St. Helena Parish Nursing Home

F 0628 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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 REDACTED] and was transferred from the facility to a local hospital emergency room

on [DATE REDACTED]. Further review revealed Resident #4 returned to the facility on [DATE REDACTED]. 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 REDACTED].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 REDACTED].On 10/01/2025 at 7:48 a.m., an interview was conducted with S1ADM. He stated S3BOM was responsible for updating the Emergency Transfer Log that provides written notice to the Ombudsman for all resident transfers.On 10/01/2025 at 8:18 a.m., an interview was conducted with S3BOM. She stated she was responsible for updating the Ombudsman Emergency Transfer log and to document any resident transfers to the hospital and/or emergency room. She stated she was notified daily of all resident transfers through

the Census Change Sheet. She reviewed the facility's Census Change Sheet for August 2025 and confirmed Resident #4's transfer to the hospital emergency room on [DATE REDACTED] was not documented. On 10/01/2025 at 8:43 a.m., an interview was conducted with S1ADM. He stated the resident's assigned nurse was responsible for updating the Census Change Sheet at time of the transfer. He reviewed the facility's Census Change Sheet and the facility's Ombudsman Emergency Transfer Log for August 2025. He confirmed Resident #4's transfer to the hospital emergency room on [DATE REDACTED] was not documented and should have been. On 10/01/2025 at 12:05 p.m., an interview was conducted with S4LPN. She confirmed

she did not fill out the Census Change Sheet when Resident #4 was transferred to the hospital emergency room on [DATE REDACTED]. She stated she did not know she was required to complete the Census Change Sheet with each resident transfer to the hospital and/or emergency room. On 10/01/2025 at 1:22 p.m., an interview was conducted with S2DON. She stated she expected all resident transfers to be documented on the Census Change Sheet by their assigned nurse to allow for the Ombudsman Transfer Log to be accurate.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

(X6) DATE

FORM CMS-2567 (02/99) Previous Versions Obsolete

Facility ID:

If continuation sheet

Event ID:

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/01/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

St. Helena Parish Nursing Home

32 North 2nd Street Greensburg, LA 70441

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0640

Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.

Level of Harm - Minimal harm or potential for actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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 REDACTED] and was discharged to a local hospital on [DATE REDACTED]. 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.

She stated an MDS assessment should be completed upon a resident's discharge from the facility. She confirmed Resident #3 discharged from the facility on 08/11/2025 and there was no discharge assessment opened, completed, or transmitted, and there should have been.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet