St. Helena Parish Nursing Home

Inspectors wroteBased on record review and interview, the facility failed to electronically submit payroll based staffing information for direct care staff as required. The deficient practice had the potential to affect the 57 residents residing in the facility. Review of the facility's Payroll Based Journal (PBJ) Staffing Data Report for Fiscal Year Quarter 1 2026 (October 1, 2025 through December 31, 2025) revealed, in part, the facility failed to submit staffing data for the quarter. On 05/04/2026 at 10:00 a.m., an interview was conducted with S1ADM. A request was made for the provider's PBJ Final Validation report for Quarter 1 of fiscal year 2026 (10/01/2025 through 12/31/2025). On 05/05/2026 at 10:45 a.m., an interview was conducted with S1ADM. S1ADM stated he was responsible for entering the facility's PBJ data each quarter. [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure services provided by the facility met professional standards by failing to ensure nursing staff did not borrow medications from one resident to administer to another resident for 1 (#11) of 17 residents reviewed in the final sample. Review of Resident #11's Clinical Record revealed he was admitted to the facility on [DATE] and had diagnoses, which included Rash and Other Nonspecific Skin Eruption. Review of Resident #11's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/16/2026 revealed that the resident had a Brief Interview for Mental Status (BIMS) of 15, indicating the resident was cognitively intact. Review of Resident #11's current Physician Orders revealed the following, in part: Order date: [...]

Inspectors wroteBased on record review and interviews, the facility failed to ensure all medical records regarding the resident's code status contained accurate documentation for 1 (#18) of 24 residents reviewed for advanced directives in the initial screening process.

Inspectors wroteBased on record review and interviews, the facility failed to:Ensure a resident with an identified mental health diagnosis was referred for a Preadmission Screening Resident Review (PASRR) Level II evaluation as required for 2 (#1 and #3) of 3 sampled residents' records reviewed for PASRR.Ensure a resident with a new psychiatric diagnosis and/or admitted to inpatient psychiatric facility was referred for a Preadmission Screening Resident Review (PASRR) Level II evaluation as required for 2 (#1 and #3) of 3 sampled residents' records reviewed for PASRR.1. Resident #1 Review of Clinical Record revealed Resident #1 was admitted on [DATE] with diagnoses as follows: Traumatic Subdural Hemorrhage, Anxiety Disorder, Irritability and Anger, and Major Depressive Disorder. Review of Resident #1's PASRR Level I Form dated 09/12/2024 revealed no mental health diagnoses. [...]

Inspectors wroteBased on record reviews and interviews, 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 1 (#4) of 4 (#1, #3, #4, #5) residents reviewed for admission, transfer and discharge requirements. Review of Resident #4's Medical record revealed he was admitted to the facility on [DATE] and was transferred from the facility to a local hospital emergency room on [DATE]. Further review revealed Resident #4 returned to the facility on [DATE]. Review of the facility's Ombudsman Emergency Transfer Log for August 2025 revealed no documentation of Resident #4's transfer to a hospital emergency room on [DATE]. Review of the facility's Census Change Sheet for August 2025 revealed no documentation of Resident #4's transfer to the hospital emergency room on [DATE]. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure a resident's discharge assessment was completed and transmitted for 1 (#3) of 5 (#1, #2, #3, #4, and #5) residents reviewed for Resident Assessment. Review of Resident #3's Clinical Record revealed he admitted to the facility on [DATE] and was discharged to a local hospital on [DATE]. Review of Resident #3's Minimum Data Set (MDS) Assessments revealed no discharge MDS was opened and/or completed. On 10/01/2025 at 1:52 p.m., an interview was conducted with S5MDS. She stated she was one of the facility's MDS nurses. She confirmed Resident #3 had discharged from the facility on 08/11/2025 and a discharge MDS had not been opened, completed, nor transmitted, and should have been. On 10/01/2025 at 1:56 p.m., an interview was conducted with S6ADON. [...]

Inspectors wroteBased on interviews, observations, and record reviews, the facility failed to protect the residents' right to be free from sexual abuse, psychosocial abuse, and neglect for 1 (#1) of 6 (#1, #2, #3, #R4, #R5, and #R6) sampled residents reviewed for abuse. The facility failed to protect Resident #1 from being sexually and psychosocially abused by Resident #2. This deficient practice resulted in an Immediate Jeopardy (IJ) situation on 08/01/2025 at 7:59 p.m., when Resident #2, a cognitively intact resident with a history of sexually inappropriate behaviors and a convicted sex offender, put his hand between Resident #1's upper thighs and touched her vaginal area. Resident #1 had a BIMS of 2, which indicated she was severely cognitively impaired. From 7:59 p.m. [...]

Inspectors wroteBased on observation, record reviews and interviews, the facility failed to ensure notifications of changes in residents' conditions were made for 2 (#1 and #2) of 4 (#1, #2, #3, and #R6) residents reviewed for behavioral services. The facility failed to ensure:1. S12NP was notified Resident #2 had an increase in inappropriate sexual behaviors; and 2. S12NP was notified Resident #2 sexually and psychosocially abused Resident #1.1. Review of Resident #2's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses, which included Bipolar Disorder and Depression. Further review revealed Resident #2 was a convicted sex offender. Review of Resident #2's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/23/2025 revealed a Brief Interview for Mental Status (BIMS) of 14, which indicated Resident #2 was cognitively intact. [...]

Inspectors wroteBased on record reviews and interviews, the facility failed to coordinate assessments with the resident's Pre-admission Screening and Resident Review (PASRR) Level II by failing to incorporate PASRR Level II determinations and recommendations into a resident's transitions of care for 1 (#2) of 3 (#2, #3, and #R6) residents reviewed for sexual behaviors. Review of Resident #2's clinical record revealed he was admitted to the facility on [DATE] with diagnoses including, Bipolar Disorder and Depression. Review of Resident #2's Form 142 revealed he was approved for admission by Level II authority for a temporary period of 03/04/2025 - 03/03/2026. Review of Resident #2's PASRR Level II Evaluation Summary and Determination Notice dated 03/11/2025 revealed the Level II authority had approved 365 days for nursing facility placement and the following to occur: 1. [...]

Inspectors wroteBased on record reviews and interviews, the provider failed to develop and implement a comprehensive person centered care plan for each resident as evidenced by failing to:1. Develop a comprehensive person centered care plan for 2 of 2 (#2 and #3) residents who were registered sex offenders; and 2. Implement a care plan intervention for 1 (#2) of 3 (#2, #3, and #R6) residents reviewed for sexual behaviors. Review of the facility's policy dated 12/27/2019 and titled, Plan of Care revealed the following, in part:Policy StatementIt is the policy of the facility to promote seamless interdisciplinary care for our residents by utilizing the interdisciplinary plan of care based on assessment, planning, treatment, service and intervention. It is utilized to plan for and manage resident care as evidenced by documentation from admission through discharge for each resident. [...]

Inspectors wroteBased on record reviews and interview, the facility failed to ensure staff was provided Quality Assurance and Performance Improvement (QAPI) training for 5 (S7LPN, S8LPN, S9CNA, S10CNA, and S11CNA) of 5 (S7LPN, S8LPN, S9CNA, S10CNA, and S11CNA) personnel files reviewed. Review of S7LPN's personnel file revealed a hire date of 07/26/2024. Further review of S7LPN's personnel file revealed no documented evidence, and the facility presented no documented evidence, S7LPN received QAPI training as required. Review of S8LPN's personnel file revealed a hire date of 12/01/2023. Further review of S8LPN's personnel file revealed no documented evidence, and the facility presented no documented evidence, S8LPN received QAPI training as required. Review of S9CNA's personnel file revealed a hire date of 04/16/2025. [...]

Inspectors wroteBased on observation, record reviews, and interviews, the facility failed to ensure a resident's care plan was revised by failing to update problems, goals, and interventions after she was sexually and psychosocially abused for 1 (#1) of 4 (#1, #2, #3, and #R6) residents reviewed for care plans. Review of Resident #1's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses, which included Alzheimer's Disease, Mood (Affective) Disorder, and Major Depressive Disorder. Review of Resident #1's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/12/2025 revealed a Brief Interview for Mental Status (BIMS) of 2, which indicated Resident #1 was severely cognitively impaired. Review of the facility's Incident Log revealed, Resident #1 was involved in a Physical Aggression Received incident. [...]

Inspectors wroteBased on observation, record reviews and interviews, the facility failed to ensure each resident had the right to be free from physical abuse for 2 (#1 and #2) of 4 (#1, #2, #3, and #R1) residents reviewed for abuse. The facility failed to ensure: 1. Resident #1 was free from physical abuse by S5CNA, and 2. Resident #2 was free from physical abuse by Resident #R1. This deficient practice resulted in actual physical harm on 04/20/2025 at 4:54 a.m., when S5CNA punched Resident #1, a cognitively intact resident, twice on the left side of the face and the left upper lip resulting in Resident #1 being sent to the local emergency room. The resident was diagnosed with a 2.5 cm laceration of left face which required 4 stiches and a contusion of left orbital area. After returning to the facility, Resident #1 continued to have pain when eating and drinking.

Inspectors wroteBased on interview and record review, the facility failed to ensure all alleged allegations involving physical abuse was reported immediately, but not later than 2 hours after the allegation was made to the State Survey Agency, for 1 (#2) of 4 (#1, #2, #3 and R1) residents investigated for abuse.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure services were provided to meet quality professional standards. The facility failed to ensure nursing staff documented a resident's change in condition for 1 (#1) of 4 (#1, #2, #3, R1) residents sampled. This had the potential to affect 58 residents residing in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure its facility assessment was updated annually and included staffing level(s) needed for emergencies, weekends and specific shifts, such as day, evening, and night. The deficient practice had the potential to affect the 56 residents residing in the facility.

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure a Significant Change Minimum Data Set (MDS) Assessment was completed within 14 days for residents who transferred hospice services for 2 of 2 (#19 and #42) sampled residents receiving hospice services.

Inspectors wroteBased on record review and interviews, the facility failed to ensure the Minimum Data Set (MDS) assessments accurately reflected the resident's status for 3 (#14, #52, and #56) of 17 sampled residents reviewed for PASRR.

Inspectors wroteBased on observation and interviews, the facility failed to implement and maintain an infection prevention control program to help prevent the development and transmission of infection for 1 (#24) out of 2 (#24 and #8) residents reviewed for wound care. The facility failed to ensure personnel consistently removed soiled PPE and preformed proper hand hygiene during wound care.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure the results from the most recent recertification survey was readily available for resident review. This deficient practice had the potential to affect the 56 residents who currently resided in the facility.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure nurse staffing data was posted daily in a prominent location readily accessible to residents and visitors. This deficient practice had the potential to affect any of the 56 residents residing in the facility.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident residing in the facility. The facility failed to ensure: 1. Residents received adequate supervision for 1 (#18) of 3 (#18, #23, and #46) residents care planned for hourly rounding to prevent falls; 2. A functional call light system was in place for 1 (#18) of 23 resident's reviewed in the initial pool. This deficient practice resulted in an immediate jeopardy situation for Resident #18, on 02/27/2024 at 12:00 a.m. when staff failed to perform hourly rounding on Resident #18. The facility's video footage revealed no staff entered Resident #18's room from 12:00 a.m. until 3:17 a.m. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to maintain an adequately equipped call system by failing to ensure: 1. CNA staff had sufficient functioning devices to respond to resident call lights for 1 (#18) of 23 resident's reviewed in the initial pool for call lights. 2. A staff member was assigned to monitor the scroll board for unanswered call lights from 8:00 p.m. to 8:00 a.m. This deficient practice had the potential to affect any of the 54 residents residing in the facility who utilized the call light system. This deficient practice resulted in an immediate jeopardy situation for Resident #18, a resident who required staff assistance with toileting and transfers, on 02/27/2024 at 3:39 a.m., when CNA staff did not have pager's to receive notification that Resident #18 pushed her call light and required assistance. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure residents received adequate supervision by failing to ensure 1 (#18) of 3 (#18, #23, and #46) residents care planned for hourly rounding received adequate supervision to prevent falls. This deficient practice resulted in an immediate jeopardy situation for Resident #18, on 02/27/2024 at 12:00 a.m. when staff failed to perform hourly rounding on Resident #18. The facility's video footage revealed no staff entered Resident #18's room from 12:00 a.m. until 3:17 a.m. then did not enter again until 4:24 a.m. Resident #18 was found on the floor of her room by staff on 02/27/2024 at 4:24 a.m. after Resident #18's roommate verbally called out for staff to come help Resident #18. Resident #18 was transferred to the emergency room and diagnosed with a Right Humerus Fracture. [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure each resident was given the appropriate treatment and services to maintain his or her ability to carry out activities of daily living for 1 (#18) of 6 (#17, #18, #19, #28, #51 and #109) residents reviewed for ADLs. This deficient practice had the potential to affect any of the 50 residents residing in the facility who required staff assistance with ADLs. This deficient practice resulted in an actual harm for Resident #18, a resident who required staff assistance with toileting and transfers, on 02/27/2024 at 3:39 a.m., when Resident #18 pushed her call light and required assistance with toileting. CNA staff did not provide ADL care to Resident #18 in a timely manner which lead to her getting out of bed unassisted and falling. Staff found Resident #18 on the floor at 4:24 a.m. [...]

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to implement a person-centered plan of care by failing to follow Physician's Orders for 2 (#24 and #39) of 7 (#17, #19, #28, #24, #39, #51, and #109) residents reviewed for Physician Orders. The facility failed to ensure: 1. Compression stockings were applied daily for Resident #24; and 2. Tube feedings were administered as ordered for Resident #39.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure residents who required assistance to carry out activities of daily living received the necessary services to maintain personal hygiene for 5 (#17, #19, #28, #51 and #109) of 6 (#17, #18, #19, #28, #51 and #109) residents reviewed for ADLs.

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure residents' drug regimens were free from unnecessary medications. The facility failed to ensure residents' clinical records showed documentation of a diagnosed condition for which psychotropic medications were prescribed for 2 (#18 and #38) of 5 (#9, #18, #24, #38, and #43) residents reviewed for unnecessary medications.

Inspectors wroteBased on interviews and record reviews, the facility failed to maintain accurately documented medical records in accordance with accepted professional standards and practices for 1 (#39) of 2 (#30 and #39) residents reviewed for Nutrition. The facility failed to accurately document administration of Resident #39's tube feeding.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to maintain an infection prevention and control program designed to provide a safe and sanitary environment and to help prevent the development and transmission of communicable diseases for 4 (#14, #26, #36, and #45) of 5 (#14, #26, #36, #45, and #50) residents reviewed for incontinence care and/or toileting. The facility failed to ensure: 1. Staff practiced appropriate hand hygiene and proper glove use during incontinence care for Residents #14, #26, and #36; 2. Staff practiced appropriate hand hygiene and proper glove use during toileting for Resident #45; and 3. Staff performed effective incontinence care for Resident #26.

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure each resident had the right to be free from physical abuse by another resident for 1 (#17) of 3 (#10, #17, and #38) residents reviewed for abuse. The facility failed to protect Resident #17 from physical abuse by Resident #38.

Inspectors wroteBased on interviews and record review, the facility failed to ensure services were provided to meet quality professional standards for 1 (#6) of 4 (#6, #7, #37, and #43) residents reviewed. The facility failed to accurately document the placement and removal of Resident #6's hearing aids per Physician's Orders.