Below average — CMS composite of the measures below.
The next survey window likely opens around February 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 Mary Anna Nursing Home during CMS and state inspections, most recent first.
A resident with hemiplegia, multiple chronic conditions, and wheelchair dependence was transported by a CNA who failed to apply the van’s restraining lap belt, did not stop to reposition the resident after being told she was sliding, and left her unattended in the van while stopping at a personal residence. During this time, the resident slid from her wheelchair onto the floor of the van. The CNA returned, did not call the facility or seek assistance, and drove the resident back while she remained on the floor, without reporting when the fall occurred or how long the resident had been on the floor. The facility’s investigation, referencing existing abuse/neglect, fall management, and transportation safety policies and prior staff training, substantiated neglect and the situation was cited as Immediate Jeopardy.
A wheelchair-dependent, cognitively intact resident with multiple comorbidities, including hemiplegia, CHF, DM with neuropathy, chronic pain, cervical spinal stenosis, and COPD, was transported in the facility van by a CNA who had been trained on transportation safety policies requiring use of restraints and seat belts. The CNA did not apply the van’s restraining lap belt and did not reposition the resident after the resident reported sliding down in the wheelchair. The CNA then stopped at her personal residence, left the resident unattended in the van, and during this time the resident slid from the wheelchair onto the van floor. On returning to the van, the CNA found the resident on the floor but did not call the facility for assistance and drove back with the resident still on the floor, where staff later assessed and lifted the resident from the van floor. Surveyors determined this constituted an Immediate Jeopardy situation.
Failure to Implement Fall Care Plan Intervention: A resident with dementia, severe cognitive impairment, and high fall risk had a fall care plan intervention to keep a reacher within reach, but staff did not identify it as an intervention and the device was not observed with the resident. The resident stated she did not have the reacher, and the DON confirmed there was no documentation supporting that it was in place per the care plan.
A resident with cancer, dysphagia, and DM with CKD had a significant 7.11% weight loss after hospitalization, but the facility did not follow its weight loss management policy. Staff did not document timely notification of the RD, MD, or RP, did not hold the required IDT review, did not document weekly weights or monthly follow-up, and no new nutrition interventions were in place when the resident later was recommended sugar free health shakes that were not provided with meals.
Two residents received Voltaren 1% gel without the dosage ordered by the physician, including one resident with severe cognitive impairment and another with moderate cognitive impairment. In addition, staff did not document notifying the physician of a resident’s edema and incoherent status, did not complete a post-nebulizer assessment, and did not follow the care plan for daily weights and monitoring of breath sounds.
Residents did not receive mail on Saturdays because the Office Manager collected mail from the PO box Monday through Friday only and no staff member was assigned to check the box on Saturdays. A resident reported receiving mail only on weekdays, and the Administrator confirmed residents were not able to receive mail on Saturdays.
Nebulizer tubing and face mask were found connected to a nebulizer machine beside a resident’s bed, not dated, and not stored in a plastic bag when not in use. The resident had active nebulizer orders for ipratropium-albuterol and PRN albuterol, and the DON confirmed the tubing should be dated and properly stored per policy.
Failure to Implement Enhanced Barrier Precautions: The facility did not consistently follow EBP for two residents. One resident with a surgical wound and additional wounds had no EBP signage posted outside the room, and the DON confirmed the sign should have been there. Another resident with a PEG tube had an order for gown and glove use during feeding tube care, but an LPN administered meds via PEG without donning a gown.
The facility failed to ensure residents were free from physical restraints used for convenience, as bolsters were applied without consent, physician's orders, or assessments. This affected four residents with cognitive impairments and mobility issues, highlighting a systemic issue in following restraint policies.
A resident with Alzheimer's and a history of falls experienced multiple falls due to inadequate interventions. Despite being dependent on staff and having severely impaired cognitive skills, the facility's interventions, such as reminders to balance and wear well-fitted shoes, were confirmed as inappropriate by the DON. The resident's falls included incidents with a walker and slipping in urine.
The facility failed to assess the risk of entrapment from bed rails for three residents before installation, despite their severe cognitive impairments and medical conditions. The facility's policy requires such assessments and informed consent, but documentation was lacking, as confirmed by the administrator.
Resident Neglect During Unsafe Wheelchair Van Transport
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from neglect during transportation in the facility van. A CNA responsible for transport did not follow the facility’s transportation safety policies and procedures, including the requirement to properly secure residents with restraining seatbelts. The resident involved had multiple medical diagnoses, including hemiplegia and hemiparesis following cerebral infarction, chronic systolic heart failure, type 2 diabetes with autonomic neuropathy, chronic pain due to trauma, cervical spinal stenosis, and COPD. The resident was cognitively intact with a BIMS score of 15 and was dependent on a wheelchair for mobility and staff assistance for transfers using a lift. During a return trip from a physician appointment, the CNA failed to attach the van’s restraining lap belt across the resident’s lap. While en route, the resident told the CNA that she felt like she was sliding down in her wheelchair. Despite this verbal report, the CNA did not stop the van to reposition the resident or correct the lack of restraint. Instead, the CNA continued driving until reaching her personal residence. The CNA then went inside her residence, leaving the resident unattended in the van and still not properly secured or repositioned. While the CNA was inside her personal residence, the resident slid out of her wheelchair onto the floor of the transportation van. When the CNA returned to the van, she found the resident on the floor but did not call the facility for assistance and did not transfer the resident back into the wheelchair. The CNA then drove approximately 15.3 miles back to the facility with the resident remaining on the floor of the van. Upon arrival, the CNA did not inform facility staff when the fall had occurred or how long the resident had been on the floor. The resident was later assessed with no injuries, and the facility’s investigation substantiated neglect based on these events and the CNA’s failure to follow established policies on abuse, neglect, fall management, and transportation safety. The facility’s policies in place at the time defined neglect as the failure of the facility, its employees, or service providers to provide goods and services necessary to avoid physical harm, pain, mental anguish, or emotional distress. The transportation policy required adequate training of personnel transporting residents, including safe wheelchair transportation, proper use of restraints, and procedures for what to do if someone falls. The CNA had completed annual abuse and neglect training and had acknowledged the transportation training checklist and passenger assistive techniques, which included always using seat belts and ensuring passenger restraints fit securely. Despite this training and policy framework, the CNA did not secure the resident with the lap belt, did not respond appropriately when the resident reported sliding, left the resident unattended in the van, failed to seek assistance after the fall, and transported the resident back to the facility while she remained on the floor of the van. These actions and inactions led to the substantiated neglect and the Immediate Jeopardy determination.
Removal Plan
- Immediately assessed Resident #26 upon return to the facility.
- Terminated the employment of S4CNA.
- Updated the facility's transportation policy to state to call the facility in the event of a fall if non-emergent or to call 911 if it is an emergency.
- Completed an in-service with transportation drivers regarding policy changes and performed competency checks on loading and unloading residents in wheelchairs; counseled drivers on never leaving residents unsupervised and on notifying nursing immediately in the event of a fall.
- Implemented mandatory monitoring by the DON or designee 3 times per week, including checks on arrival/departure to ensure residents are safely anchored and properly seated, quizzing drivers on who to call in the event of a fall, and speaking with residents about their trip.
- Monitor transportation compliance weekly at staff meetings and address at quarterly QAPI meetings and other intervals as needed to ensure compliance.
Failure to Secure Wheelchair-Dependent Resident and Provide Supervision During Van Transport
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and proper use of the transportation van’s restraining seatbelt for a wheelchair-dependent resident during transport. The facility had a written Transportation Policy and Passenger Assistive Techniques procedure requiring that residents who use wheelchairs be safely secured with passenger restraints and that seat belts be used for all passengers. The CNA responsible for transport had completed the Transportation Training Checklist and acknowledged the transportation policy and passenger assistive procedures, which included guidance on safe wheelchair transportation, use of restraints, and what to do if someone falls. The resident involved was admitted with multiple significant diagnoses, including hemiplegia and hemiparesis following cerebral infarction, chronic systolic (congestive) heart failure, type 2 diabetes mellitus with diabetic autonomic neuropathy, chronic pain due to trauma, cervical spinal stenosis, and COPD. A quarterly MDS assessment documented that the resident was cognitively intact with a BIMS score of 15, was dependent on a wheelchair for mobility, and required staff assistance with transfers using a lift. Despite this dependence on staff for safe mobility and transfers, the resident was transported in the facility van without the restraining lap belt being applied. During the return trip from a medical appointment, the resident reported to the CNA driver that she felt she was sliding down in her wheelchair. The CNA did not stop the van to reposition or secure the resident with the restraining seatbelt and continued driving until reaching her own personal residence. The CNA then left the resident unattended in the van while she went inside her residence. While unsupervised and not secured by a seatbelt, the resident slid out of the wheelchair onto the floor of the van. When the CNA returned, she found the resident on the floor but did not call the facility for assistance and did not transfer the resident back into the wheelchair. Instead, the CNA drove the resident back to the facility while the resident remained sitting on the floor of the van. Upon arrival, staff, including an LPN, observed the resident on the van floor and assisted with assessment and lifting the resident from the floor. The incident was determined by surveyors to constitute an Immediate Jeopardy situation on the date of occurrence.
Removal Plan
- Immediately assessed Resident #26 upon return to the facility.
- Terminated the employment of S4CNA.
- Updated the facility's transportation policy to state to call the facility in the event of a fall if non-emergent or to call 911 if it is an emergency.
- Completed an in-service with transportation drivers to communicate policy changes and perform competency checks on loading and unloading residents in wheelchairs; counseled drivers on never leaving residents unsupervised and on notifying nursing immediately in the event of a fall.
- Implemented mandatory monitoring by the DON or designee: checks upon arrival and departure 3 times per week to ensure residents are safely anchored in the van and properly seated; quiz transport drivers at each departure/arrival on who to call in the event of a fall; counsel on notifying nursing immediately in the event of a fall.
- Monitor compliance weekly at staff meetings and address at quarterly QAPI meetings and other intervals as needed to ensure compliance.
Failure to Implement Fall Care Plan Intervention
Penalty
Summary
The facility failed to implement a person-centered care plan for Resident #1 to maintain the resident’s highest practicable physical, mental, and psychosocial well-being. Resident #1 was admitted on 08/08/2024 with diagnoses including type 2 diabetes mellitus with diabetic neuropathy, gastroesophageal reflux disease, vitamin D deficiency, osteoarthritis, dementia, hypertension, hyperlipidemia, and a history of falling. The quarterly MDS showed a BIMS score of 7, indicating severe cognitive impairment with daily decision making, and the quarterly fall risk assessment showed a score of 18, indicating high fall risk. The care plan for falls included an intervention dated 02/09/2026 to encourage use of a reacher and ensure the device was within reach. During observations on 03/17/2026, Resident #1 did not have a reacher plainly visible and was later observed without one. The resident stated she did not have the device and asked the surveyor to get her one. A CNA did not identify the reacher as a fall intervention, and an LPN also did not identify it as a fall intervention and reported being unaware that the reacher was part of the fall intervention. The DON was informed of the findings and confirmed there was no documentation to support that a reacher was in place per the plan of care.
Failure to Follow Weight Loss Management Policy After Significant Resident Weight Loss
Penalty
Summary
The facility failed to ensure a resident maintained acceptable nutritional status by not following its weight loss management policy after a significant weight loss was identified. Resident #2 was admitted with diagnoses including malignant neoplasm of the pylorus, dysphagia following cerebral infarction, and type 2 diabetes mellitus with chronic kidney disease. The resident’s record showed weights of 182.8 pounds on 01/05/2026 and 169.8 pounds on 02/03/2026 after a hospitalization for diabetic ketoacidosis and a gastrointestinal bleed, which reflected a 7.11% weight loss in one month. A nursing note documented that the resident returned from the hospital with a 13-pound weight loss and was eating 75-100% of meals, but there was no documentation that the dietitian, attending physician, or responsible party were notified within 24 hours, no IDT meeting within 72 hours, and no weekly weights or monthly IDT review as required by policy. The record also showed no dietitian assessment in February 2026 and no order for nutritional supplements or an appetite stimulant at that time. The resident’s care plan identified a possible nutritional deficit related to diabetes mellitus and non-compliance with diet, but there were no new interventions documented after the significant weight loss was identified. Later, the dietitian noted the resident had lost 13.6 pounds over two months and recommended sugar free health shakes with meals for weight maintenance, but observations on two separate days showed the resident did not receive the shakes with lunch. Staff confirmed the shakes were not on hand and had not been provided, and the DON confirmed the resident had not received any health shakes since the dietitian’s recommendation.
Medication Administration and Change-in-Condition Monitoring Deficiencies
Penalty
Summary
Nurses and nurse aides were not ensured to have the appropriate competencies to care for residents by failing to clarify the correct dosage for ordered Voltaren 1% external gel for two residents. One resident had diagnoses including type 2 diabetes mellitus with diabetic neuropathy, GERD, vitamin D deficiency, osteoarthritis, dementia, hypertension, hyperlipidemia, and a history of falling, and had a BIMS score of 7 indicating severe cognitive impairment. The resident had a physician order for Voltaren 1% gel to be applied to both hands twice daily for osteoarthritis, but the medication was administered without the dosage ordered by the physician. Another resident with diagnoses including CAD, heart failure, hypertension, GERD, renal insufficiency, and arthritis had a BIMS score of 11 indicating moderate cognitive impairment and also had a physician order for Voltaren 1% gel to be applied to both lower extremities twice daily for pain, but the medication was likewise administered without the dosage ordered by the physician. The facility also failed to notify the physician of changes in condition for a resident who had diagnoses including carotid artery stenosis, heart failure, hypertension, cardiomegaly, cerebral ischemia, stage 3 CKD, dysuria, lumbar compression fracture, history of falling, traumatic hemorrhage of the right cerebrum, dyspnea, nasal bone fracture, and anxiety, and whose MDS showed severely impaired cognitive skills for daily decision making. The care plan required monitoring and reporting edema, weight gain over 2 lbs a day, difficulty breathing, level of consciousness, and breath sounds. The record documented 4+ edema in the lower extremities, medication being held because the resident was incoherent, and wheezing and congestion treated with ipratropium-albuterol nebulizer solution, but there was no documentation that the physician was notified of the edema or level of consciousness, no documentation of a post-nebulizer assessment, and the resident was weighed weekly instead of daily as planned.
Residents Did Not Receive Mail on Saturdays
Penalty
Summary
The facility failed to ensure residents received mail on Saturdays. During a resident council interview, Resident #19 reported receiving mail Monday through Friday but not on Saturdays. The Office Manager stated she picked up the facility's mail and residents' mail from the post office Monday through Friday and distributed residents' mail after returning, but did not go to the post office on Saturdays. The Administrator confirmed that both the facility's mail and residents' mail were delivered to the provider's post office box, that the Office Manager had the key and collected mail Monday through Friday, and that the facility did not have a dedicated staff member to check the post office box on Saturdays. The Administrator confirmed residents were not able to receive mail on Saturdays.
Nebulizer Tubing Not Dated or Properly Stored
Penalty
Summary
The facility failed to provide respiratory care in accordance with its own policy for Resident #5, who was admitted with diagnoses including chronic systolic congestive heart failure, atherosclerotic heart disease, type 2 diabetes mellitus, ischemic cardiomyopathy, anxiety disorder, and a fracture of the neck of the right femur sequela. Current physician orders in March 2026 included ipratropium-albuterol inhalation solution every 6 hours for 3 days and albuterol sulfate inhalation solution every 6 hours as needed for wheezing or shortness of breath, and the EMAR documented that the resident received the ordered ipratropium-albuterol treatments. The facility policy stated that oxygen and nebulizer tubing would be changed twice per month on the 1st and 15th, dated at that time, and checked each shift to ensure the tubing remained in a designated bag and was labeled properly. However, observations of the resident’s room showed a nebulizer machine on the dresser beside the bed with the tubing and face mask connected to the side of the machine, not dated, and not properly stored in a plastic bag. A DON observed the same condition and confirmed that the nebulizer tubing should be dated and the tubing and face mask should be stored in a plastic bag when not in use.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to maintain an infection control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections. For Resident #5, who was admitted with diagnoses including type 2 diabetes mellitus, right hip pain, aftercare following right hip replacement surgery, presence of a right artificial hip joint, fracture sequela of the right femur neck, and chronic venous hypertension with ulcer and inflammation, the record showed physician orders for daily care of a right hip incision and wounds to the left great toe and right heel. The admission MDS indicated a BIMS score of 14 and that the resident had a surgical wound and unstageable wounds present on admission. During observation and interview, the resident stated she had a right hip wound with slight drainage and wounds on her left great toe and right heel, but there was no signage posted outside her room indicating Enhanced Barrier Precautions were in place. The DON confirmed the resident should have been on EBP and that a sign should have been posted. For Resident #14, the record showed diagnoses including traumatic brain injury, aphasia, post-traumatic seizures, hemiplegia, and gastrostomy status, and the quarterly MDS indicated severe impairment with daily decision making. The resident had a feeding tube, and the physician’s order for EBP required hand sanitizer on entry and exit and gown and gloves for high-contact care activities, including device care or use of the feeding tube. During observation, an LPN administered medications via PEG tube without donning a gown. The LPN was unable to confirm that a gown was required until after reviewing the order, and the DON was informed that EBP had not been implemented as ordered for this resident.
Failure to Obtain Consent and Physician's Order for Restraint Use
Penalty
Summary
The facility failed to ensure that residents were free from the use of physical restraints imposed for discipline or convenience. Specifically, the facility did not obtain consent, secure a physician's order, or conduct appropriate assessments before using roll control bolsters on residents' beds. This deficiency was observed in four out of five residents reviewed for restraints, indicating a systemic issue in the facility's adherence to its own policies and regulatory requirements. Resident #20, who had severe cognitive impairment and was dependent on staff for mobility, was observed with bolsters on the bed without prior assessment, consent, or a physician's order. Similarly, Resident #24, with cognitive impairment and extensive assistance needs, was also found with bolsters without the necessary documentation and approvals. Both residents had care plans indicating a potential for falls, but the facility did not follow the required procedures for restraint use. Residents #11 and #29 were also subjected to the use of bolsters without documented assessments, consents, or physician's orders. Resident #11 had a history of falls and severe cognitive impairment, while Resident #29 had multiple diagnoses including dementia and was dependent on staff for daily living activities. Interviews with the facility's administrator confirmed these failures, highlighting a lack of compliance with the facility's policies and regulatory standards regarding restraint use.
Inadequate Fall Prevention Interventions for Resident
Penalty
Summary
The facility failed to ensure a resident was free from accident hazards by not implementing appropriate interventions after each fall. The resident, who had a history of falls and several medical conditions including Alzheimer's disease, dementia, and a hip replacement, experienced multiple falls over a period of time. The medical record review revealed that the resident had severely impaired cognitive skills and was dependent on staff for daily activities. Despite this, the interventions documented after each fall were inadequate to prevent further incidents. The resident's falls were documented on three separate occasions, with the first incident occurring when the resident's feet got tangled in her walker, causing her to fall and hit her head. Subsequent falls included slipping in her own urine while attempting to go to the bathroom. The care plan interventions, such as reminding the resident to get her balance before moving and wearing well-fitted shoes, were confirmed by the Director of Nursing to be inappropriate for preventing falls in this resident. The facility's failure to implement effective fall prevention strategies contributed to the ongoing risk of falls for the resident.
Failure to Assess Bed Rail Entrapment Risk
Penalty
Summary
The facility failed to ensure that residents were assessed for the risk of entrapment from bed rails prior to their installation. This deficiency was identified for three residents who were reviewed for accident hazards. The facility's policy requires an assessment of risks, including entrapment, and obtaining informed consent before installing bed rails. However, for residents with severe cognitive impairments and various medical conditions, such as chronic heart failure, dementia, and diabetes, there was no documentation of such assessments being conducted. Resident #15, who had severe cognitive skills for daily decision-making and required total assistance with activities of daily living, was observed with bed rails in place without prior risk assessment. Similarly, Resident #11, with a history of falls and severe cognitive impairment, and Resident #20, who was totally dependent on staff for mobility, also had bed rails installed without documented risk assessments. Interviews with the facility administrator confirmed the lack of assessments for these residents, indicating a failure to adhere to the facility's policy and procedures regarding bed rail installation.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 6 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Wisner
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Plantation Oaks Nursing & Rehabilitation Center | 0.8 mi | ★★★★★ | 6 | 0 |
| Plantation Manor Nursing And Rehab Center, Llc | 12.6 mi | ★★★★★ | 0 | 0 |
| Legacy Nursing And Rehabilitation Of Winnsboro | 13.3 mi | ★★★★★ | 0 | 0 |
| Camelot Leisure Living | 25.3 mi | ★★★★★ | 11 | 0 |
| Haven Nursing Center | 26.5 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Mary Anna Nursing Home.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.