Below average — CMS composite of the measures below.
The next survey window likely opens around March 2027
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 Southern Hills Healthcare And Rehabilitation during CMS and state inspections, most recent first.
A resident with dementia, anxiety, insomnia, and a new bipolar disorder diagnosis had an active bipolar diagnosis on the quarterly MDS, but the record did not show a level II PASARR referral. Social Services said the resident had a permanent level II PASARR but could not provide documentation, and the DON confirmed the PASRR referral was not completed after the new diagnosis.
A resident admitted with cerebral infarction and COPD had an order for Xarelto related to the cerebral infarction, but the care plan did not include a problem or approach for the stroke diagnosis or anticoagulant therapy. An MDS nurse acknowledged the resident had not been care planned for the cerebral infarction or anticoagulant use.
Failure to transmit an MDS assessment: A resident with DM2, HF, and paranoid schizophrenia had an assessment entered as the wrong type, and the MDS nurse acknowledged that the annual assessment had not been transmitted within the required timeframe.
A resident who was physically dependent and at high risk for falls was left unsupervised during incontinent care when a CNA turned away to retrieve supplies, leaving the bed in a high position. The resident lost grip on the side rail and fell, resulting in a fractured femur and transfer to the ER. Staff interviews confirmed the lack of supervision and improper bed positioning directly led to the incident.
A resident with severe cognitive impairment was subjected to unwanted sexual contact by another resident in an unlit dining room. The facility failed to implement protective measures or report the incident, resulting in Immediate Jeopardy. Staff interviews revealed a lack of communication and training on abuse policies.
A resident with cognitive impairments was subjected to unwanted sexual contact by another resident, and the incident was not reported to the necessary authorities within the required timeframe. The facility's staff, including the DON, were aware of the incident but failed to notify the administrator or report it to the state agency and law enforcement, resulting in an Immediate Jeopardy situation.
A facility failed to protect a resident from sexual abuse by another resident and did not report the incident to the state agency or law enforcement. The DON did not provide in-service training to all staff on abuse and neglect, and the Administrator was not informed of the incident until months later. No interventions were put in place to ensure resident safety, leading to an Immediate Jeopardy situation.
A resident with severe cognitive impairment was involved in a sexual abuse incident where another male resident inappropriately touched them. Despite the incident being reported by a CNA to an RN, the resident's representative and physician were not notified. The DON acknowledged the oversight and confirmed the lack of notification.
The facility failed to ensure physician orders were in place for two residents' care devices. A resident with Alzheimer's and impaired cognition had a wander guard alarm without a physician's order. Another resident with a PICC line for antibiotics lacked orders for its maintenance or discontinuation. These deficiencies were acknowledged by the DON.
The facility failed to assess the risk of entrapment for three residents using bed rails, as required by policy. Despite physician orders and care plans indicating the use of assist rails for bed mobility, there was no documentation of entrapment risk assessments. Observations confirmed the presence of raised rails, and staff interviews revealed that maintenance checks for entrapment risk were not conducted.
The facility failed to complete an annual performance review for a CNA, identified as S11, for the year 2024. S11's personnel record, reviewed by Human Resources, confirmed the absence of this required evaluation.
A facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with a midline catheter and surgical wound, necessary for preventing infection transmission. Observations showed missing EBP signage and unavailable PPE, acknowledged by the DON, indicating a lapse in infection control practices.
A facility failed to update a resident's care plan following a resident-to-resident abuse incident. The resident, with moderate cognitive impairment and multiple psychiatric diagnoses, was involved in a sexual abuse incident. Despite this, the care plan was not revised to include increased monitoring or supervision. The DON confirmed the oversight during interviews.
A resident with a urinary catheter was observed with the Foley catheter bag placed on the floor, which is against basic care standards. The resident has multiple medical conditions, including dementia and hypertension, and is dependent on staff for toileting. The issue was confirmed by the DON and acknowledged by the Corporate Nurse.
A resident with multiple medical conditions, including malnutrition and dysphagia, was receiving enteral feeding at an incorrect rate. The physician's order specified a rate of 45 ml/hr, but observations showed the feeding pump infusing at 60 ml/hr. This discrepancy was confirmed by an LPN, indicating a failure to provide appropriate care for the resident's feeding tube.
The facility did not have the required members present for the quarterly QAA meetings since the last annual survey. A review of the QAA Committee Summary sign-in sheet showed that the meeting included the Administrator, DON, Medical Director, and a Nurse Practitioner, but the Administrator later confirmed that the required members were not present.
Failure to Complete PASARR Referral for New Bipolar Disorder Diagnosis
Penalty
Summary
The facility failed to refer one resident with a new diagnosis of bipolar disorder for a level II PASARR. Resident #70 was admitted on 10/09/2020 and had diagnoses including generalized anxiety disorder, dementia, bipolar disorder current episode mixed severe with psychotic features, and insomnia. Review of the resident’s quarterly MDS showed an active diagnosis of bipolar disorder, but the medical record did not contain documentation that a level II PASARR referral had been completed for the new diagnosis. During interview, the Social Services staff member stated the resident had a permanent level II PASARR but could not produce documentation, and the DON later confirmed that a level II PASRR referral was not completed after the new bipolar disorder diagnosis.
Missing Care Plan for Cerebral Infarction and Anticoagulant Therapy
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for Resident #33, who was admitted with diagnoses including cerebral infarction and chronic obstructive pulmonary disease. The resident had a physician order dated 02/13/2026 for Xarelto 10 mg by mouth in the evening related to cerebral infarction, but the Comprehensive Care Plan did not include a problem and approach for either the cerebral infarction or the anticoagulant therapy. During an interview on 04/14/2026 at 12:40 p.m., the S3MDS Nurse acknowledged that Resident #33 had not been care planned for cerebral infarction and the use of an anticoagulant and stated that this should have been done.
Failure to Transmit MDS Assessment
Penalty
Summary
The facility failed to transmit Resident #56’s assessment within 14 days after completion for 1 of 1 residents reviewed for resident assessments. Resident #56 was admitted on 08/19/2024 with diagnoses including type 2 diabetes with hyperglycemia, heart failure unspecified, and paranoid schizophrenia. Review of the MDS assessments showed a quarterly assessment dated [DATE] with a status of inactivated and another assessment dated [DATE] with a status of annual and export ready. During interview on 04/14/2026 at 1:30 p.m., the MDS nurse stated that the assessment dated [DATE] had been entered as a quarterly assessment but should have been an annual assessment, and acknowledged that the 02/24/2026 assessment had not been transmitted.
Failure to Provide Adequate Supervision During Incontinent Care Results in Resident Fall and Fracture
Penalty
Summary
A deficiency occurred when a resident, who was cognitively intact but physically dependent on staff for activities of daily living (ADL) and at high risk for falls, was not provided adequate supervision during incontinent care. The resident had a history of impaired mobility, rheumatoid arthritis, and a previous femur fracture, and required extensive assistance with bed mobility. During the incident, a CNA was providing incontinent care with the resident's bed in a high position and turned away from the resident to retrieve an adult brief from the over bed table, leaving the resident unsupervised. While the CNA was turned away, the resident lost her grip on the side rail and fell from the bed, resulting in a fractured right femur. The resident was found on the floor by staff, complaining of significant pain, and was subsequently transferred to the emergency room where the fracture was confirmed. The incident report and staff interviews confirmed that the CNA did not ensure the resident was secure and safe in the bed before turning away, and the bed was left in a high position, increasing the risk of injury. Interviews with the resident and staff revealed that the resident was unable to hold onto the side rails for long due to arthritis, and the CNA was reportedly distracted, possibly using a cell phone during care. The failure to maintain supervision and ensure the resident's safety during care directly led to the resident's fall and injury. The deficiency was identified as immediate jeopardy due to the serious harm that resulted from the lack of supervision.
Failure to Protect Resident from Sexual Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from sexual abuse and psychosocial harm, resulting in an Immediate Jeopardy situation. A cognitively impaired resident was subjected to unwanted sexual contact by another resident in an unlit dining room. The incident was observed by a CNA, who reported it to an RN. Despite the resident's clear indication of discomfort and non-consent, the facility did not implement protective measures or report the incident to the appropriate state agency or law enforcement. The resident who committed the abuse had a history of moderate cognitive impairment and was on antipsychotic medication. However, the resident's comprehensive care plan did not include any interventions or monitoring following the incident. The victim, who had severe cognitive impairment, was not provided with protective measures in her care plan after the incident. The facility's failure to act increased the risk of further harm to all residents. Interviews with facility staff revealed a lack of communication and training regarding the incident. The Director of Nursing did not ensure all staff were in-serviced on abuse and neglect policies, and the Administrator was not informed of the incident until months later. The facility's reportable incident list did not include the sexual abuse incident, indicating a failure to comply with reporting requirements.
Failure to Report Sexual Abuse Incident
Penalty
Summary
The facility failed to report an alleged incident of sexual abuse involving two residents in a timely manner. A Certified Nursing Assistant (CNA) observed one resident engaging in unwanted sexual contact with another resident in the facility's dining room. The incident was not reported immediately to the facility's administrator, the appropriate state agency, or local law enforcement as required by the facility's policy and federal regulations. The incident involved a resident with cognitive impairments who was subjected to unwanted sexual contact by another resident. Despite the resident's cognitive condition, the incident was not reported to the necessary authorities within the required two-hour timeframe. The facility's Director of Nursing (DON) and other staff members were aware of the incident but failed to notify the administrator or report it to the state agency and law enforcement. The failure to report the incident resulted in an Immediate Jeopardy situation, as it posed a high likelihood of additional harm to the residents. The facility's administrator was not informed of the incident until several months later, and no report was submitted to the appropriate authorities. This lack of action and communication within the facility led to a significant deficiency in ensuring the safety and well-being of the residents.
Failure to Protect Resident from Abuse and Report Incident
Penalty
Summary
The facility failed to administer its resources effectively and efficiently, resulting in a deficiency related to the protection of residents from abuse. Specifically, the facility did not have an effective system in place to protect a resident from sexual abuse by another resident. The incident occurred when a CNA observed one resident inappropriately touching another resident in the facility's dining room. The resident who was touched, who is cognitively impaired, confirmed the unwanted contact and expressed discomfort. Despite the absence of a significant decline in mental or physical functioning, the incident was determined to have caused severe psychosocial harm. The facility also failed to report the abuse to the appropriate state agency and law enforcement. The Director of Nursing (DON) did not provide in-service training to all staff on abuse and neglect following the incident and failed to notify the Administrator of the incident. The Administrator was not made aware of the incident until several months later and acknowledged that a report should have been submitted. The Corporate Nurse was informed of the incident the day after it occurred but did not ensure the Administrator was notified. Interviews revealed that no interventions were put in place to ensure the safety of the resident involved or other residents. The DON admitted responsibility for overseeing interventions and staff training but failed to ensure these were implemented. The facility's failure to implement protective measures created a high likelihood of additional harm to the residents. The Immediate Jeopardy was identified and later removed after the facility implemented a plan of removal.
Failure to Notify After Sexual Abuse Incident
Penalty
Summary
The facility failed to notify a resident's representative and physician following an incident of sexual abuse. A resident with severe cognitive impairment, including diagnoses of unspecified dementia, schizophrenia, Alzheimer's disease, and major depressive disorder, was involved in an incident where another male resident inappropriately touched them in the dining room. Despite the incident being reported by a CNA to an RN, there was no documentation indicating that the resident's representative or physician was informed of the event. The Director of Nursing acknowledged the oversight and confirmed the lack of notification to the resident's representative and physician.
Lack of Physician Orders for Resident Care Devices
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for two residents. Resident #22, who has Alzheimer's disease, anxiety disorder, and chronic kidney disease, was identified as an elopement risk with impaired safety awareness. Despite having a wander guard alarm device on their ankle, there was no physician's order for its use. This oversight was acknowledged by the Director of Nursing during an interview. Resident #326, admitted with spinal stenosis, fusion of the spine, Parkinson's disease, Type 2 diabetes, and a UTI, had a PICC line for one dose of antibiotic. However, there was no physician's order for the maintenance, monitoring, or discontinuation of the PICC line. This deficiency was also acknowledged by the Director of Nursing, indicating a lapse in ensuring proper medical orders were in place for the resident's care.
Failure to Assess Bed Rail Entrapment Risk
Penalty
Summary
The facility failed to ensure the correct use and maintenance of bed rails for three residents, leading to a deficiency in assessing the risk of entrapment. Resident #13, who was admitted with a diagnosis of unspecified glaucoma, had assist rails for bed mobility and positioning as per physician orders. However, the medical record did not contain any assessments for entrapment risk after the rails were applied, despite observations confirming the presence of raised assist rails on both sides of the bed. Similarly, Resident #50, with diagnoses including schizoaffective disorder and hypertension, also had assist rails for bed mobility and positioning. The care plan and physician orders supported the use of these rails, but like Resident #13, there was no documentation of entrapment risk assessments in the medical record. Observations confirmed the presence of raised assist rails on both sides of the bed. Resident #51, who had multiple medical conditions including cerebral infarction and dementia, was also found to have raised quarter side rails on both sides of the bed. Despite having a physician order for assist rails, the restraint necessity/positioning device form incorrectly indicated that no device was in use. Interviews with facility staff revealed that maintenance checks for entrapment risk were not performed for these residents, highlighting a systemic issue in the facility's assessment and documentation processes.
Failure to Complete Annual Performance Review for CNA
Penalty
Summary
The facility failed to ensure an annual performance review was completed for one of the Certified Nurse Assistants (CNA), identified as S11, out of a sample of five CNAs. S11 was initially hired on February 3, 2017, and rehired on October 28, 2021. Upon review of S11's personnel record, it was found that the 2024 annual performance review was not completed. This deficiency was confirmed during an interview with S9 from Human Resources, who acknowledged the absence of the 2024 performance review in S11's personnel file.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, specifically in implementing Enhanced Barrier Precautions (EBP) for a resident who was reviewed for antibiotic use. The resident, who was admitted with diagnoses including spinal stenosis, Type 2 Diabetes, and a urinary tract infection, had undergone neck surgery and was receiving intravenous antibiotics for an infection. Despite having a midline catheter and a surgical wound, which necessitated EBP, the facility did not have appropriate signage or readily available personal protective equipment (PPE) for staff. Observations revealed that the necessary EBP signage was missing, and PPE supplies were not accessible, which was acknowledged by the Director of Nursing. The resident had a midline catheter in the upper left arm and a surgical wound on the neck, conditions that required EBP to prevent the transmission of multidrug-resistant organisms. The lack of EBP implementation was confirmed during interviews with the resident and the Director of Nursing, highlighting a significant lapse in the facility's infection control practices.
Failure to Update Care Plan After Resident Abuse Incident
Penalty
Summary
The facility failed to revise the care plan for a resident following an incident of resident-to-resident abuse. The resident, who was admitted with diagnoses including bipolar disorder, major depressive disorder with psychotic features, anxiety disorder, intellectual disabilities, and delusional disorders, had a moderate cognitive impairment as indicated by a BIMS score of 09 out of 15. Despite using antipsychotic medication routinely, the resident was involved in a sexual abuse incident with another resident. The comprehensive care plan was not updated to include increased monitoring or supervision after this incident. The Director of Nursing confirmed the oversight during interviews, acknowledging that the care plan should have been revised to address the increased risk following the incident.
Inadequate Catheter Care for Resident
Penalty
Summary
The facility failed to provide appropriate care for a resident with a urinary catheter, leading to a deficiency in preventing urinary tract infections. The resident, who has a history of cerebral infarction, essential hypertension, dementia with behavioral disturbance, and other conditions, was observed with a Foley catheter bag placed on the floor. This was noted during two separate observations on the same day, once in the morning and again in the afternoon, with confirmation from the Director of Nursing that the catheter bag should not be on the floor. The Corporate Nurse also acknowledged that keeping the catheter bag off the floor is a basic standard of care.
Incorrect Enteral Feeding Rate for Resident
Penalty
Summary
The facility failed to ensure appropriate treatment and services for a resident with a feeding tube, leading to a deficiency. The resident, who has medical diagnoses including moderate protein calorie malnutrition, dysphagia, atrial fibrillation, and Parkinson's disease, was observed to receive enteral feeding at an incorrect rate. According to the physician's order dated 12/17/2024, the resident's feeding should have been administered at 45 ml/hr for 20 hours to deliver the prescribed nutritional intake. However, observations on 02/03/2025 revealed that the enteral feeding pump was infusing at 60 ml/hr, which was confirmed by an LPN during an interview. This discrepancy between the ordered and actual infusion rate was not addressed, resulting in a failure to provide the appropriate care for the resident's feeding tube.
QAA Meeting Attendance Deficiency
Penalty
Summary
The facility failed to ensure the required members were present for the quarterly Quality Assessment and Assurance (QAA) meetings since the last annual survey. A review of the facility's QAA Committee Summary sign-in sheet revealed that during the meeting on October 9, 2024, the signatures of the Administrator, Director of Nursing (DON), Medical Director, and a Nurse Practitioner were present. However, during an interview on February 7, 2025, the Administrator confirmed that the required members were not present during this meeting.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Shreveport
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Bradford Skilled Nursing And Rehabilitation | 0.1 mi | ★★★★★ | 8 | 0 |
| The Guest House Skilled Nursing Rehabilitation | 0.7 mi | ★★★★★ | 0 | 0 |
| Heritage Manor South | 2 mi | ★★★★★ | 4 | 0 |
| Garden Park Nursing & Rehab Ctr, Llc | 2 mi | ★★★★★ | 9 | 0 |
| Spring Lake Skilled Nursing And Rehabilitation | 3.5 mi | ★★★★★ | 5 | 0 |
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