Below average — CMS composite of the measures below.
The next survey window likely opens around April 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 St. Helena Parish Nursing Home during CMS and state inspections, most recent first.
Failure to Submit PBJ Staffing Data: The facility failed to electronically submit payroll-based staffing data for direct care staff for a quarterly reporting period. The ADM stated he was responsible for entering the PBJ data each quarter and confirmed there was no documentation that the required PBJ Final Validation report had been submitted for review.
An LPN borrowed Vistaril from one resident and gave it to another resident when the ordered medication was unavailable. The resident was cognitively intact and had an order for Vistaril 25 mg QID for rash/itching. Staff later confirmed the medication was borrowed from another resident instead of following the facility’s refill process, and the DON stated this was not acceptable.
A resident’s chart contained an outdated LaPost that showed CPR was desired, while the EHR had a DNR order and the red binder held an updated LaPost matching the DNR status. An LPN confirmed the physical chart did not contain the current form, and the DON stated the chart should match the current code status order.
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 Submit PBJ Staffing Data
Penalty
Summary
The facility failed to electronically submit payroll-based staffing information for direct care staff as required. Review of the facility’s Payroll Based Journal (PBJ) Staffing Data Report for Fiscal Year Quarter 1 2026, covering October 1, 2025 through December 31, 2025, showed that staffing data for the quarter was not submitted. During an interview on 05/04/2026, a request was made for the provider’s PBJ Final Validation report for that quarter. On 05/05/2026, the ADM stated he was responsible for entering the facility’s PBJ data each quarter and confirmed he did not have documentation showing the facility submitted PBJ data for Quarter 1 of fiscal year 2026 and that it should have been submitted. As of 05/05/2026 at 4:15 p.m., the provider still had not submitted its PBJ Validation report for review.
Medication Borrowed From Another Resident
Penalty
Summary
The facility failed to ensure nursing services met professional standards when staff borrowed medication from one resident to give to another resident. Resident #11 was admitted with diagnoses including rash and other nonspecific skin eruption, and his quarterly MDS showed a BIMS of 15, indicating he was cognitively intact. He had a physician order for Vistaril 25 mg by mouth four times daily for itching/rash, and the MAR showed the medication was routinely administered except for entries on 05/02/2026 at 8:00 p.m. and 05/04/2026 at 8:00 a.m., which were coded as "other/see progress notes." Nursing notes documented that on 05/02/2026, an LPN noted the Vistaril was awaiting pharmacy, and on 05/04/2026 another LPN documented the medication was out and would be ordered. During interview, Resident #11 stated he was told his Vistaril was out and that he did not receive the 8:00 p.m. dose on 05/02/2026. He also stated that on 05/03/2026 he received all four doses and was told the nurses borrowed Vistaril from another resident while waiting for his medication to be delivered. Staff interviews confirmed the event. One LPN stated she realized only one pill remained, faxed a refill request to the pharmacy, and later borrowed three Vistaril pills from Resident #36 to administer to Resident #11 on 05/03/2026 at 8:00 a.m., 1:00 p.m., and 5:00 p.m. She stated she should not have done so. Another LPN confirmed Resident #11 was out of Vistaril and that medication was borrowed from another resident to give to him. The DON stated the expected process was to fax or call the pharmacy for a refill, or contact the on-call pharmacist if the medication was needed outside regular hours, and confirmed it was not acceptable to borrow medications from one resident for another.
Inaccurate Code Status Documentation in Resident Record
Penalty
Summary
The facility failed to ensure that all medical records for one resident reviewed for advanced directives contained accurate documentation regarding code status. Resident #18 was admitted to the facility and had a physician order in the electronic health record indicating DNR code status. However, the resident’s physical chart contained an older LaPost form dated earlier that had CPR checked and was signed by the resident, indicating the resident wanted resuscitation if found with no pulse or respirations. During interview, an LPN reviewed the red binder and confirmed there was an updated LaPost form in the binder that matched the DNR physician order, but the physical chart still contained the outdated LaPost form and did not include the updated one. The DON stated that the most current LaPost should be kept in the physical chart and red binder and should match the current code status order, and that all medical records should contain accurate and updated documentation.
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.
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Illustrative
What surveyors actually found near you
We read the 23 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
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Greensburg
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Lodge At Tangi Pines | 10.2 mi | ★★★★★ | 6 | 0 |
| Golden Age Healthcare And Rehabilitation Center | 18.3 mi | ★★★★★ | 7 | 0 |
| Liberty Community Living Ctr | 24.3 mi | ★★★★★ | 10 | 0 |
| Heritage Healthcare Of Hammond | 26 mi | ★★★★★ | 6 | 0 |
| Hammond Nursing Home | 26.4 mi | ★★★★★ | 6 | 0 |
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