The facility policy stated hot liquids should be monitored to prevent scalding.
Failure to Maintain Effective Pest Control in Resident Room
Penalty
Summary
The facility failed to maintain an effective pest control program to ensure the environment was free of pests and insects, affecting a room shared by Resident #1 and Resident #3 and having the potential to affect 89 residents in the facility. On 04/30/2026 at 8:30 a.m., during an observation with the housekeeping staff member (S3Housekeeping) in this room, a live roach was seen crawling on the wall, on top of Resident #1’s personal refrigerator, and underneath the desk-style phone on top of the refrigerator. S3Housekeeping stated she had seen one roach in the same room the previous day. Around 8:40 a.m., the maintenance staff member (S2Maintenance) reported that a CNA (S4Certified Nurse Aide) had informed him the previous afternoon about a roach on the wall in that room. At 8:45 a.m., further observation of the same room with S2Maintenance revealed roach feces and dead roach carcasses on top of Resident #1’s refrigerator, and when S2Maintenance lifted the phone and a book from the top of the refrigerator, live roaches ran out from underneath. At 8:53 a.m., the CNA (S4Certified Nurse Aide) confirmed she had noticed a roach in the room the day before. Later, at 12:45 a.m., the administrator (S1Administrator) reported that when he accompanied maintenance to the room and the refrigerator was lifted, a couple of live roaches ran out from underneath it. In a subsequent interview at 4:30 p.m., S1Administrator confirmed there were live roaches in the room of Resident #1 and Resident #3 and acknowledged they should not have been present.
Failure to Follow Care-Planned Mechanical Lift Transfer Resulting in Fractures
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received adequate assistance during transfers by not following the resident’s care plan, which required use of a mechanical lift with two-person assistance. The resident had been admitted with diagnoses including end stage renal disease with dependency on renal dialysis, other specified disorders of bone density and structure, chronic pain, and osteoarthritis. The resident’s annual and quarterly MDS assessments documented intact cognition with a BIMS score of 15 and indicated the resident was totally dependent for chair/bed transfers. The care plan, initiated at admission, specified that transfers were to be performed using a mechanical lift with two staff assisting. On the date of the incident, the resident had returned from dialysis and required assistance transferring from a wheelchair to a bed. According to interviews, a CNA and an LPN were involved in the transfer. The LPN reported that a mechanical lift was rolled into the resident’s room, but the CNA stated the resident did not want to use the lift. Despite knowing that the resident was care planned for mechanical lift use, the CNA proceeded to transfer the resident manually by placing her arms under the resident’s arms while the resident wrapped her arms around the CNA’s waist. During this manual transfer from wheelchair to bed, a popping sound was heard from the resident’s shoulders and the resident immediately complained of pain in both arms. Progress notes from that day documented that staff heard an audible pop from both shoulders while assisting the resident and that the resident complained of pain. The physician was notified, x-rays of both upper extremities were ordered, and the resident was transferred to a local emergency room at the family’s request. Facility x-rays and hospital records confirmed acute fractures of the left clavicle and right humerus, described in the hospital record as an acute mildly displaced left distal clavicular fracture and an acute mildly displaced fracture of the right proximal humeral diaphysis. The facility’s incident report later documented that the LPN and CNA did not utilize a mechanical lift during the transfer from wheelchair to bed, and the administrator confirmed through interviews and review of camera footage that the transfer had been performed without the mechanical lift, contrary to the resident’s assessed needs and care plan. Initially, the resident, the LPN, and the CNA all reported that the injury occurred while staff were assisting the resident with a change of clothing. The hospital record also reflected the resident’s report that the injury occurred while staff were assisting her with changing clothes while she was in the mechanical lift. However, during the facility’s subsequent investigation, the administrator reviewed camera footage showing the mechanical lift being brought into and then removed from the room within a short period of time, and questioned whether that time frame was sufficient to complete a lift transfer. Both the LPN and CNA acknowledged that it was not enough time and ultimately admitted that the lift had not been used and that the injury occurred during a manual transfer from wheelchair to bed, not during clothing change. This sequence of actions and inactions—specifically, the decision to disregard the care-planned mechanical lift transfer and instead perform a manual transfer—led directly to the resident’s bilateral upper extremity fractures and constituted the cited deficiency.
Unauthorized Disclosure of Resident Medical Information to Outside Provider
Penalty
Summary
The facility failed to maintain residents' right to confidentiality of their medical records when a staff member in Social Services transmitted resident information to a contracted outside provider without obtaining consent. Review of the facility’s Resident Rights and Dignity policy, revised 03/07/2011, showed the facility was to safeguard all resident records and handle release of information in a manner that protected resident rights. Contrary to this policy, review of an email dated 10/15/2025 from the Social Services staff member to a contracted provider showed that face sheets for multiple residents were attached. These face sheets contained residents’ names, dates of birth, Social Security numbers, admit dates, Medicare/Medicaid numbers, drug allergies, care providers, pharmacy names, emergency contacts, diagnoses, and advance directive information. Further review of another email dated 03/20/2026 from the same Social Services staff member to the contracted provider showed that a facility census for a specific date was sent, which included information on all 80 residents in the facility. The census listed each resident’s room number, name, date of birth, status in the facility, primary payer source, and room rate designation. In interviews, the Social Services staff member stated that every month to every quarter she sent a daily census to the contracted provider so they could identify residents not receiving their services and then approach those residents about services. When surveyors requested evidence of resident consent for release of medical records to this provider, the Social Services staff member and the Chief Operating Officer both confirmed that the facility had no documentation of consent obtained prior to releasing the residents’ information, and acknowledged that the information had been sent on at least two occasions.
Incorrect Enteral Feeding Formula Administered Contrary to Physician Order
Penalty
Summary
The facility failed to ensure a resident received the correct enteral feeding formula as ordered by the physician. Review of the resident’s April 2026 physician orders showed an order for Glucerna 1.2 to be administered at 50 ml/hour for 12 hours per day, with an increase to 60 ml/hour for 21 hours per day if tolerated. During observation on 04/21/2026 at 1:20 PM, the resident was noted to be receiving Isosource at a rate of 60 ml/hour instead of the ordered Glucerna 1.2. In a subsequent interview and observation at 1:31 PM, an LPN confirmed that Isosource was being administered at 60 ml/hour and acknowledged that this was the wrong enteral feeding type compared to the physician’s order for Glucerna 1.2. Later, the DON stated that the LPN should have verified the physician’s order for the resident’s enteral feeding prior to administration. This deficiency centers on the administration of an incorrect enteral feeding product despite a clear physician order specifying a different formula and rate, as confirmed through record review, direct observation of the feeding in progress, and staff interviews.
Medication Error Rate Exceeded Due to Late Administration of Scheduled Medications
Penalty
Summary
The deficiency involves the facility’s failure to maintain a medication error rate below 5 percent, as required, resulting in a calculated error rate of 29 percent during a medication pass for one resident. Facility policy stated that medications were to be administered within one hour of their prescribed time unless otherwise specified. Review of the resident’s April 2026 physician orders and eMAR showed multiple medications scheduled for 9:00 AM, including aspirin EC 81 mg daily, calcium carbonate 600 mg twice daily, ascorbic acid 500 mg daily, carvedilol 25 mg twice daily, furosemide 20 mg daily, potassium chloride ER 20 mEq daily, thiamin HCl 100 mg daily, timolol maleate ophthalmic 0.5% one drop to both eyes daily, and docusate sodium 100 mg daily. On the observed medication pass, the LPN administered all of these medications at 11:24 AM, outside the facility’s accepted administration window of one hour before to one hour after the scheduled 9:00 AM time. The LPN acknowledged that the medications were scheduled for 9:00 AM and should have been given between 8:00 AM and 10:00 AM. The DON confirmed that medications were to be administered within that one-hour-before to one-hour-after window and that the LPN should not have administered the medications at 11:24 AM without a physician order to change the medication times. Based on 31 opportunities for error and 9 errors identified, surveyors calculated a medication error rate of 29 percent.
Failure to Restart and Administer Physician-Ordered Medications After Hospital Readmission
Penalty
Summary
The facility failed to ensure a resident was free from significant medication errors when nursing staff did not administer multiple physician-ordered medications following the resident’s readmission from the hospital. The resident was readmitted on 03/09/2026, and the handwritten physician order sheet dated that day directed that the resident receive acetaminophen 500 mg, 2 tablets every 6 hours as needed; Eliquis 2.5 mg, 1 tablet twice daily; buspirone 5 mg, 1 tablet three times daily; losartan 25 mg, 2 tablets daily; mirtazapine 7.5 mg, 1 tablet nightly; quetiapine 25 mg, 2 tablets nightly; senna 8.6 mg, 1 tablet twice daily; and Vistaril every 8 hours as needed. Review of the March 2026 eMAR showed no evidence that any of these ordered medications were administered between 03/09/2026 and 03/19/2026. In interviews, the DON stated that nurses were responsible for clarifying orders with the physician when a resident returned from the hospital, and a clinical support LPN confirmed that the resident’s medications should have been restarted and administered per the written orders on 03/09/2026 but were not.
Failure to Document Enteral Feeding Administration in eMAR
Penalty
Summary
The facility failed to ensure nursing staff documented the administration of ordered enteral feeding in accordance with professional standards for one resident receiving tube feedings. The resident had physician orders in April 2026 for Glucerna 1.2 at 50 ml/hour for 12 hours daily, with instructions to increase to 60 ml/hour for 21 hours daily if tolerated. Review of the resident’s April 2026 electronic medication administration record (eMAR) showed no documentation that Glucerna 1.2 was administered at 60 ml/hour for 21 hours on 04/21/2026 and 04/22/2026. However, surveyor observations on 04/21/2026 at 9:40 AM and on 04/22/2026 at 2:41 PM confirmed the resident was receiving Glucerna 1.2 at 60 ml/hour at those times. In an interview, the DON stated that when nurses administered the Glucerna 1.2, they should have documented the administration in the medication administration record. This lack of documentation of enteral feeding administration, despite direct observation of the feeding being provided, constituted the deficiency in maintaining medical records in accordance with accepted professional standards.
Failure to Perform Hand Hygiene Between Glove Changes During Wound Care
Penalty
Summary
Surveyors identified a deficiency in infection prevention and control when a treatment nurse failed to perform required hand hygiene during wound care for Resident #1. The facility’s “Using Gloves” policy, revised 03/10/2011, stated that employees were to wash hands after removing gloves and that gloves did not replace handwashing. Resident #1 had a physician’s order in April 2026 for treatment of a diabetic wound on the left second toe, including cleansing with normal saline or wound cleanser, patting dry, applying silver alginate to the wound bed, and covering with a clean dry dressing three times weekly and as needed. During an observation on 04/21/2026 at 10:43 AM, the treatment nurse removed the existing dressing, removed her gloves, did not perform hand hygiene, and then applied new gloves. She then cleaned the resident’s left second toe wound, again removed her gloves, did not perform hand hygiene, and applied new gloves before placing the calcium alginate and dry dressing. In an interview immediately afterward, the treatment nurse stated she had completed hand hygiene before and after the wound care but had not done so between glove changes because there was no hand sanitizer in the room and she did not wash her hands as an alternative. The DON later confirmed that the nurse should have performed hand hygiene between every glove change. This sequence of observations, interviews, and record review showed that the nurse’s actions during wound care did not follow the facility’s hand hygiene and glove-use policy, resulting in the cited infection control deficiency.
Failure to Provide Required Annual In-Service Training for CNA
Penalty
Summary
The facility failed to ensure that a Certified Nursing Assistant (CNA), identified as S12CNA, received at least 12 hours of in-service training annually as required. Review of S12CNA’s personnel file showed that this CNA was hired on 03/23/2025 and did not have documentation demonstrating completion of the required 12 hours of annual in-service education, including topics such as dementia care and abuse prevention. During an interview on 04/23/2026 at 4:23 PM, the Chief Operations Officer (S1) confirmed that the facility had no documented evidence that S12CNA had completed the mandated 12 hours of in-service training for the year.
Hot Coffee Served Without Temperature Monitoring
Penalty
Summary
The facility failed to have a system in place to ensure coffee was served at a safe temperature to prevent scalds and burns for one resident. The report states that 112 residents consumed meals and beverages prepared by the facility's kitchen. A review of the facility policy on hot liquids stated that residents with risk factors for injury from hot liquids should have precautions implemented, and that food service staff should monitor and maintain food temperatures that comply with food safety requirements but do not exceed recommended temperatures to prevent scalding. Resident #79 was involved in an incident on 02/24/2026 when the resident spilled coffee while in bed and sustained redness to the left arm and buttocks area. The incident report stated that the resident was trying to get coffee from the table when the cup fell, and that a non-spill cup would be given to the resident. During an interview, the resident stated she had burns on her left forearm and left hip after spilling hot coffee from a Styrofoam cup with a lid while placing it on the over-bed table. The dietary manager stated that staff did not check coffee temperatures before sending coffee to the floor, and a brewed canister of coffee was observed at 158.1 degrees F.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
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