Below 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 Adira Medical Resort during CMS and state inspections, most recent first.
Surveyors found that the facility failed to follow and document physician-ordered wound care for three residents with complex wounds and pressure ulcers. One resident with extensive burns, multiple pressure ulcers, and open wounds had numerous daily wound treatments ordered for the heel, buttocks, thigh, back, and umbilical area, yet the TAR showed many dates with no documentation of care despite a care plan directing treatments as ordered and weekly wound monitoring. Another resident with a sacral pressure ulcer and paraplegia had scheduled wound vac treatments ordered twice weekly, but wound care was not documented on two ordered days. A third resident with an unstageable heel ulcer, a surgically repaired lower leg fracture, and additional wounds had daily and three-times-weekly wound treatments ordered for the breast, heel, and surgical site, with multiple treatment dates lacking documentation. The ADON/Treatment Nurse and the Administrator confirmed there was no evidence that the ordered wound care had been provided on the missing dates.
Missing CNA Skills Competency Documentation: The facility failed to ensure two CNAs had documented skills competency in their personnel records. Record review showed both aides had hire dates on file, but no evidence of completed competency assessments was present, and the Administrator confirmed the missing documentation during interview.
The facility failed to obtain CNA registry verification prior to hire for 2 of 5 CNA personnel records reviewed. Two CNAs had hire dates listed in their files, but neither record contained documented evidence of CNA registry verification. The Administrator reviewed both files and confirmed the missing verification.
A resident with documented allergies to tomatoes and potatoes was served lunch that included tomatoes in a tomato-based shrimp etouffee. The meal ticket identified the tomato allergy, the resident confirmed the allergy, and a CNA also verified it. The Dietary Manager stated the dish had been overlooked by accident and should not have been served.
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 Follow and Document Physician-Ordered Wound Care Treatments
Penalty
Summary
The deficiency involves the facility’s failure to follow physician orders and document wound care treatments for multiple residents with significant skin integrity issues. The facility’s own undated "Wound Treatment Management" policy states that wound treatments will be provided in accordance with physician orders, including cleansing method, type of dressing, and frequency of dressing change, and that treatments will be documented on the Treatment Administration Record (TAR) or in the electronic health record. Despite this policy, record review and interviews showed that ordered wound treatments were either not documented or had no evidence of being completed for three of five sampled residents reviewed for wounds. One resident was admitted with extensive burns involving 80–89% of body surface with third-degree burns, multiple pressure ulcers (including left heel and left hip), open wounds of the thorax and abdominal wall, morbid obesity, Type 2 diabetes, anemia, chronic embolism and thrombosis, atherosclerosis of the left leg, and diastolic congestive heart failure. This resident had multiple physician orders for daily and PRN wound care to the left heel, right buttock, left buttock, left thigh, back, and umbilical area, specifying cleansing with wound cleanser and application of collagen powder, calcium alginate, Santyl, Betadine, and appropriate dressings. The resident’s care plan included interventions to administer treatments as ordered and monitor wound healing weekly. Review of the March TAR showed wound care was not documented as done for the left heel, right buttock, left buttock, left thigh, and umbilical wounds on numerous dates throughout the month, and the back wound lacked documentation on several specific dates. The ADON/Treatment Nurse and the Administrator both confirmed there were multiple instances with no evidence that wound care had been provided as ordered. Another resident, admitted with a sacral pressure ulcer, essential hypertension, and paraplegia, had physician orders for sacral wound care using a wound vac system on specified days and PRN for dislodgement or leaks, with detailed instructions for cleansing, applying adaptic, black vac foam, and setting the device at a prescribed mmHg continuous pressure. The care plan included administering treatments as ordered, monitoring wound healing weekly, and turning/repositioning at least every two hours. Review of the February and March TARs revealed that wound care for the sacral wound was not documented as done on two ordered treatment days. The ADON/Treatment Nurse and the Administrator confirmed that there was no evidence wound care had been provided on those dates. A third resident, admitted with an unstageable left heel pressure ulcer, a displaced bimalleolar fracture of the right lower leg with surgical repair, Type 2 diabetes, and hypertension, had multiple wound care orders. These included daily and PRN wound care to the left breast and left heel with specified cleansing agents (wound cleanser, Betadine), calcium alginate, and bordered foam dressings, as well as orders for right lower leg/right foot surgical site care three times weekly, including cleaning around pin sites with chloraprep, applying an ABD pad, cast padding, and securing with an ace wrap. The care plan called for administering treatments as ordered, monitoring wound healing, and turning/repositioning at least every two hours. Review of the March TAR showed that wound care for the left breast and left heel was not documented as done on multiple dates, and surgical site care to the right lower leg/right foot was not documented on several of the ordered treatment days. The ADON/Treatment Nurse and the Administrator confirmed there were multiple dates with no evidence that the ordered wound care had been provided.
Missing CNA Skills Competency Documentation
Penalty
Summary
Nurses and nurse aides were not ensured to have the appropriate competencies to care for every resident in a way that maximized each resident's well being. Based on record review and interview, the facility failed to ensure CNA personnel had documented skills competency for 2 of 5 CNA records reviewed. Review of one CNA's personnel record showed a hire date of 01/14/2025, but no documented skills competency was found. Review of a second CNA's personnel record showed a hire date of 10/22/2025, but no documented skills competency was found. During an interview on 01/21/2026 at 1:34 p.m., the Administrator reviewed both personnel files and confirmed the facility did not have documented evidence of skills competencies for either CNA.
Missing CNA Registry Verification Prior to Hire
Penalty
Summary
The facility failed to obtain CNA registry verification prior to hire for 2 of 5 CNA personnel records reviewed, specifically S4CNA and S7CNA. S4CNA’s personnel record showed a hire date of 09/20/2025, but the record did not contain documented evidence that CNA registry verification had been obtained. S7CNA’s personnel record showed a hire date of 09/04/2025, and the record likewise did not contain CNA registry verification. During an interview on 01/21/2026 at 2:28 p.m., the Administrator reviewed both personnel files and confirmed that the facility did not have documented evidence of CNA registry verification prior to hire for either CNA.
Failure to Honor Resident Food Allergy
Penalty
Summary
The facility failed to honor and accommodate a resident’s food allergies by serving a lunch tray that included tomatoes to Resident #20, whose medical record listed allergies to tomatoes and potatoes. Resident #20 was admitted with diagnoses including type 2 diabetes mellitus without complications and urinary tract infection, and the Diet Requisition Form signed by the DON documented new admission allergies of potatoes and tomatoes. On observation, the resident’s lunch tray meal ticket identified an allergy to tomatoes, yet the tray contained tomatoes in a tomato-based shrimp etouffee. During interview, the resident confirmed the tomato allergy, a CNA read the meal ticket and confirmed the allergy, and the Dietary Manager later stated the tomato-based shrimp etouffee had been overlooked by accident and should not have been served to the resident.
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.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 116 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Bossier City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Cypress Point Nursing & Rehabilitation Center | 0.8 mi | ★★★★★ | 0 | 0 |
| Old Brownlee Community Care Center | 1.4 mi | ★★★★★ | 0 | 0 |
| Heritage Manor Health & Rehab | 2.2 mi | ★★★★★ | 8 | 0 |
| Pilgrim Manor Skilled Nursing And Rehabilitation | 3.1 mi | ★★★★★ | 8 | 0 |
| Highland Place Rehab And Nursing Center | 6.1 mi | ★★★★★ | 4 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.