Above average — CMS composite of the measures below.
The next survey window likely opens around December 2026
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 Green Pine Acres Nursing Home during CMS and state inspections, most recent first.
A TMA left two labeled insulin pens unattended on a medication cart while checking blood sugars, and staff confirmed medications should not be left unsecured. The facility also had a TCU medication refrigerator with multiple temperatures below the required range and missed log entries, and the DON was unaware of the out-of-range readings until the log was reviewed. The fridge contained insulin and vaccines, and the pharmacist later reviewed the exposed medications.
Medication Error and Narcotic Count Discrepancy: The facility failed to ensure accurate medication administration for two residents when an TMA mistakenly gave one resident’s lorazepam to another resident and an LPN replaced the tablets in the bottle instead of reporting the error. One resident was on hospice with cancer, HF, and COPD, and the other had cancer and palliative care. The error was not documented as a medication error or reported to administration, and the narcotic records were altered with scratched-out entries and inconsistent counts.
The facility failed to accurately code the MDS for two residents, leading to discrepancies in their documented range of motion (ROM) status. One resident's assessments showed impaired ROM due to multiple sclerosis and quadriplegia, while another had limited ROM in the right shoulder, elbow, and ankle. However, their MDS inaccurately indicated no limitations. The LPN responsible admitted to misinterpreting the coding criteria, and the DON emphasized the importance of accurate ROM documentation.
A resident with impaired cognition and a history of falls was not adequately protected due to the facility's failure to assess the range of motion sensor alarms. Despite having a sensor pad and alarm system, the alarms did not alert staff to the resident's movements, resulting in unwitnessed falls. Staff interviews revealed a lack of awareness about the range limitations of the alarms, and the facility did not conduct necessary investigations or tests to ensure the alarms functioned as intended.
A resident with Alzheimer's and dementia experienced inappropriate touching by a nursing assistant, which was reported late to the facility administrator and state agency. The incident was initially reported by another nursing assistant to an RN, who failed to escalate it within the required two-hour timeframe. The administrator was informed three days later, contrary to the facility's policy.
A resident with Alzheimer's and dementia was allegedly subjected to inappropriate touching by a nursing assistant (NA-B), witnessed by another assistant (NA-A). The incident was reported to the facility's administrator three days later, during which time NA-B continued to work. The facility's policy requires immediate protective measures, which were not implemented until NA-B was suspended three days after the incident.
A resident experienced a significant decline in health, including severe cognitive impairment and increased dependency in ADLs, along with a 9.2% weight loss. The facility failed to complete a required significant change in status assessment, as staff did not recognize the need due to unfamiliarity with the new MDS format.
Unsecured insulin pens and out-of-range medication refrigerator temperatures
Penalty
Summary
The facility failed to ensure medications were secured when two residents’ insulin pens were left unattended on a TCU medication cart. One resident was cognitively intact with diagnoses including heart disease and diabetes and had an order for daily Lantus insulin. Another resident was cognitively intact with diagnoses including renal insufficiency and diabetes and had an order for Lantus insulin twice daily. During observation, a TMA was preparing medication at the cart, then walked away into the dining area and into residents’ rooms to check blood sugars, leaving the two labeled insulin pens on the cart without direct observation. The TMA stated she had set the pens on the cart and left them there, and an LPN later removed the pens from the cart. Staff stated medications should not be left unattended on medication carts. The facility’s medication storage policy stated all drugs must be stored in locked compartments and, during a medication pass, medications must be under the direct observation of the person administering them or locked in the medication storage area/cart. The observation showed the insulin pens were left on the cart while the TMA was away from the cart and unable to observe them. RN and LPN staff confirmed that medications should not be left unattended because someone else could pick them up and use them. The facility also failed to maintain safe refrigeration temperatures for one of four medication refrigerators on the TCU. The refrigerator temperature log showed multiple temperatures below the required range and several missed entries. During observation, the medication room contained two unlocked refrigerators, and RN stated the fridge temperatures were supposed to be checked twice daily and maintained between 36 and 46 degrees Fahrenheit. The DON stated she was unaware of the out-of-range temperatures and blank entries until the log was reviewed. The pharmacist later reviewed the medications stored in the refrigerator and recommended destruction and replacement of one Lantus pen, one Novolog pen, one Prevnar injection, one T-Dap vaccine, and one COVID vaccine.
Medication Error and Narcotic Count Discrepancy
Penalty
Summary
The facility failed to follow its policies and acceptable standards of practice to ensure medication administration accuracy for 2 residents reviewed for narcotic count accuracy. R23 had diagnoses including breast cancer, heart failure, COPD, and was receiving hospice services. R23 had an order for lorazepam 0.5 mg every 4 hours as needed for anxiety/agitation, but the record did not show that R23 ever received the medication. The Individual Narcotic Record showed lorazepam was received for R23, and later a handwritten entry indicated two tablets were administered, but that entry was scratched out and replaced with a remaining quantity of 5. During observation, R23’s lorazepam bottle contained three 0.5 mg tablets and one 1 mg tablet broken into two pieces, totaling five 0.5 mg tablets. R66 had diagnoses including cancer and palliative care and had an order for lorazepam 1 mg four times a day for anxiety/shortness of breath. The Medication Administration Record showed R66 received lorazepam 1 mg, and the Individual Narcotic Record showed a handwritten entry that one tablet was administered by TMA-B. During interview, LPN-B stated she was aware of a discrepancy with R66 and R23’s lorazepam narcotic count and recalled replacing tablets in R23’s bottle because they were the same strength, even though one tablet had been broken in half. LPN-B stated TMA-B had mistakenly used R23’s medication for R66 and that she only fixed it. TMA-B stated he mistakenly administered R23’s lorazepam tablets to R66 and realized the error after documenting the administration under R23. TMA-B stated he immediately told LPN-B, but neither staff member completed a medication error report or reported the error to administration. LPN-B stated she did not inform administration because she replaced the medication in the bottle and thought it was not a big deal. The pharmacist stated he was unaware of the error and that the facility must complete a medication error report and should not borrow medications between residents. The DON and administrator stated staff were expected to report medication errors and follow facility policy, and the facility policy required the six rights of medication administration to be followed with each medication or treatment.
Inaccurate MDS Coding for Range of Motion
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) was accurately coded to reflect the range of motion (ROM) status for two residents, R2 and R29. R2's physical therapy evaluation and mobility assessments identified impaired ROM in both upper and lower extremities, with specific contractures noted. However, R2's MDS inaccurately indicated no limitations in ROM, despite diagnoses of multiple sclerosis and quadriplegia. Observations confirmed R2's limited dexterity and movement, contradicting the MDS coding. Similarly, R29's care plan and assessments documented limited ROM in the right shoulder, elbow, and ankle, yet the MDS inaccurately reflected no limitations. Observations showed R29's inability to reposition herself in a wheelchair, further highlighting the discrepancy. The LPN responsible for completing the MDS assessments admitted to potentially misinterpreting the ROM coding criteria, only marking impairments if there was a risk of injury. The Director of Nursing disagreed with the MDS coding, emphasizing the importance of accurately reflecting ROM limitations to account for the residents' needs for assistance with activities of daily living. The facility's policy and the CMS Long-Term Care Facility Resident Assessment Instrument Manual outlined the necessity for comprehensive assessments and accurate MDS coding, which were not adhered to in these cases.
Failure to Assess Motion Sensor Range Leads to Resident Falls
Penalty
Summary
The facility failed to ensure that motion sensor pager devices were properly assessed for range upon implementation, leading to a deficiency in preventing accidents for a resident identified as R60. The manufacturer's instructions indicated that the range of the monitors was between 150 to 300 feet, but environmental factors such as concrete or brick walls and heavy electrical equipment could affect the range. The facility did not assess the range of the alarm boxes in relation to the sensors to ensure they functioned as intended, which resulted in the alarm not alerting staff to R60's movement. R60, a resident with moderately impaired cognition, required assistance with activities of daily living and had a history of multiple falls. Despite having a sensor pad on her bed and a sensor box in the bathroom doorway, the facility's records lacked evidence of any assessment of the alarm box ranges. This oversight contributed to R60 experiencing unwitnessed falls, as the alarm did not sound when she attempted to self-transfer to the bathroom, leading to falls on multiple occasions. Interviews with staff revealed a lack of awareness regarding the range limitations of the motion sensor alarms. The Director of Nursing and the administrator admitted that they had never tested the range of the motion sensor alarms and were unsure of the exact range. The facility's policy required a systematic approach for the safe use of resident alarms, including verifying that alarms were used in accordance with the care plan and monitoring for effectiveness. However, the facility failed to conduct an investigation or test the alarm system following R60's falls, resulting in a deficiency in providing adequate supervision to prevent accidents.
Failure to Timely Report Allegation of Abuse
Penalty
Summary
The facility failed to timely report an allegation of staff-to-resident abuse involving a resident diagnosed with Alzheimer's disease, depression, anxiety, and dementia. The incident occurred when a nursing assistant (NA-B) inappropriately touched the resident's breast and made a comment, which was witnessed by another nursing assistant (NA-A). NA-A reported the incident to a registered nurse (RN-B) shortly after it occurred. However, RN-B, who was aware of the two-hour reporting requirement for abuse allegations, did not report the incident to the director of nursing or the administrator. The administrator was informed of the incident three days later by RN-A, who initially did not consider the incident significant until it was brought up again by NA-A. The facility's policy requires suspected abuse to be reported to the administrator and the state agency within two hours of suspicion. Despite this policy, the incident was not reported in a timely manner, and no staff education was implemented following the late reporting.
Delayed Response to Alleged Staff-to-Resident Abuse
Penalty
Summary
The facility failed to implement immediate protection for residents following an allegation of staff-to-resident sexual abuse. The incident involved a resident with Alzheimer's disease, depression, anxiety, and dementia. A nursing assistant (NA-B) was reported to have inappropriately touched the resident's breast and made a sound effect, which was witnessed by another nursing assistant (NA-A). NA-A felt the action was inappropriate and reported the incident to a registered nurse (RN-B) shortly after it occurred. The facility's administrator was notified of the incident three days later, during which time NA-B continued to work. The facility's policy on abuse, neglect, and mistreatment requires immediate safety measures to protect residents, such as separating the suspected perpetrator from residents. However, these measures were not implemented until three days after the incident, when NA-B was suspended. This delay in action resulted in a failure to protect the resident and potentially other residents from further harm.
Failure to Complete Significant Change in Status Assessment
Penalty
Summary
The facility failed to complete a significant change in status assessment for a resident (R56) who experienced a notable decline in health. Initially, R56's admission MDS indicated moderate cognitive impairment and required varying levels of assistance with daily activities. However, a subsequent quarterly MDS revealed severe cognitive impairment and increased dependency in activities of daily living (ADLs), along with a significant weight loss of 9.2%. Despite these changes, the medical record lacked evidence of a significant change in status MDS or a progress note explaining why it was not required. Interviews with staff revealed that the registered nurse (RN-B) responsible for completing the MDS did not recognize the need for a significant change assessment due to unfamiliarity with the new MDS format. The director of nursing (DON) was aware of the resident's weight loss but not the decline in ADL function. The facility's policy and the CMS RAI Manual both indicate that a significant change in status assessment is necessary when there are declines in multiple areas of a resident's health status, which was not adhered to in this case.
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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.
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Nursing homes near Menahga
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Heritage Living Center | 11.2 mi | ★★★★★ | 2 | 0 |
| Fair Oaks Lodge | 22 mi | ★★★★★ | 7 | 0 |
| Perham Living | 26.1 mi | ★★★★★ | 7 | 0 |
| Frazee Care Center | 29.4 mi | ★★★★★ | 6 | 0 |
| Lakewood Health System | 29.6 mi | ★★★★★ | 3 | 0 |
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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.