Adira Medical Resort
Inspection history, citations, penalties and survey trends for this long-term care facility in Bossier City, Louisiana.
- Location
- 4405 Airline Drive, Bossier City, Louisiana 71111
- CMS Provider Number
- 195247
- Inspections on file
- 27
- Latest survey
- January 21, 2026
- Citations (last 12 mo.)
- 6 (2 serious)
Citation history
Health deficiencies cited at Adira Medical Resort during CMS and state inspections, most recent first.
A resident with dementia and a history of wandering was not assessed for elopement risk upon readmission, despite multiple documented incidents of wandering and exit-seeking behavior. The resident was allowed to exit the facility with the Medical Director, left unsupervised, and subsequently eloped to a nearby business before being retrieved by staff. Required assessments and care plan updates were not completed, and exit doors were found unsecured, contributing to the incident.
A resident was able to leave the facility unsupervised and walk along a busy road after staff failed to complete a required elopement risk assessment at readmission and did not implement necessary precautions. The DON and Administrator acknowledged responsibility for oversight and staff education, but the LPN responsible for the admission assessment was unaware of the requirement, leading to the resident's unsupervised exit and subsequent retrieval from a nearby business.
A resident with severe cognitive impairment and a history of wandering was not assessed for elopement risk upon readmission, and the behavioral section of the MDS was inaccurately completed due to staff not reviewing progress notes. The resident exhibited exit-seeking behaviors, including being found outside the facility, but required assessments and documentation were not performed as per facility policy.
A resident with multiple complex medical conditions did not receive a STAT chest x-ray on the same day it was ordered by the physician. The x-ray was completed the following day, and the physician was not notified of the delay. Both an LPN and the DON confirmed the x-ray should have been completed as ordered and that the physician should have been informed.
A resident requiring total staff assistance for toileting, due to multiple medical conditions including hemiplegia, was left unattended in the restroom for 15 minutes after activating the emergency call light. No staff were present in the hallway or at the nurse's station to respond, and both an LPN and the DON confirmed the delay in answering the resident's request for assistance.
Two residents did not receive care as ordered by their physicians: one did not receive prescribed antibiotics for a UTI on several occasions, and another did not receive required wound care for pressure ulcers on multiple dates. These omissions were confirmed by both nursing staff and the DON, with documentation in the MAR and TAR supporting the missed treatments.
Nurse staffing data was not updated and posted daily as required, with the displayed information being several days old. The Interim DON acknowledged the lapse in maintaining current staffing postings.
A resident with multiple medical conditions and intact cognition did not receive prescribed Temazepam for three consecutive nights because the medication was not available. Nursing staff confirmed the medication was not refilled in time and was missing from the medication cart, despite facility procedures requiring timely reordering.
A resident with multiple health conditions and moderately impaired cognition experienced an incident resulting in injury and hospital transfer. The facility did not immediately notify the resident's representative due to missing contact information in the medical record, and notification was delayed until after the resident's return from the hospital.
A resident admitted with multiple complex diagnoses, including diabetes, dementia, and chronic kidney disease, did not have a baseline care plan developed within 48 hours of admission. This omission was confirmed by both an LPN and the administrator, who acknowledged the required care plan was not completed.
The facility did not have an RN on duty for 8 consecutive hours on one day, as confirmed by staffing records and administrative review. This lapse in RN coverage had the potential to affect all residents in the facility.
The facility failed to manage advanced directives effectively, leading to discrepancies in residents' medical records and a lack of documentation that residents or their representatives received information on advance directives. Several residents' code statuses were either missing or inconsistent, and staff interviews revealed systemic issues in handling DNR orders.
The facility failed to assess residents for the risk of entrapment from bed rails and did not obtain physician orders for their use. Observations revealed several residents using bed rails without necessary assessments and orders, despite their medical conditions and cognitive impairments. Staff confirmed the lack of documentation, resulting in a deficiency related to accident hazards.
The facility failed to adequately monitor the drug regimens of several residents, leading to deficiencies in managing conditions related to prescribed medications. A resident on Bumex for edema was not monitored for edema, while another on Apixaban and Furosemide was not monitored for bleeding or edema. Additionally, a resident on Furosemide was not monitored for edema, and another on Dabigatran was not monitored for bleeding. These failures were confirmed by LPNs during interviews.
The facility failed to monitor side effects and behaviors for two residents receiving psychotropic medications, Buspirone and Cymbalta, despite care plans requiring such monitoring. Both residents were cognitively intact, and the oversight was confirmed by LPNs during interviews.
The facility failed to ensure CNAs underwent criminal background checks before employment and did not conduct monthly nurse aide registry/adverse action list searches for three CNAs. Two CNAs were hired without completed background checks, and the absence of monthly registry checks was confirmed by HR.
The facility failed to complete baseline care plans within 48 hours for two residents admitted with complex medical conditions, including hemiplegia, diabetes, and heart failure. The DOCO confirmed that it was the nurse's responsibility to complete these plans, which were not found in the residents' records.
The facility failed to provide proper respiratory care for three residents. A resident received oxygen therapy without a physician's order, while two residents had CPAP equipment improperly stored when not in use. One of these residents also lacked a physician's order and care plan for CPAP use. The facility's policy for oxygen therapy was not followed, and there was no policy for CPAP equipment storage.
A facility failed to provide appropriate dialysis care for a resident by not obtaining weekly weights as per the care plan and not completing the hemodialysis communication record form. The resident, with end-stage renal disease, had scheduled dialysis sessions, but records showed incomplete or missing communication forms, and assessments were not performed upon return from dialysis. The DON confirmed these deficiencies.
The facility did not ensure RN services for at least 8 consecutive hours daily during FY Quarter 3 2024. The PBJ Staffing Report showed a lack of licensed nursing coverage on multiple dates, and the facility's staffing records confirmed the absence of RN services on specific days. The administrator acknowledged these deficiencies during an interview.
The facility did not conduct annual performance evaluations for two CNAs, S13 and S14, as required. S13 CNA, hired in 2018, lacked evaluation documentation since early 2023, while S14 CNA, hired in 2023, had no evaluation since hire. HR confirmed the absence of these evaluations.
The facility inaccurately submitted staffing data to CMS for a fiscal quarter, indicating a lack of 24-hour licensed nursing coverage on specific dates. However, internal records showed coverage was present. The administrator suggested that agency staffing hours might have been omitted in the submission process.
The facility did not conduct QAA meetings quarterly as required. There was no meeting in the first quarter, and the DON was absent from the second quarter meeting. The Administrator confirmed these deficiencies during an interview.
The facility failed to administer influenza, pneumococcal, and COVID-19 vaccines to two residents who had consented to receive them during the admission process. The deficiency was due to the admission packets not being scanned and provided to the Infection Preventionist, resulting in the necessary consents not being received for vaccine administration.
The facility failed to ensure CNAs received required dementia care training, as evidenced by a review of a CNA's personnel record, which lacked documentation of such training. This was confirmed by HR during an interview.
Failure to Assess and Supervise Resident with Wandering Tendencies Resulting in Elopement
Penalty
Summary
The facility failed to assess a resident for elopement risk upon readmission and did not identify the need for supervision despite the resident displaying wandering tendencies. The resident, who had diagnoses including dementia, unsteadiness on feet, and generalized muscle weakness, was readmitted to the facility and was not evaluated for elopement risk as required by facility policy. Documentation in the medical record and progress notes indicated repeated incidents of wandering, including attempts to exit the facility and entering other residents' rooms, but no updated interventions or care plan adjustments were made to address these behaviors. On the day of the incident, the resident was last seen sitting in a common area before being allowed to exit the facility's locked front door with the Medical Director, who was unaware of the resident's elopement risk. The resident was left unattended on the facility's front porch and subsequently walked along a busy road to a nearby dental office. Facility staff were notified by the dental office and retrieved the resident, who was then returned to the facility. Interviews with staff confirmed that the required elopement risk assessment was not completed at the time of readmission, and that staff responsible for completing the assessment did not do so. Further review revealed that the facility's policies required all residents to be assessed for elopement risk upon admission, quarterly, with significant changes in condition, and when behaviors indicated. However, the responsible staff did not complete the assessment, and the social services staff did not review relevant progress notes when completing the behavioral section of the MDS. Exit doors were also found to be unlocked when they should have been secured, and staff interviews confirmed lapses in supervision and communication regarding the resident's wandering and elopement risk.
Failure to Assess and Supervise Resident at Risk for Elopement
Penalty
Summary
The facility failed to administer its resources effectively and efficiently to ensure the highest practicable well-being of a resident who was at risk for elopement. Specifically, the Director of Nursing (DON) did not ensure that nursing staff conducted a risk for elopement assessment at the time of the resident's readmission, and elopement precautions were not implemented. The charge nurse responsible for the admission assessment, which includes the elopement risk assessment, did not complete this assessment and was unaware that it was required at readmission. As a result of these failures, the resident was able to leave the facility unsupervised. The resident exited through the facility's locked front door with the Medical Director and was left unattended on the front porch. The resident then walked along a busy four-lane road without supervision and entered a nearby dental office. The facility was notified by the dental office staff, and the resident was retrieved and returned to the facility by therapy staff. The last observation of the resident in the facility was in the day area, and the elopement was discovered when the dental office contacted the facility. Interviews with facility staff confirmed that the required elopement risk assessment was not completed at readmission, and there was a lack of awareness and oversight regarding the policy for such assessments. Both the DON and the Administrator acknowledged their responsibility for policy oversight and staff education, including training on admission and elopement assessments. The failure to assess and supervise the resident placed the resident at risk and resulted in an Immediate Jeopardy situation.
Failure to Assess and Accurately Document Elopement Risk and Behaviors
Penalty
Summary
The facility failed to complete a nursing assessment and elopement risk assessment for a resident at the time of readmission, despite the resident having diagnoses including dementia, unsteadiness on feet, and generalized muscle weakness. The resident had a BIMS score indicating severe cognitive impairment. Documentation showed that the resident exhibited wandering and exit-seeking behaviors shortly after readmission, including an attempt to exit through the front door and later being found outside the facility in the parking lot. However, there was no evidence in the medical record that an elopement risk assessment was performed at readmission as required by facility policy. Additionally, the behavioral section of the resident's Minimum Data Set (MDS) was not completed accurately. The staff member responsible for this section did not review the resident's progress notes and instead relied on verbal reports from other staff. As a result, the MDS did not reflect the resident's wandering and exit-seeking behaviors. Interviews with facility staff confirmed that the required assessments were not completed and that the behavioral section of the MDS would have been completed differently if the progress notes had been reviewed.
Failure to Timely Complete STAT Chest X-ray as Ordered
Penalty
Summary
The facility failed to implement the plan of care for one resident by not completing a STAT chest x-ray as ordered by the physician. The resident, who had multiple diagnoses including acute respiratory failure with hypercapnia, pneumonia, type 2 diabetes mellitus, spinal stenosis, hypertension, and dysphagia, was admitted on a specified date. A STAT chest x-ray was ordered on 04/18/2025, but the x-ray was not performed until the following day, 04/19/2025. Documentation confirmed the delay, and interviews with the LPN and DON verified that the x-ray should have been completed on the same day as ordered and that the physician was not notified of the delay.
Failure to Respond Timely to Resident's Request for Toileting Assistance
Penalty
Summary
A resident with a history of left femur fracture, hemiplegia, hyperlipidemia, hypertension, irritable bowel syndrome, parkinsonism, major depressive disorder, esophageal obstruction, gastronomy, and dysphagia was assessed as requiring total staff assistance for toileting due to right-sided hemiplegia. The resident's care plan identified a self-care performance deficit and specified the need for total assistance with toileting. On the observed date, the resident was found in the restroom calling for help while attempting to sit on the toilet without assistance. The emergency call light was activated and audible at the nurse's station, but no staff were present in the hallway or at the nurse's station to respond. Staff failed to answer the resident's call light and request for assistance for 15 minutes. Interviews with an LPN and the DON confirmed that the assigned CNAs were not present on the hall and that the resident's request should have been answered in a timely manner.
Failure to Implement Physician-Ordered Care Plans for Two Residents
Penalty
Summary
The facility failed to implement physician-ordered care plans for two of three sampled residents. For one resident with diagnoses including dependence on renal dialysis, type 2 diabetes mellitus, and chronic fatigue syndrome, the facility did not administer the prescribed antibiotic, Levofloxacin 250 mg, on multiple specified dates as ordered for a urinary tract infection. This omission was confirmed by both the LPN and the Interim DON during interviews, and the missed doses were documented in the resident's Medication Administration Records. Another resident, admitted with conditions such as a sacral pressure ulcer, muscle wasting, spondylosis with myelopathy, wheelchair dependence, and chronic pain syndrome, did not receive wound care as ordered by the physician. Orders included specific wound care regimens for the left hip and sacrum, but review of the Treatment Administration Records showed that wound care was not completed on several dates. The Interim DON acknowledged that the required wound care was not provided on those dates as documented.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that nurse staffing data was posted on a daily basis at the beginning of each shift. During an observation, it was noted that the staffing information displayed was dated four days prior to the current date. In an interview, the Interim DON/Director of Clinical Operations confirmed that the posted staffing data was outdated and acknowledged that it should have been updated daily. No information about residents or their medical conditions was included in the report.
Failure to Provide Ordered Controlled Medication Due to Unavailability
Penalty
Summary
The facility failed to ensure that a controlled medication, Temazepam 7.5 mg, was available and administered as ordered for a resident with diagnoses including Type 2 diabetes mellitus, acute osteomyelitis, difficulty walking, prosthetic heart valve, and generalized anxiety disorder. The resident had an intact cognitive status, as indicated by a BIMS score of 15. According to the physician's order, the resident was to receive Temazepam at bedtime for anxiety. However, review of the Medication Administration Record (MAR) showed that the medication was not administered on three consecutive nights due to it not being available. Interviews with nursing staff confirmed that the medication was not on the medication cart and had not been refilled in a timely manner, despite facility procedures requiring medications to be reordered before running out. The resident reported being informed by nursing staff that the pharmacy had not filled the prescription and there was no Temazepam left. Observations and staff interviews further verified that the medication was not available when needed, resulting in missed doses.
Failure to Immediately Notify Resident's Representative After Injury
Penalty
Summary
The facility failed to immediately notify a resident's representative following an incident that resulted in injury. According to the facility's policy, the responsible party must be notified after all resident falls, possible injuries, or changes in physical or mental function. In this case, a resident with multiple diagnoses, including type 2 diabetes mellitus, unspecified dementia, muscle weakness, difficulty walking, cognitive communication deficit, and chronic kidney disease, experienced an incident on 03/16/2025 that required transport to a local hospital via EMS. The resident's medical record indicated a moderately impaired cognition with a BIMS score of 11. Review of the medical record and incident log showed that the facility did not notify the resident's family immediately after the incident. The family was not contacted until the resident returned from the hospital, and the delay was attributed to the absence of family contact information on the resident's face sheet and profile page at the time of the incident. The administrator confirmed that the family was not notified until the following morning, and the responsible party questioned why notification had not occurred sooner.
Failure to Develop Baseline Care Plan Upon Admission
Penalty
Summary
The facility failed to develop a baseline care plan for one of three sampled residents within 48 hours of admission. Record review showed that the resident was admitted with multiple diagnoses, including type 2 diabetes mellitus, unspecified dementia, muscle weakness, difficulty walking, cognitive communication deficit, and chronic kidney disease. The resident's admission MDS assessment indicated moderately impaired cognition with a BIMS score of 11. Despite these complex medical needs, there was no evidence in the medical record that a baseline care plan had been completed. This deficiency was confirmed during interviews with both an LPN and the facility administrator, who acknowledged that the baseline care plan was not done as required.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to ensure that a registered nurse (RN) was on duty for 8 consecutive hours per day, 7 days per week, as required. Review of staffing records and the Nursing/Ancillary Personnel Staffing Pattern Reporting Form for the period in question revealed that there were no RN staffing hours recorded on 03/21/2025. This was confirmed by both the Human Resource Director and the Administrator during interviews and review of the relevant documentation. The absence of RN coverage on this date had the potential to affect all 24 residents residing in the facility. No specific details about individual residents' medical history or condition at the time of the deficiency were provided in the report.
Failure to Manage Advanced Directives
Penalty
Summary
The facility failed to ensure an effective system was in place for managing advanced directives, resulting in discrepancies and omissions in residents' medical records. Specifically, the facility did not accurately reflect the residents' wishes for emergency basic life support for several residents. For instance, Resident #1's medical record lacked an order for code status, and Resident #15's code status was inconsistent across different parts of the medical record. Additionally, Resident #9 had a care plan for DNR, but the physician's DNR order was unsigned, and there was no documentation that the resident or their representative received information about advance directives. The facility also failed to provide and document that residents and/or their representatives were given information on advanced directives upon admission. This was evident in the cases of multiple residents, including Resident #76, Resident #77, and Resident #126, where there was no documentation of the residents receiving written information regarding advance directives. Furthermore, Resident #77's DNR order was misplaced in another resident's electronic record, and the code status was not updated in the system. Interviews with facility staff revealed systemic issues in the handling of DNR orders and advance directives. Staff reported that residents were considered full code until a DNR order was signed by a physician, but there were delays and inconsistencies in updating the electronic health records. The Medical Director acknowledged discrepancies in code status and emphasized that residents' code status should align with their family's wishes. The Director of Clinical Operations confirmed that admission packets were not entered into the electronic health records in a timely manner, leading to inaccuracies and incomplete documentation of residents' advance directives.
Failure to Assess and Document Bed Rail Use
Penalty
Summary
The facility failed to ensure that residents were assessed for the risk of entrapment from bed rails and did not obtain a written order from a physician for the use of bed rails prior to their installation. This deficiency was identified for seven residents who were reviewed for accident hazards. The facility's policy requires that all residents using restraints, including bed rails, be evaluated for safety risks and that a specific physician's order be documented in the resident's medical record detailing the medical reason, type of restraint, and when it is to be used. Observations during the survey revealed that several residents were using bed rails without the necessary assessments and physician orders. For instance, Resident #4, who had moderately impaired cognition and was dependent on staff for activities of daily living, was observed with quarter side rails in use without a documented physician's order or an assessment for the risk of entrapment. Similar findings were noted for Residents #20, #125, #22, #75, #9, and #126, all of whom had various medical conditions and cognitive impairments, and were dependent on staff for daily activities. Interviews with staff, including the Director of Nursing, confirmed the lack of documentation for physician orders and risk assessments for the use of bed rails for these residents. The facility's failure to adhere to its own policy and regulatory requirements for the use of bed rails resulted in a deficiency related to accident hazards, as the necessary safety evaluations and physician authorizations were not completed prior to the installation and use of bed rails.
Failure to Monitor Drug Regimens for Unnecessary Medications
Penalty
Summary
The facility failed to ensure that the drug regimens of several residents were free from unnecessary medications, as evidenced by inadequate monitoring of specific conditions related to their prescribed medications. Resident #9, who was cognitively intact and diagnosed with conditions including Parkinson's disease and chronic kidney disease, was prescribed Bumex for edema and congestive heart failure. However, the facility did not conduct the required monitoring for edema, as indicated in the resident's care plan, which included monitoring for side effects and effectiveness every shift. Resident #11, with a history of cerebral infarction and other health issues, was on anticoagulant therapy with Apixaban and diuretic therapy with Furosemide. The facility failed to monitor for bleeding related to the anticoagulant and for edema related to the diuretic, despite these being high-risk drug classes. The care plan for Resident #11 included specific interventions for monitoring side effects and effectiveness, which were not followed. Similarly, Resident #76, who was cognitively intact and had conditions such as hemiplegia and chronic kidney disease, was prescribed Furosemide for edema. The facility did not monitor for edema as required. Resident #175, with a BIMS score indicating cognitive intactness and conditions like atrial fibrillation, was on Dabigatran for anticoagulant therapy. The facility failed to monitor for bleeding, as outlined in the care plan. These deficiencies were confirmed through interviews with LPNs who acknowledged the lack of monitoring for these residents.
Failure to Monitor Psychotropic Medication Side Effects
Penalty
Summary
The facility failed to ensure that the drug regimens for two residents were free of unnecessary medications, specifically regarding the monitoring of side effects and behaviors for psychotropic medications. Resident #9, who was cognitively intact with a BIMS score of 15, was receiving Buspirone for anxiety. However, the October 2024 medication administration record (MAR) did not show any monitoring for side effects and behaviors, despite the care plan requiring such monitoring every shift. This oversight was confirmed during an interview with an LPN who acknowledged the lack of monitoring. Similarly, Resident #175, also cognitively intact with a BIMS score of 14, was prescribed Cymbalta for depression. The MAR for October 2024 similarly lacked documentation of monitoring for side effects and behaviors, contrary to the care plan's directives. This deficiency was also confirmed by an LPN during an interview. Both cases highlight the facility's failure to adhere to care plans and ensure proper monitoring of residents on psychotropic medications.
Non-compliance with CNA Background Checks and Registry Searches
Penalty
Summary
The facility failed to comply with Federal, State, and Local Laws, and Professional Standards by not ensuring that Certified Nursing Assistant (CNA) staff underwent and passed criminal background checks prior to employment. Specifically, two CNAs, identified as S12 and S14, were hired without completed criminal background checks at the time of their employment. S12 was hired on May 17, 2024, and S14 on July 23, 2023, with both background checks only performed on September 6, 2024. Additionally, the facility did not conduct monthly searches of the nurse aide registry/adverse action list for three CNAs, identified as S12, S13, and S14. This was confirmed during an interview with S15 from Human Resources, who acknowledged the absence of documentation for both the criminal background checks prior to hire and the monthly registry/adverse action list searches for the mentioned CNAs.
Failure to Complete Baseline Care Plans for New Admissions
Penalty
Summary
The facility failed to ensure that a baseline care plan was completed within 48 hours of admission for two residents, identified as #75 and #76, out of a sample of 20. Resident #75 was admitted with diagnoses including hemiplegia and hemiparesis following a cerebral infarction, diabetes mellitus with diabetic polyneuropathy, and hyperlipidemia. A review of Resident #75's medical records revealed that the Admission MDS was in progress but not completed, and there was no evidence of a completed Baseline Care Plan. During an interview, the Director of Clinical Operations (DOCO) confirmed that it was the nurse's responsibility to complete the Baseline Care Plan upon admission, and acknowledged that it had not been done for Resident #75. Similarly, Resident #76 was admitted with multiple diagnoses, including hemiplegia and hemiparesis following a cerebral infarction, chronic atrial fibrillation, hypertension, heart failure, chronic kidney disease, prediabetes, chronic pain, and insomnia. The Admission 5-day MDS indicated that Resident #76 was cognitively intact with a BIMS score of 15. However, a review of the medical record showed that a Baseline Care Plan had not been completed. The DOCO confirmed during an interview that the baseline care plan was missing and reiterated that it was the nurse's responsibility to complete it upon admission.
Deficiencies in Respiratory Care and Equipment Storage
Penalty
Summary
The facility failed to ensure that oxygen therapy was provided according to its policy and procedure for three residents. Resident #12 was receiving oxygen therapy without a physician's order, which was confirmed by the Director of Nursing who could not find an order specifying the oxygen flow rate. This resident had a history of chronic obstructive pulmonary disease (COPD) with acute exacerbation and was observed using oxygen at 2 liters per minute via nasal cannula without a documented order. Resident #15's CPAP equipment was not stored properly when not in use. The CPAP mask and tubing were observed hanging over the head of the bed and on top of the CPAP machine, rather than being stored in a plastic bag as reported by an LPN. This resident had a history of chronic obstructive pulmonary disease, heart failure, and obstructive sleep apnea, and was cognitively intact with a BIMS score of 15 out of 15. Resident #175 was using a CPAP machine without a physician's order or a care plan addressing its use. The CPAP mask and tubing were found on the floor, not stored in a plastic bag as they should have been. The resident reported using the CPAP machine at night, but there was no documentation in the care plan or physician orders to support this. The Director of Clinical Operations confirmed the lack of a policy for storing CPAP equipment when not in use.
Deficiency in Dialysis Care and Communication
Penalty
Summary
The facility failed to provide dialysis care consistent with professional standards for a resident requiring such services. The deficiency involved not obtaining weekly weights as outlined in the resident's care plan and failing to complete the hemodialysis communication record form, which is crucial for ensuring proper communication between the nursing home and the dialysis facility. The resident, who was cognitively intact, had multiple medical diagnoses including end-stage renal disease and was on a renal diet with scheduled hemodialysis sessions three times a week. The review of the resident's records revealed several instances where the dialysis communication forms were incomplete or missing, indicating a lack of proper communication and documentation. Specific dates were noted where the facility and the dialysis center failed to complete their respective sections of the form, and assessments and vital signs were not performed upon the resident's return from dialysis. The Director of Nursing confirmed these deficiencies during an interview, acknowledging the failure to adhere to the care plan and complete necessary documentation.
Failure to Ensure RN Coverage
Penalty
Summary
The facility failed to ensure the use of registered nurse (RN) services for at least 8 consecutive hours a day, 7 days a week during Fiscal Year Quarter 3 2024, specifically from April 1 to June 30. The Payroll Based Journal (PBJ) Staffing Report indicated that the facility did not have licensed nursing coverage for 24 hours on several dates, including May 4, 5, 18, 26, June 2, 16, 22, 23, 29, and 30. A review of the facility's Nursing/Ancillary Personnel Staffing Pattern Reporting Form dated October 17, 2024, confirmed that RN services were not utilized on May 5 and May 18, 2024. During an interview on October 17, 2024, the facility's administrator acknowledged the absence of RN services on these specific dates.
Failure to Conduct Annual CNA Performance Evaluations
Penalty
Summary
The facility failed to conduct annual performance evaluations for two Certified Nursing Assistants (CNAs), identified as S13 and S14, out of five CNA personnel records reviewed. S13 CNA was hired on January 5, 2018, and there was no documentation of an annual performance evaluation since January 12, 2023. S14 CNA was hired on July 23, 2023, and there was no documentation of an annual performance evaluation since their hire date. During an interview on October 17, 2024, S15 from Human Resources confirmed the absence of documentation for these evaluations.
Inaccurate Staffing Data Submission to CMS
Penalty
Summary
The facility failed to accurately submit mandatory direct care staffing information to the Centers for Medicare & Medicaid Services (CMS) for Fiscal Year Quarter 3 2024. The Payroll Based Journal (PBJ) Staffing Report indicated that the facility did not have licensed nursing coverage 24 hours a day on several specific dates within the quarter. However, a review of the facility's Nursing/Ancillary Personnel Staffing Pattern Reporting Form for those dates showed that licensed nursing coverage was indeed present. During an interview, the facility's administrator reported that the corporate office submits the PBJ data to CMS using the facility's time clock management system and suggested that agency staffing hours might have been omitted from the submission.
QAA Meetings Not Conducted Quarterly with Required Staff
Penalty
Summary
The facility failed to conduct Quality Assessment and Assurance (QAA) meetings at least quarterly with the required staff present since the last annual survey. A review of the QAA binder with the Administrator revealed that there was no QAA meeting held for the first quarter. Additionally, the Director of Nursing (DON) was not present for the QAA meeting in the second quarter. During an interview, the Administrator confirmed these deficiencies, acknowledging the absence of a meeting in the first quarter and the DON's absence in the second quarter meeting.
Failure to Administer Consented Vaccinations
Penalty
Summary
The facility failed to ensure that immunizations were administered to residents who consented to receive them during the admission process. Specifically, two residents who had consented to receive the pneumonia and COVID-19 vaccines did not have these vaccines administered. The facility's policy requires that the Director of Nursing, in conjunction with the Infection Preventionist or RN designee, ensure that vaccines are offered and administered upon admission, and that physician orders are obtained for these vaccines. However, the review of the residents' medical records revealed no physician orders or documentation indicating that the vaccines were administered. The deficiency occurred because the admission packets, which included the Immunization Informed Consent forms, were not scanned and provided to the Infection Preventionist. This oversight resulted in the Infection Preventionist not receiving the necessary consents to administer the vaccines. Interviews with the Infection Preventionist and the Director of Clinical Operation confirmed that the failure to scan and deliver the admission packets led to the residents not receiving their immunizations as consented.
CNA Training Deficiency in Dementia Care
Penalty
Summary
The facility failed to ensure that Certified Nursing Assistants (CNAs) received the required training, specifically in dementia care, as evidenced by the personnel record review of one CNA. The CNA, identified as S12, was hired on May 17, 2024, but their personnel record did not contain documentation of the required dementia training. This deficiency was confirmed during an interview with S15 from Human Resources, who reviewed S12's personnel record and acknowledged the absence of documentation for dementia training.
Latest citations in Louisiana
A resident with Parkinson’s disease, essential tremor, dementia, and legal blindness, who was care planned as being at risk for burns from hot liquids and to receive hot beverages in lidded cups at temperatures not exceeding 130°F, sustained 2nd and 3rd degree burns to the left thigh after spilling coffee during a group activity. The facility’s policy required hot beverages to be cooled to 120–130°F and mandated temperature monitoring, but the coffee served at the time of the incident was reported by dietary staff to be 140°F, and the coffee temperature log did not include documentation for the 10:00 a.m. service when the spill occurred. This failure to adhere to the hot beverage policy and to consistently monitor and document beverage temperatures resulted in actual harm to the resident.
A resident with severe cognitive impairment, multiple chronic conditions, and hospice services required extensive assistance for transfers. During a transfer from wheelchair to bed performed by a CNA, the resident’s left lower leg rubbed against an enabler bar that had a missing end cap, creating a sharp edge. An LPN observed a large laceration on the leg and identified the defective enabler bar as the source of injury. The resident was sent to the ED, where a deep, 25.5 cm stellate laceration required extensive cleaning, internal and external sutures, a tetanus shot, and subsequent daily wound care and antibiotics due to delayed healing. The incident occurred despite facility policies and the Maintenance Supervisor’s responsibilities requiring regular inspection of bed rails and enabler bars for hazards.
The facility did not maintain the required 8 consecutive hours of daily RN coverage on multiple days, as time card records showed that the only scheduled RN worked less than 8 hours on several occasions. The administrator confirmed that this RN was the sole RN scheduled during the period reviewed and acknowledged that full daily RN coverage was not provided on the identified days.
The facility failed to maintain adequate supplies of clean bath towels and bed linens despite its own assessment identifying the need to keep sufficient PAR levels for these items. A resident with a history of traumatic brain injury and another with type 2 DM and asthma, both cognitively intact, reported that towels and linens were often unavailable, with one resident’s family providing personal linens due to frequent shortages. The grievance log documented a complaint about missing personal towels and sheets, and staff, including laundry personnel, a CNA, and the ADON, confirmed that clean towels and bed linens were frequently unavailable during multiple weeks, affecting all residents in the facility.
A resident with severe cognitive impairment, dementia, and multiple comorbidities, assessed as high risk for elopement due to prior exit-seeking and wandering, was found alone outside near the front entrance in a flower bed by an oncoming LPN. The LPN assisted the resident and notified staff inside, and the responsible party later reported the same event. Despite a written wandering and elopement policy requiring notification of regulatory agencies after such incidents, the Administrator acknowledged that this elopement was not reported to the State Survey Agency as required by state law.
A resident with multiple conditions, including type 2 DM, dementia with behavioral symptoms, gait abnormalities, and an anxiety disorder, was documented in progress notes as having eloped and been found outside in a flower bed, and later was found to have a diabetic ulcer on the right heel. Review of the comprehensive care plan showed it was not revised to address either the elopement or the new diabetic ulcer, and the MDS coordinator acknowledged that the care plan should have been updated to reflect these changes in condition.
A resident with type 2 DM, dementia, mobility impairments, and other comorbidities was admitted with a documented deep tissue injury on the right heel, but no corresponding MD wound care orders or treatments were recorded for approximately one month despite a care plan directive to assess for skin breakdown and treat as ordered. A NP note referenced treatment with gentian violet and foam, yet this was not supported by physician orders or the TAR. Later, a wound care nurse identified a diabetic ulcer on the same heel and initiated gentian violet and foam dressings after an order was finally obtained, with treatments documented on only a few dates. The resident was later seen in the ED for cellulitis related to the diabetic heel ulcer and discharged with antibiotics, and both the wound care nurse and NP confirmed gaps in assessment, ordering, and follow-up of the heel wound.
Staff failed to follow infection control protocols during incontinence care for two residents, including not performing required hand hygiene between glove changes and after contact with stool, and placing soiled items on clean linens. CNAs provided perineal care, handled residents’ clean clothing, body surfaces, wheelchairs, and room surfaces, and managed soiled briefs and pads without appropriate glove changes or hand sanitizing, contrary to facility policy. Both CNAs later acknowledged they should have performed hand hygiene and changed gloves correctly, and the DON confirmed that staff are expected to follow these infection prevention practices.
Two residents were not treated in a manner that promoted dignity and quality of life. One resident with left-sided weakness and a flaccid arm following a stroke requested a bedpan, but a CNA told her she was wearing a diaper and could use it instead, despite therapy having recommended bedpan use and the resident not wanting to use a diaper. Another resident with vascular dementia, a history of C. diff enterocolitis, heart failure, and depression, and a moderately impaired BIMS score continued to receive meals on disposable dishware in the dining room even though contact isolation precautions had been discontinued, and nursing leadership confirmed this should not have occurred.
A resident with paraplegia, severe cognitive impairment (BIMS 6), and dependence for mobility and hygiene was repeatedly observed in bed and in a Geri chair without access to a call light, despite facility policy requiring call lights to be within easy reach when residents are in bed or confined to a chair. On multiple occasions throughout the day, the call light was found on the floor or hanging on the side of the bed, out of the resident’s reach. The resident reported being unable to reach the call light, and both a CNA and the DON acknowledged that the call light was not within reach and should have been accessible.
Resident Burn from Overheated Coffee and Failure to Follow Hot Beverage Policy
Penalty
Summary
The deficiency involves the facility’s failure to ensure the environment was free from accident hazards and that residents received adequate supervision to prevent accidents, specifically related to serving hot beverages. The facility had a written policy titled “Serving Hot Beverages and Soup,” revised in 07/2007, which required the Food Service Department to monitor the temperature of all hot liquids to prevent burns if they contacted skin. The policy specified that coffee should be chilled to 120–130°F before being served and that the Food Service Department was responsible for ensuring all hot beverages, including those for activities, left the kitchen at the proper temperature. However, the coffee temperature log for March only included entries for 6:00 a.m. and 2:00 p.m., with no slot or documentation for 10:00 a.m. coffee temperatures, despite coffee being served at that time. Resident #1 was admitted with diagnoses including Parkinson’s disease, unspecified dementia, essential tremor, and legal blindness. A quarterly MDS with an ARD of 12/31/2025 showed a BIMS score of 13, indicating the resident was cognitively intact, and Section GG indicated no functional limitation in upper extremity range of motion. The resident’s care plan included a focus that the resident was at risk for burns from hot liquids, with interventions such as encouraging consumption of hot liquids while sitting at a table, requiring use of a cup with a lid for all hot beverages, and specifying that the temperature of hot liquids should not exceed 130°F. Another care plan focus addressed impaired visual function related to legal blindness, with interventions to provide activities adjusted to the resident’s visual disability. During a 10:00 a.m. group activity, Resident #1 spilled hot coffee on her lap. The dietary manager later confirmed that coffee was served at 6:30 a.m., 10:00 a.m., and 2:00 p.m., and that the dietary aide who prepared the coffee for the incident reported the coffee temperature as 140°F, which exceeded the facility’s policy limit of 130°F. Resident #1 reported that she spilled coffee on herself while sitting at a table in the activity room and that the coffee was hot and burned when it was spilled. Subsequent nursing and NP assessments documented two in-house–acquired wounds on the resident’s left upper thigh: one described as a blister and one as a burn, later characterized by the NP as a full-thickness (3rd degree) burn and a partial-thickness (2nd degree) burn. These findings, combined with the lack of documented 10:00 a.m. temperature monitoring and the reported serving temperature of 140°F, demonstrate that the facility did not follow its hot beverage policy and failed to protect the resident from an avoidable burn hazard.
Failure to Maintain Safe Enabler Bar Results in Severe Leg Laceration
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident’s enabler bar was free from accident hazards, resulting in an actual injury. The facility’s own Bed and Side Rails policy required a designee to inspect all bed frames, mattresses, and bed rails, including grab bars and assist bars, as part of a regular maintenance program. The Maintenance Supervisor job description also required daily tours of the property to identify and correct hazardous conditions and liability hazards. Despite these requirements, the enabler bar on one resident’s bed had a missing end cap, creating a sharp edge that was not identified or corrected prior to use. The affected resident had been admitted with multiple diagnoses, including Peripheral Vascular Disease, Malnutrition, Chronic Kidney Disease, Depression, and Alzheimer’s Disease, and had a BIMS score of 5, indicating severe cognitive impairment. The resident was receiving hospice services and required extensive assistance of one staff person with transfers, as documented in the care plan. On the date of the incident, a CNA assisted the resident with a transfer from a wheelchair to the bed. During this transfer, the resident’s left lower leg rubbed against the enabler bar that had the missing end cap and sharp edge. Nursing documentation recorded that the CNA called an LPN to the room and the LPN observed a large laceration on the resident’s left lower leg with bleeding, which the CNA reported had occurred during the transfer. The LPN noted that the enabler bar had a missing end cap, resulting in a sharp edge, and that the resident’s leg had contacted this area during the transfer. The resident was sent to the emergency department, where records described a very large stellate laceration measuring 25.5 cm on the lateral left lower leg, extending deep to the fascia and requiring extensive cleaning and a complicated repair with internal and external sutures, as well as a tetanus vaccination. Subsequent physician notes documented that the wound required ongoing assessment, daily wound care, and two courses of Bactrim DS due to the extent and depth of the laceration and delayed healing, with sutures removed in stages over several weeks.
Failure to Maintain Required Daily RN Coverage
Penalty
Summary
The facility failed to ensure that a registered nurse (RN) was on duty for 8 consecutive hours per day, 7 days a week, as required. Review of the time card report for staff member S5RN from 02/22/2026 through 03/24/2026 showed that on five specific dates—02/25/2026, 02/26/2026, 02/27/2026, 02/28/2026, and 03/01/2026—there were fewer than 8 consecutive hours of RN coverage, with recorded work times of 6.50, 7.48, 6.48, 7.50, and 7.50 hours respectively. During an interview on 03/25/2026 at 9:35 a.m., the Administrator (S1) confirmed that S5RN was the only RN scheduled between 02/22/2026 and 03/21/2026 and acknowledged that the facility did not have 8 consecutive hours of RN coverage on the identified dates. No additional information was provided in the report regarding specific residents, their medical conditions, or any clinical events occurring during the periods without full RN coverage.
Failure to Maintain Adequate Supply of Clean Towels and Bed Linens
Penalty
Summary
The facility failed to provide residents with a safe, functional, sanitary, and comfortable environment by not ensuring the consistent availability of clean bath towels and bed linens. The facility’s own Facility Assessment Tool, updated on 03/23/2026, identified bed and bath linen as non-medical supplies for which PAR levels must be maintained at all times to ensure adequate supplies. Despite this, multiple interviews and record reviews showed that clean linens and towels were often unavailable. One resident, admitted on 12/05/2022 with diagnoses including diffuse traumatic brain injury and allergic rhinitis and a BIMS score of 15 (no cognitive impairment), reported that bath towels and bed linens were often unavailable, most recently during the week of 03/15/2026 through 03/21/2026. Another resident, admitted on 07/12/2023 with diagnoses including type 2 diabetes mellitus and asthma and a BIMS score of 15, had filed a grievance on 01/10/2026 reporting that personal bath towels and sheets were missing from the laundry and later reported that family had to provide personal linens because the facility frequently lacked bath towels and bed linens. Staff interviews corroborated these reports: a laundry staff member stated the facility frequently did not have clean bath towels and bed linens available for residents; a CNA reported that clean bath towels and bed linens were unavailable for residents during the week of 03/08/2026 through 03/14/2026; and the ADON confirmed that the facility did not have clean bath towels and bed linens available for residents on 03/23/2026. This pattern of unavailability affected the facility’s census of 58 residents.
Failure to Report Resident Elopement to State Survey Agency
Penalty
Summary
The deficiency involves the facility’s failure to report a resident elopement to the State Survey Agency as required by state law and by the facility’s own Wandering and Elopement Policy dated 11/15/2023. That policy directs that when a resident returns after an elopement, the DON or charge nurse must examine the resident, notify the attending physician, complete an incident/accident report, document the event in the medical record, and notify regulatory agencies per state guidelines. Record review showed that one resident, admitted on 01/09/2026, had multiple diagnoses including type 2 diabetes mellitus, cognitive communication deficit, aphasia, muscle wasting and atrophy, gait and mobility abnormalities, disorientation, unspecified dementia with anxiety, psychotic and mood disturbance, anxiety disorder, and essential hypertension. A Quarterly MDS documented a BIMS score of 4, indicating severely impaired cognition, and the resident was assessed as an elopement risk level 3 due to a history of attempted elopement at home, wandering with purpose in the facility, and exit-seeking behavior. Progress notes and interviews confirmed that on 02/08/2026 the resident was found outside the facility alone in the flower bed at the front of the building, bent over with hands in the dirt, by an oncoming nurse arriving for her shift. The LPN reported she parked her car, went to assist the resident, and alerted staff inside that the resident was outside alone. The resident’s responsible party similarly reported that the resident had been found outside alone in front of the facility on that date. During interview, the Administrator confirmed that the resident, who had dementia and a BIMS score of 4, had been found outside in the flower bed in front of the facility and acknowledged that this incident was not reported to the State Survey Agency, constituting a failure to report the elopement in accordance with state law and facility policy.
Failure to Revise Care Plan After Elopement and Development of Diabetic Ulcer
Penalty
Summary
The deficiency involves the facility’s failure to revise a resident’s comprehensive care plan following significant changes in condition, specifically an elopement and the development of a diabetic ulcer. The resident was admitted with multiple diagnoses, including type 2 diabetes mellitus, cognitive communication deficit, aphasia, muscle wasting and atrophy at multiple sites, gait and mobility abnormalities, disorientation, unspecified dementia with associated anxiety, psychotic and mood disturbances, an anxiety disorder, and essential hypertension. Progress notes documented that the resident was found outside the facility in a flower bed, bent over with hands in the dirt, after having eloped from the building. Further review of the resident’s progress notes showed that a diabetic ulcer was identified on the resident’s right heel the day after the elopement. Despite these documented changes in condition, review of the resident’s comprehensive care plan revealed no revisions to address the actual elopement event or the new diabetic ulcer on the right heel. During an interview, the MDS Coordinator confirmed that the resident’s care plan should have been revised to reflect both the elopement and the development of the diabetic ulcer, but it was not.
Failure to Implement and Document Diabetic Foot and Heel Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with professional standards of practice and the comprehensive care plan for a resident with diabetes and multiple comorbidities. The resident was admitted with type 2 diabetes mellitus, cognitive communication deficit, aphasia, muscle wasting and atrophy, gait and mobility abnormalities, disorientation, unspecified dementia with associated psychiatric symptoms, anxiety disorder, and hypertension. On admission, the Minimum Data Set and skin assessment documented a deep tissue injury on the right heel. A nurse practitioner’s progress note dated shortly after admission described a deep tissue injury on the right heel being treated with gentian violet and foam and noted the heel was tender to touch. However, there were no corresponding physician’s orders for wound care treatment on the January and early February physician order sheets, and the treatment administration records for that same period showed no wound care treatments provided. The resident’s care plan for diabetes included an approach to check the body for breaks in the skin and treat promptly as ordered by the physician, but the facility did not develop and implement specific approaches addressing the documented right heel injury. A wound care nurse’s progress note later identified a diabetic ulcer on the right heel, described as tender and spongy, and documented application of gentian violet–soaked gauze and foam dressing. Only then was a physician’s order written to monitor the right heel and apply gentian violet dampened gauze and a protective dressing on specified days, with the treatment administration record showing documentation of these treatments on only three dates. The resident’s responsible party reported that the resident was discharged and subsequently required emergency department treatment for cellulitis due to a diabetic ulcer on the right heel, for which antibiotics were prescribed. The wound care nurse confirmed the initial documentation of a deep tissue injury without any physician’s orders for treatment and that the diabetic ulcer was not identified until nearly a month after admission, and the nurse practitioner confirmed he examined the right heel only once during that period.
Failure to Follow Hand Hygiene and Glove Protocols During Incontinence Care
Penalty
Summary
The deficiency involves the facility’s failure to maintain an infection prevention and control program during incontinence care, specifically related to hand hygiene, glove use, and handling of soiled linens. The facility’s own policy for bladder incontinence care requires staff to perform handwashing or use alcohol gel, don disposable gloves, cleanse the perineal and anal areas, then remove and discard gloves and perform hand hygiene before proceeding. During observed incontinence care for one resident, a CNA donned clean gloves and used perineal wipes to remove bowel movement from the resident’s buttocks, then, without changing gloves or performing hand hygiene, placed a clean incontinence pad and brief under the resident. The CNA placed a soiled brief and urine-soaked bed pad at the foot of the bed on top of the resident’s clean comforter, then disposed of the soiled brief in the trash, spread a clean incontinence pad on the bed, and secured a clean brief, all without changing gloves or performing hand hygiene. The same CNA continued to touch the resident’s clean clothing, body, wheelchair armrests, and room door, transferred the resident to the wheelchair, and moved the resident into the hallway, then returned to retrieve the soiled incontinence pad and carried it down the hall to the soiled linen barrel before finally disposing of gloves, again without any observed hand hygiene during the entire episode of care. In a separate observation involving another resident, two CNAs provided incontinence care without performing hand hygiene before donning gloves. One CNA removed bowel movement from the resident’s buttocks, discarded the soiled brief, removed soiled gloves, and donned clean gloves without hand hygiene, then touched the resident’s extremities, bed linens, and applied a clean brief and incontinence pad. The CNA again changed gloves and dressed the resident in a clean gown, touching multiple body areas, without hand hygiene. The second CNA unfastened the brief, confirmed the resident remained soiled, wiped remaining stool, and helped secure the clean brief without changing soiled gloves or performing hand hygiene. Both CNAs later confirmed in interviews that they should have performed hand hygiene and changed gloves appropriately, and the DON confirmed staff are expected to change gloves when soiled or moving from contaminated to clean areas, sanitize hands between glove changes and between residents, and avoid placing soiled linen on clean linen.
Failure to Honor Resident Dignity and Discontinue Unnecessary Isolation Practices
Penalty
Summary
The deficiency involves failure to honor residents' rights to dignity and self-determination. One resident, who was lying in bed and requested a bedpan, was observed on 03/25/2026 at 8:59 a.m. using the call light with surveyor assistance. When the CNA entered the room, she stated the resident was wearing a diaper, could not get up due to left-sided weakness from a stroke, and said the resident "can go in her diaper" instead of providing a bedpan as requested. A COTA later reported that therapy had recommended the resident use a bedpan and had removed the bedside commode the previous day, and that the resident did not want to use a diaper. The COTA also stated the resident’s left arm was flaccid and that she required maximum assistance of two people. A second deficiency involved another resident who continued to receive meals on disposable dishware in the dining room after contact isolation precautions had been discontinued. This resident had diagnoses including vascular dementia, enterocolitis due to Clostridium difficile, hyperlipidemia, heart failure, and depression, and had a BIMS score of 9, indicating moderately impaired cognition. A physician order for single room isolation with contact precautions had been discontinued on 02/17/2026, yet on 03/23/2026 at 11:20 a.m., the resident was observed receiving a lunch tray on disposable dishware while seated in the dining room. The ADON confirmed the resident was no longer on contact precautions and should not have been receiving meals on disposable dishware.
Failure to Keep Call Light Within Reach for Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s call light was accessible as required by facility policy and necessary to reasonably accommodate the resident’s needs. The facility’s policy on answering call lights, dated 01/16/2026, states that when a resident is in bed or confined to a chair, the call light must be within easy reach. Resident #3 was admitted on 12/07/2023 with diagnoses including mononeural disorder, paraplegia, epilepsy, and peripheral vascular disease. A quarterly MDS with an ARD of 03/03/2026 documented a BIMS score of 6, indicating severe cognitive impairment, and showed the resident required setup assistance with eating, was dependent for toileting and personal hygiene, and needed substantial/maximal assistance to roll left to right. On multiple observations on 03/24/2026, surveyors found the resident’s call bell out of reach despite the resident’s reliance on it to express needs. At 10:12 a.m., the resident was lying in bed with eyes closed and the call bell was on the floor on the right side of the bed, not within reach. At 12:24 p.m., the resident was awake and alert in bed, and again the call bell was on the floor and not reachable; the resident stated he could not reach it. During an interview at 12:45 p.m., a CNA familiar with the resident confirmed the resident could express needs with short responses and used the call bell. At 12:48 p.m., with the CNA present, the call bell was still on the floor and not within reach, and the CNA acknowledged it should have been accessible. Later observations at 1:41 p.m. and 3:00 p.m. found the resident awake and alert in a reclined position in a Geri chair, with the call bell hanging on the side of the bed and again out of reach; the DON, present at 3:00 p.m., confirmed the call bell was not within reach and should have been.
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