Gulfport Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Gulfport, Mississippi.
- Location
- 11240 Canal Road, Gulfport, Mississippi 39503
- CMS Provider Number
- 255341
- Inspections on file
- 18
- Latest survey
- June 5, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Gulfport Care Center during CMS and state inspections, most recent first.
A resident with a history of hallucinations and dementia exited the facility through an alarmed door, and staff failed to investigate the alarm or promptly report the elopement. The resident was found outside by dietary staff, and the incident was not reported to the State Agency until two days later. The delay in reporting and lack of immediate investigation placed residents at risk and constituted Immediate Jeopardy and Substandard Quality of Care.
A resident with a history of hallucinations and dementia exited the facility unsupervised after staff failed to respond to an audible door alarm. The resident was found outside by a dietary employee, and nursing staff were unaware of the elopement until notified. No immediate investigation was initiated, and key staff were not informed of the incident until days later, resulting in a delayed response to the event.
Two residents experienced significant lapses in supervision and safety interventions: one resident with dementia and hallucinations exited the facility unsupervised after staff failed to respond to an active door alarm, and another resident with a femur fracture was manually transferred by CNAs without the required mechanical lift, resulting in an ankle injury. Staff interviews revealed a lack of adherence to policies regarding alarm response and transfer procedures, and no valid exceptions were documented for the manual transfer.
Staff did not follow care plans for three residents, including failing to provide PEG tube site care resulting in a purulent wound, not ensuring a call light was within reach for a resident at risk for falls, and not using a mechanical lift as directed for a resident requiring assistance with transfers, which led to an ankle sprain.
Two residents receiving enteral feedings did not receive proper care: one had a PEG site with an old, soiled dressing and no physician orders or monitoring for over 20 days, resulting in purulent drainage and infection, while another had a feeding bag that was not properly labeled with required information. Staff confirmed these deficiencies through observation and record review.
A resident with a history of cerebral infarction and severely impaired cognition was found in bed unable to reach her call light, which was wrapped around a light fixture and out of reach. Staff interviews confirmed the resident could not have moved the call light herself and acknowledged it was their responsibility to ensure accessibility, in accordance with facility policy.
A resident's privacy was compromised when personal care instructions related to dialysis were posted on her door, making confidential medical information visible to others. Staff confirmed the sign's presence and acknowledged that such information was already documented in the care plan. The resident, who was cognitively intact and undergoing regular dialysis, had not requested the signage, and facility policy required confidentiality of personal and medical records.
A resident was admitted to hospice services, but staff did not complete a required Significant Change in Status Assessment (SCSA) within 14 days, as mandated by facility policy and the RAI Manual. Interviews and record reviews confirmed the omission, despite staff acknowledging that hospice admission is a qualifying event for an SCSA.
Two residents had inaccurate MDS assessments: one was not coded as receiving hospice care despite being on hospice, and another was incorrectly coded as having bed rails used as a physical restraint, even though staff stated the rails were for mobility assistance. Staff interviews revealed a lack of a system to ensure MDS accuracy, with verification limited to section completion.
Surveyors found that staff failed to store food according to professional standards and facility policy, including the presence of expired milk in a cooler and improper storage of Key Lime juice that required refrigeration. The Dietary Manager and Administrator confirmed these issues and acknowledged that food safety procedures were not followed.
A facility failed to treat a resident with respect and dignity when a CNA used inappropriate language after the resident had an accident in bed. The incident was confirmed by the resident and her roommate, both of whom were cognitively intact. The CNA involved had previously been accused of discourteous behavior and was terminated following the investigation.
Failure to Timely Report and Investigate Resident Elopement
Penalty
Summary
The facility failed to timely report an incident of elopement involving a resident with a history of hallucinations and dementia. The resident, who was cognitively intact at admission with a BIMS score of 15, was last seen inside the facility at approximately 4:00 AM and was later found unsupervised in the facility parking lot by dietary staff at around 4:30 AM. Facility staff were unaware that the resident had left the building through an alarmed door, and staff did not investigate the audible alarm when it sounded. The resident reported feeling threatened by a nurse, which prompted her to leave the facility, and she was found outside by a staff member arriving for work. Despite the incident, the facility did not report the elopement to the State Agency until two days later. Interviews revealed that the LPN on duty heard the alarm but did not investigate, and the Administrator was not fully informed of the circumstances until returning to work after the weekend. The Director of Nursing was also unaware of the incident until after the State Agency began its investigation. The delay in reporting and lack of immediate investigation into the alarm and the resident's whereabouts constituted a failure to follow the facility's policy on incident investigation and reporting, which requires timely reporting of elopements and other reportable incidents. The deficiency was determined to be Immediate Jeopardy and Substandard Quality of Care, as the delay in reporting and failure to investigate placed the resident and others at continued risk for unsupervised exit, increasing the likelihood of serious harm. The facility's own investigation confirmed that staff did not respond appropriately to the alarm and did not account for the resident's whereabouts until notified by dietary staff.
Failure to Timely Investigate Resident Elopement After Alarm Ignored
Penalty
Summary
The facility failed to initiate a timely investigation after a resident with a history of hallucinations and dementia exited the facility unsupervised. The resident was last seen inside the facility at approximately 4:00 AM and was found by dietary staff in the facility parking lot around 4:30 AM. Staff were unaware that the resident had left the building, despite an audible alarm sounding on an exit door, which was not investigated by staff at the time. Interviews revealed that the LPN on duty heard the alarm but did not investigate, and other staff members also failed to respond to the alarm. The resident was discovered outside by a dietary employee arriving for work, who then notified nursing staff. The resident reported leaving the facility due to feeling threatened by a nurse. The LPN and other staff brought the resident back inside but did not conduct an immediate investigation or interview the dietary staff who found the resident. The Administrator was notified of the alarm and the resident's exit but was not made aware of the full circumstances, including that the resident had been found outside by non-nursing staff, until several days later. The Director of Nursing was also not informed of the elopement until the State Agency arrived. As a result, the facility did not begin an internal investigation into the incident until two days after the event, delaying the identification of root causes such as staff failure to respond to alarms and lack of awareness of the resident's whereabouts.
Failure to Prevent Elopement and Ensure Safe Transfer Techniques
Penalty
Summary
The facility failed to ensure adequate supervision and implement safety interventions to prevent accidents for two residents. In the first incident, a resident with Parkinson's disease, dementia, and a history of hallucinations exited the facility unsupervised through an exit door that triggered an alarm. Staff did not immediately investigate the alarm, assuming it was malfunctioning, and did not conduct a room-to-room check to account for all residents. The resident was found outside in the parking lot by a dietary staff member approximately 30 minutes later, appearing confused, tired, and reporting feeling threatened by a nurse. Multiple interviews confirmed that staff heard the alarm but did not respond appropriately, and some staff were unfamiliar with the facility's policies regarding alarms and elopement. In the second incident, another resident with a right femur fracture and a care plan requiring a stand-assist mechanical lift was manually transferred by two CNAs without the use of the required lift. During the transfer, the resident's foot became caught under the wheelchair, resulting in a right ankle sprain. The CNAs involved were agency staff who did not provide a reason for not using the mechanical lift, despite the resident's care plan and room signage indicating its necessity. The resident reported that the lift was available in the room at the time of transfer, and she did not refuse its use. The incident was later reported to therapy staff, and the resident was unable to fully participate in physical therapy for several weeks due to the injury. Interviews with facility staff, including the DON and care plan nurse, confirmed that the use of a mechanical lift was required for the resident and that CNAs are not permitted to determine lift methods. The facility's policy allows for manual transfers only in specific circumstances, such as emergencies or mechanical failure, but no such exception was documented for this incident. The charge nurse also confirmed that the facility operates as a no-manual-lift environment and that the CNAs did not provide justification for their actions.
Failure to Follow Care Plans for PEG Site Care, Safe Transfers, and Call Light Accessibility
Penalty
Summary
Staff failed to follow the comprehensive care plan for three residents, resulting in deficiencies in care. For one resident with a recent PEG tube placement, there was no documented PEG site care order until several weeks after admission, despite the care plan indicating the need for site care and monitoring for infection. The resident reported that no one had performed PEG site care, and observations revealed an old, discolored dressing with purulent, foul-smelling drainage and signs of infection at the site. Another resident, who required staff assistance with transfers and had a care plan specifying the use of a stand-assist mechanical lift, was manually transferred by two CNAs without the lift. This manual transfer resulted in the resident's foot becoming caught under a wheelchair, leading to a right ankle sprain. The resident confirmed that the transfer was not performed according to the care plan and that the injury affected her ability to participate in therapy. A third resident, who was at risk for falls, had a care plan intervention requiring the call light to be within reach. During observation, the call light was found wrapped around a light fixture and not accessible to the resident, who reported being unable to get help when needed. Staff confirmed that ensuring the call light was within reach was their responsibility, but this was not done at the time of observation.
Failure to Provide Proper PEG Site Care and Label Enteral Feeding Equipment
Penalty
Summary
The facility failed to ensure proper care and monitoring of enteral feeding and gastrostomy sites for two residents. One resident, who had recently received a PEG tube prior to admission, reported that no site care had been performed and described the site as draining and unclean. Observations confirmed an old, discolored dressing with green and black purulent drainage and a foul odor, with the dressing dated several days prior. Record review and staff interviews revealed that there were no physician orders for PEG site care or monitoring for approximately 21 days after admission, and the site had not been assessed or the dressing changed as required. The resident continued to receive bolus feedings during this period, and staff confirmed the lack of orders and monitoring. Another resident receiving tube feedings was observed with a feeding bag that was not properly labeled. The bag only included the resident's last name and date, but did not indicate the time it was hung, the type of enteral feeding, or the rate. Staff interviews confirmed that the label was incomplete and did not meet facility policy, which requires the full name, rate, time and date hung, and type of feeding to be included. The family member present was also unaware of the type of enteral feeding being administered. Both residents had relevant medical histories, including recent surgical aftercare and gastrostomy status. The deficiencies were identified through observation, interview, and record review, and were confirmed by staff and facility leadership. The lack of timely physician orders, monitoring, and proper labeling of enteral feeding equipment directly contributed to the deficiencies cited.
Call Light Not Accessible to Resident with Severe Cognitive Impairment
Penalty
Summary
A deficiency occurred when staff failed to ensure that a call light was within reach for a resident with severe cognitive impairment. During an observation, the resident was found lying in bed and stated she needed help but could not get anyone. The call light devices, including a round palm pad call light, were observed wrapped around a light fixture and not accessible to the resident. Staff interviews confirmed that the resident could not have physically wrapped the call lights around the fixture herself, and that it was the responsibility of the certified nurse aide to ensure call lights were within reach during morning rounds. The licensed practical nurse and director of nursing both stated that call lights should always be accessible to residents. The resident involved had a history of cerebral infarction and was assessed as having severely impaired cognition, as indicated by a BIMS score of 00 on the most recent Minimum Data Set assessment. The facility's policy required that call lights be kept within reach of residents at all times to provide a means of communication with staff. Despite this policy, the call light was not accessible, and staff acknowledged the oversight during interviews.
Failure to Maintain Resident Privacy and Confidentiality
Penalty
Summary
The facility failed to maintain the privacy and confidentiality of a resident's personal and medical information by posting signage on the resident's door that disclosed specific care instructions related to dialysis. The sign indicated that the resident was to have a pad placed underneath her on certain days before going to dialysis. This information was visible to anyone passing by the room, including staff, visitors, and other residents. Multiple staff members, including an LPN and a CNA, confirmed the presence of the sign and acknowledged that the information was already documented in the resident's care plan. The resident involved was cognitively intact, as indicated by a BIMS score of 15, and had not requested the signage to be posted. The resident had a history of chronic kidney disease and was dependent on renal dialysis, receiving treatment three times weekly. Facility policies reviewed emphasized the importance of treating residents with dignity and maintaining the confidentiality of personal and medical records. Despite these policies, the signage remained on the door until it was brought to the attention of nursing leadership, who confirmed that such postings were not appropriate.
Failure to Complete Significant Change MDS Assessment After Hospice Admission
Penalty
Summary
The facility failed to complete a Minimum Data Set (MDS) Significant Change in Status Assessment (SCSA) for a resident who was admitted to hospice services. According to the facility's policies and the Resident Assessment Instrument (RAI) Manual, an SCSA is required within 14 days when a terminally ill resident enrolls in a hospice program. Record review showed that the resident was admitted to hospice services on 8/29/24, as confirmed by both the Director of Nursing (DON) and a Licensed Practical Nurse (LPN). However, there was no evidence that an SCSA was completed or submitted within the required 14-day timeframe following the hospice admission. Interviews with facility staff, including the DON and an LPN, confirmed their understanding that hospice admission constitutes a significant change in condition requiring an SCSA. The MDS assessment history for the resident did not show a significant change assessment within the specified period after hospice admission. The resident had a history of cerebral infarction and had been readmitted to the facility earlier in the year. The deficiency was identified through interviews, record reviews, and confirmation of the facility's policies and procedures.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for two of twenty sampled residents. For one resident with a diagnosis of cerebral infarction, records showed she was admitted to hospice services, but her Quarterly MDS assessment did not indicate that she was receiving hospice care during the lookback period. Interviews with nursing staff confirmed that the resident had been on hospice since the previous year, and the omission was not identified or corrected in the MDS documentation. The process for verifying MDS accuracy was limited to staff reviewing their own sections, with no system in place to ensure overall accuracy, and the RN signature only indicated completion, not verification of accuracy. For another resident with a diagnosis of atherosclerotic heart disease, the Quarterly MDS assessment incorrectly coded the use of bed rails as a physical restraint. Facility staff, including an LPN, stated that bed rails were not considered restraints and were used to assist with mobility, and the coding of restraints on the MDS was an error. The administrator confirmed that MDS assessments are expected to accurately reflect residents' status, but the errors in both cases demonstrated a failure to ensure accurate assessment documentation.
Improper Food Storage and Use of Expired Items in Kitchen
Penalty
Summary
During a kitchen observation, surveyors identified that staff failed to store food in a sanitary manner, which did not comply with professional standards and the facility's own food storage policy. Specifically, an opened gallon of reduced-fat milk with an expiration date that had already passed was found inside a reach-in cooler. The Dietary Manager confirmed the milk was expired and was uncertain if it had been served during breakfast. Additionally, a container of Key Lime juice was found stored on a dry goods shelf, despite manufacturer instructions requiring refrigeration after purchase. The Dietary Manager acknowledged the juice was not stored according to these instructions. The facility's policy on food storage and labeling requires routine checks to identify and discard expired foods and to follow manufacturer guidelines for storage. During interviews, both the Dietary Manager and the Administrator confirmed awareness of the findings and acknowledged that the observed practices did not align with facility standards or policy requirements. No information was provided regarding specific residents affected or their medical conditions at the time of the deficiency.
Failure to Treat Resident with Respect and Dignity
Penalty
Summary
The facility failed to treat a resident with respect and dignity during care. An allegation of verbal abuse was reported by a resident's roommate, who stated that a CNA used inappropriate language while addressing the resident after she had an accident in bed. The Social Services Director confirmed the report and initiated an investigation. The resident involved confirmed the incident, stating that the CNA spoke to her in an ugly manner. The Director of Nurses and the Administrator also confirmed the incident, with the Administrator identifying the CNA involved and acknowledging the disrespectful language used. This was the second time the CNA had been accused of discourteous behavior towards residents. The personnel file of the CNA indicated that she had received training on the Vulnerable Adults Act and Resident's Rights. Both the resident involved and the reporting roommate were found to be cognitively intact, as indicated by their BIMS scores. The facility's investigation and interviews confirmed the incident, leading to the termination of the CNA. The deficiency was determined to be past non-compliance, as corrective actions were implemented before the State Agency's entrance.
Latest citations in Mississippi
A resident with advanced dementia and severe cognitive impairment sustained a bruised left eye and facial bruising after being struck by a CNA. The CNA initially claimed the injury occurred accidentally while pushing the resident to a dining table and denied hitting the resident, but an LPN and another CNA reported that the resident stated she had hit the CNA and was hit back in the eye, demonstrating a slapping motion. Nursing documentation described left orbital ecchymosis, bruising along the bridge of the nose and cheek, tenderness, minimal edema, and the resident’s complaint of soreness, confirming a significant injury resulting from the physical abuse.
The facility failed to protect residents’ right to a dignified and comfortable environment when it did not effectively manage one cognitively impaired resident’s ongoing nighttime yelling, which repeatedly disrupted the sleep of two cognitively intact residents. Staff, including a CNA, the DON, and the Administrator, were aware that this resident, diagnosed with dementia and psychosis, frequently yelled and screamed at night while often sleeping during the day. Progress notes documented nighttime hollering, and interviews confirmed that the disruptive behavior persisted over time, interfering with other residents’ ability to rest.
Surveyors found that the facility failed to protect two residents’ rights to dignity and privacy during routine care. One resident, with moderate cognitive impairment and dependent for toilet hygiene, was observed receiving incontinence care while uncovered, with the room door open and the privacy curtain only partially drawn, allowing visibility into the hallway despite facility policy requiring full privacy. Another resident, dependent for eating and with hemiplegia after a stroke, was assisted with lunch by a CNA who stood over the resident instead of sitting at eye level as required by the facility’s feeding skills checklist. Staff interviews, including with CNAs, an LPN, the DON, and the Administrator, confirmed that existing policies and in-service training directed staff to provide privacy during incontinence care and to sit beside residents when assisting with meals to ensure dignified care.
A resident with epilepsy, skin infection, an upper arm wound, gastrostomy status, and moderate cognitive impairment was observed twice resting in bed with a lunch tray while the call light was not within reach—once on the floor under the bed and once hanging behind the mattress, out of sight. The resident reported being able to use the call light but not knowing where it was. Staff, including CNAs, an LPN, the DON, and the Administrator, stated that call lights are expected to be left within residents’ reach and that training and competencies address this requirement, but there was no specific written policy on call light placement.
A resident with moderate cognitive impairment, dependent for toilet hygiene and with multiple medical conditions, was observed receiving incontinent care in which a CNA removed a urine-soaked brief, changed the bed sheet, and applied a clean brief without performing any required perineal cleansing of the front or back. Facility policy and the peri-care skills checklist specified that male residents must have the perineal area, including the penis, scrotum, and inner thighs, washed, rinsed, and dried during incontinent care. The CNA later acknowledged having been trained and competency-checked on this procedure and knowing cleansing was required. Other staff, including a CNA supervisor, an LPN, the DON, and the Administrator, confirmed that proper incontinent care includes full perineal cleansing in addition to brief changes, establishing that the observed omission did not follow facility policy or professional standards intended to prevent UTIs.
Surveyors found that staff failed to follow infection control practices during PEG tube and wound care. Two residents with PEG tubes had sites with visible brown, crusted or yellowish drainage that had not been cleaned for several days, despite physician orders for daily cleansing and, when indicated, dressings. In another case, a CNA provided peri-care for stool and then assisted with a stage IV sacral pressure ulcer dressing change without changing gloves or performing hand hygiene, contrary to facility policy and staff expectations for aseptic technique.
Surveyors found that the facility failed to maintain a safe, clean, and homelike environment when a resident’s room contained odorous soiled linens left on the floor and later placed on furniture with clean clothing, and the bed was made with torn linens exposing the mattress. Other residents reported that housekeeping did not clean under beds, and multiple large dead roaches were repeatedly observed under several beds, with one resident stating he often disposed of dead roaches himself. Residents also reported refusing to use the north shower room due to dirty clothing, feces, and residue on shower chairs and floors; an observation confirmed the presence of soiled clothing, a soiled brief, and unidentified substances on the shower chair and floor, despite staff acknowledging that CNAs were expected to clean and sanitize the shower room after each use.
The facility failed to maintain an effective pest control program, as evidenced by repeated observations of roaches and other insects in multiple resident rooms and common areas. Surveyors found gnats and dead roaches under beds, while several residents reported seeing roaches on ceilings, walls, and floors, including roaches falling onto them at night and having to remove dead roaches themselves. A family member reported bringing her own roach spray due to concerns about roaches in a loved one’s room. During a Resident Council meeting, roaches were seen crawling across the floor, and residents stated that roaches were commonly observed throughout the building. Although the contracted pest control provider reported monthly service focused mainly on entry points and exterior areas and facility staff described processes for reporting pests, the persistent roach activity showed the program was not effectively preventing or controlling pests.
A resident with multiple chronic conditions, who relied on phone contact with a seriously ill significant other, lost access to private communication after her personal cell phone was broken and sent out for repair. Facility policy guarantees residents access to a telephone and private communication, but there was no cordless phone available on the relevant hall, and staff, including the DON, SSD, and Administrator, confirmed there was no convenient method for residents on that hall to make private calls without arranging to use a staff office. This resulted in the resident having no readily available, private telephone option.
A resident with heart failure, chronic kidney disease, hypertension, moderate cognitive impairment, and total dependence on staff for personal and toilet hygiene reported difficulty obtaining assistance with ADLs. Observation revealed the resident had ten long, dirty fingernails extending several millimeters beyond the fingertips with black material underneath, and the resident stated they needed cleaning and cutting. An LPN confirmed the nails were too long and dirty, acknowledged that nursing staff were responsible for daily and weekly fingernail checks and for providing fingernail care as part of ADLs, and noted that such nails could cause skin damage or scratches. The DON and Administrator both confirmed that personal hygiene and grooming are part of ADLs and are expected to be provided for all residents dependent on staff.
Failure to Protect Cognitively Impaired Resident From Physical Abuse by CNA
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from abuse, resulting in the resident being struck in the eye by a CNA. Facility records show that a CNA reported to an LPN that the resident had a bruised left eye and initially stated the injury may have occurred while pushing the resident to the dining table due to the resident’s short, stooped posture. The CNA also reported that the resident used a racial slur toward her and that she verbally responded but denied striking the resident. However, subsequent interviews and the facility’s investigation determined that the resident’s injury was not caused by accidental contact with the dining table. Interviews with staff revealed conflicting accounts that led to the conclusion that the resident had been hit. An LPN stated that the resident reported being hit in the eye by the CNA and that another CNA heard a commotion and later observed bruising to the resident’s left eye. When this second CNA asked what happened, the resident reported that she hit the CNA and was hit back in the eye, while making a motion consistent with a slap. The LPN confirmed that the resident gave a similar account to her, indicating that the CNA had physically struck the resident. The resident involved was admitted to the Memory Care Unit with diagnoses including Alzheimer’s disease, cognitive communication deficit, and unspecified dementia with behavioral disturbance, and had a BIMS score of 5 indicating severe cognitive impairment. A nursing progress note documented an acute follow-up assessment of left orbital ecchymosis, describing a dark red circular bruise to the left eye region, dark purple bruising along the lateral bridge of the nose extending to the superior left cheek, tenderness on palpation, minimal edema, and the resident’s complaint that the area was sore. Due to advanced Alzheimer’s disease, the resident was unable to reliably express additional symptoms, but the documented physical findings supported that the resident sustained a significant injury to the eye area as a result of being struck by the CNA.
Failure to Protect Residents’ Right to Rest Due to Unmanaged Nighttime Yelling
Penalty
Summary
The deficiency involves the facility’s failure to ensure a dignified and comfortable environment by not effectively addressing ongoing disruptive nighttime behaviors of one resident that interfered with other residents’ ability to rest. Resident #1, admitted with diagnoses including Psychosis and Dementia and a BIMS score of 4 indicating severely impaired cognition, had documented episodes of hollering and yelling during nighttime hours, as noted in progress notes on 3/12/26 and 3/13/26. Interviews with cognitively intact residents, Resident #2 and Resident #3 (both with BIMS scores of 15), revealed that they frequently experienced disrupted sleep due to Resident #1 yelling loudly at night, while the environment was generally quiet during the day. Staff interviews confirmed awareness of the pattern of behavior. CNA #1, who worked both day and night shifts, reported that Resident #1 frequently yelled and screamed at intervals throughout the night and was generally quiet and often slept during the day, with staff assisting the resident out of bed into a geri-chair during both day and nighttime hours. The DON acknowledged the facility was aware of Resident #1’s increased nighttime yelling and extended daytime rest, attributing it to the resident’s Dementia and Psychosis, and stated that interventions such as monitoring, repositioning, offering care, and attempts at redirection had not stopped the behaviors. The Administrator also confirmed awareness of concerns that nighttime noise from Resident #1 affected other residents’ ability to rest. Despite this awareness and ongoing complaints from other residents, the disruptive nighttime yelling continued, resulting in a failure to uphold residents’ rights to a dignified existence and a comfortable environment.
Failure to Ensure Privacy and Dignified Care During Incontinence Care and Feeding
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents were treated with dignity and provided privacy during care, as required by resident rights policies and skills checklists. The facility’s Nursing Facility Resident Rights policy guaranteed residents the right to be treated with dignity, courtesy, and respect, and to have privacy during personal care. Facility skills checklists for feeding and peri/incontinent care specified that staff should sit facing residents at eye level when feeding and provide privacy by drawing curtains and closing doors during incontinence care. For Resident #2, surveyors observed a CNA providing incontinent care without closing the resident’s room door and with the privacy curtain only partially drawn. From the surveyor’s position at the bottom right corner of the bed, it was possible to see into the hallway while the resident was uncovered and exposed. Resident #2’s records showed admission with diagnoses including epilepsy, infection of the skin and subcutaneous tissue, an open wound of the left upper arm, and gastrostomy status. A recent MDS assessment documented a BIMS score of 11, indicating moderate cognitive impairment, and that the resident was dependent for toilet hygiene. The CNA later confirmed awareness that incontinence care required provision of privacy and that she had been trained and competency-checked on this requirement. For Resident #3, surveyors observed a CNA assisting the resident with eating while standing over the resident rather than sitting beside her, contrary to the facility’s feeding skills checklist and training. The DON intervened during the observation and instructed the CNA that staff were to sit next to residents while assisting with eating. The CNA stated she had forgotten to sit beside the resident. Resident #3’s records showed recent admission with diagnoses of cerebral infarction (stroke), anemia, and hemiplegia and hemiparesis affecting the right dominant side, and a baseline care plan indicating the resident was dependent for eating. Other staff interviews, including with a CNA supervisor, an LPN, the DON, and the Administrator, confirmed that staff were trained at least monthly on residents’ rights, respectful and dignified care, provision of privacy during incontinence care, and the expectation that staff sit beside residents when assisting with eating.
Failure to Maintain Accessible Call Light for a Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s call light was maintained within reach as required by the facility’s feeding skills checklist. The skills checklist for feeding a resident specifies that staff must leave the call light within the resident’s reach after feeding. For Resident #2, surveyors observed on two separate occasions that the call light was not accessible. On one observation, the resident was awake in bed with a lunch tray on the overbed table, and the call light was found lying on the floor under the head of the bed. The resident stated he could use his call light but did not know where it was. On a subsequent observation, Resident #2 was again in bed with a lunch tray in front of him, and the call light was hanging behind the mattress at the head of the bed, out of his sight and reach. The resident again stated he could use the call light but did not know where it was. Record review showed the resident had epilepsy, an infection of the skin and subcutaneous tissue, an open wound of the left upper arm, gastrostomy status, and a BIMS score of 11 indicating moderate cognitive impairment. Staff interviews with CNAs, an LPN, the DON, and the Administrator confirmed that call lights were expected to be within residents’ reach and answered timely, and that staff had received in-service training and competency checks on leaving call lights within reach. The Administrator also confirmed there was no specific written policy regarding call light placement.
Failure to Provide Required Perineal Cleansing During Incontinent Care
Penalty
Summary
The deficiency involves the facility’s failure to provide incontinent care in accordance with its own peri-care policy and professional standards of practice for a male resident who was dependent for toilet hygiene. The facility’s written policy for peri/incontinent care for male residents, revised in January 2023, required cleansing of the perineal area starting at the urethra and working outward, including washing and rinsing the penis, scrotum, inner thighs, and perineal area front and back, followed by thorough drying. Record review showed the resident had diagnoses including epilepsy, infection of the skin and subcutaneous tissue, an open wound of the left upper arm, and gastrostomy status, and a Quarterly MDS with a BIMS score of 11 indicating moderate cognitive impairment, with the resident assessed as dependent for toilet hygiene. On the observed date and time, CNA #1 provided incontinent care to this resident by removing a wet urine-soaked brief, changing the fitted sheet, and applying a clean, dry brief without cleansing the resident’s perineal area, front or back, contrary to facility policy. During a subsequent interview, CNA #1 acknowledged she had received in-service training and competency check-offs on peri-care and knew she was supposed to cleanse the perineal area but did not do so, stating she was nervous. Additional interviews with CNA #2 (CNA supervisor and scheduler), an LPN, the DON, and the Administrator confirmed that staff were trained using the Peri Care–Incontinent Care Skills Checklist and that proper incontinent care includes cleansing the perineal area, front and back, in addition to changing the brief. The failure to perform the required cleansing during incontinent care constituted the cited deficiency related to prevention of urinary tract infections.
Failure to Maintain Infection Control Practices During PEG Tube and Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program by not maintaining aseptic technique and not providing ordered dressing changes for residents with PEG tubes and a sacral pressure injury. Facility policies on infection control and clean dressing changes required wound care to be provided in a manner that decreases the potential for infection and cross-contamination, including removal of soiled dressings with gloves, discarding gloves, performing hand hygiene, and donning clean gloves before continuing care. The peri-care audit tool also required glove removal, hand hygiene, and re-gloving after peri-care. These standards were not followed during multiple observed care episodes. For one resident with a PEG tube and diagnoses including Alzheimer’s disease, functional quadriplegia, and gastrostomy status, surveyors observed the PEG tube site without a dressing and with a yellowish-brown substance beneath and around the external skin disk extending about one-fourth inch onto surrounding skin. A CNA and an LPN both confirmed there was no dressing in place and acknowledged the drainage at the site. The LPN stated PEG tube site care should be completed daily and as needed for increased drainage and acknowledged that, with no dressing and the amount of drainage present, there was no way to tell when the site was last cleaned. Record review showed a physician order, effective several months prior, for daily cleansing of the PEG tube stoma with normal saline, patting dry, and applying a dry drain dressing to avoid skin breakdown. For another resident with severe protein-calorie malnutrition and gastrostomy status, the PEG tube site was observed with thick brown, crusted substance beneath the external skin disk extending approximately one-half to three-fourths of an inch to the surrounding area. The resident reported the site had not been cleaned in about three days and later stated they might have to clean it themselves. Follow-up observations confirmed the site remained unclean with visible drainage, and an LPN and the DON both confirmed the presence of thick, brown drainage and that the site had not been cleaned in several days, despite an order for daily cleansing with soap and water, rinsing, patting dry, and leaving open to air or applying a dry dressing if drainage was present. In a separate observation involving a resident with a stage IV sacral pressure ulcer and severe cognitive impairment, a CNA provided peri-care for stool soiling, then immediately assisted with wound care using the same gloves worn during peri-care, without performing hand hygiene or changing gloves. The CNA, treatment nurse, DON, and ADON all acknowledged that hand hygiene and glove change should have occurred between peri-care and wound care and that this represented an infection control concern.
Failure to Maintain Clean Resident Rooms and Shower Facilities
Penalty
Summary
The deficiency involves the facility’s failure to provide a safe, clean, comfortable, and homelike environment, as required by its Resident Rights & Quality of Life Policy. For one resident, surveyors observed a bag of odorous soiled linens resting on the floor of the room, and the resident’s bed was made with a bedspread that had a football-sized hole exposing the mattress. The resident, who was cognitively intact with a BIMS score of 14 and had Type 2 Diabetes Mellitus, reported that it was not unusual for bags of soiled linens to be left on the floor and for bedding to be damaged. A CNA confirmed that soiled linens were commonly left in bags on the floor after morning care and that torn bedding should not be used, and later placed the bag of soiled linens on the resident’s furniture where his clean clothing was hanging. The resident remained upset the following day, and a dead roach was observed under his bed near the headboard. Additional deficiencies were identified in other resident rooms. One resident with End Stage Renal Disease and a severely impaired cognition (BIMS score of 5) reported that housekeeping did not clean under the bed; surveyors observed three large dead roaches under the bed, which remained there the following day. When the Housekeeping Supervisor later observed the room, five dead roaches were present under the bed, and he stated the area should not have been in that condition. Another resident, with a diffuse traumatic brain injury and a moderately impaired cognition (BIMS score of 10), reported frequently picking up and disposing of dead roaches himself because staff did not remove them, and a large dead roach was observed under his bed. The facility also failed to maintain a clean and sanitary north shower room. During a Resident Council interview, multiple cognitively intact and moderately impaired residents reported refusing to use the shower room due to cleanliness concerns, including observations of dirty clothing, feces, and residue on shower chairs and floors. A housekeeper stated that while she cleaned the shower rooms multiple times a day, CNAs were responsible for cleaning and sanitizing the shower room after each use and that she had observed occasions when CNAs failed to do so. A subsequent observation of the north shower room revealed soiled clothing, including a soiled brief, on a shower chair, a yellow fluid-like substance on the floor and shower chair, and a white powdery substance on the floor, with no staff present. The Social Services Assistant, DON, and Administrator each acknowledged that staff were expected to clean and sanitize the shower room after each use.
Ongoing Roach Activity Demonstrates Ineffective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program as required by its pest control policy dated 9/1/2014, which states the center will maintain an ongoing program to keep the building free of insects and rodents. Surveyors observed multiple instances of roach and insect activity in resident rooms and common areas. In one cognitively intact resident’s room, gnats were seen flying and a dead roach was later found under the bed near the headboard. Another resident’s room contained three large dead roaches under the bed on two consecutive days; this resident reported that roaches were regularly seen in the room, especially at night, crawling on the ceiling and falling onto him and his roommate, and that staff had been notified but he had not seen staff respond to assess or treat the issue. A third resident reported seeing roaches on the ceiling and under the bed and stated he often removed dead roaches himself because staff did not; a large dead roach was observed under his bed. A family member of another resident reported feeling it was necessary to bring her own roach spray due to concerns about roaches in the resident’s room and stated she was told she could not keep the spray in the room, expressing concern that the roach problem needed to be addressed. During a Resident Council meeting, two large roaches were observed crawling across the floor, and residents reported that roaches were commonly seen in rooms and common areas, including on walls, ceilings, and floors, particularly at night. The contracted pest control provider reported he provides monthly services, focusing on different areas each visit, primarily treating entry points and exterior areas, and stated he had not personally observed roaches and received only occasional complaints. Facility leadership, including the housekeeping supervisor, DON, and Maintenance Director, described expectations that staff report pest sightings and that pest control services are available monthly and as needed, but the ongoing presence of roaches and dead insects in resident rooms and common areas demonstrated that the pest control program was not effectively preventing or controlling pests.
Failure to Ensure Resident Access to Private Telephone Communication
Penalty
Summary
The facility failed to ensure a resident’s right to reasonable access to and privacy in the use of a telephone for communication. Facility policy on Resident Rights, revised December 2016, states that residents are guaranteed access to a telephone, mail, and email, and the ability to communicate in person and by mail, email, and telephone with privacy. Resident #1 was admitted on 12/18/24 with diagnoses including Sjogren syndrome, rheumatoid arthritis, chronic kidney disease, and morbid obesity. During an interview, the resident reported that she had dropped and broken her personal cellular telephone, which she had used for private communication, and that the facility did not have any telephone that was convenient for her to use privately. She stated that no staff had offered her the use of a staff office or any other mechanism for private communication, and she was upset because she relied on telephone contact with her significant other, who had cancer and was unable to visit. Observations and staff interviews confirmed the lack of accessible, private telephone options for residents on South Hall. An observation on the 100 Hall revealed there was no cordless telephone available for resident use. The DON confirmed that the facility did not have a method to provide residents on South Hall with private communication without first making arrangements or an appointment to use a staff office, and that the cordless telephones in the facility did not have sufficient range to reach South Hall. The SSD confirmed there were no cordless telephones at the South Hall nurses’ station that could be taken to residents’ rooms and acknowledged that Resident #1’s cell phone had been broken and sent out for repair. The Administrator also confirmed that residents on South Hall did not have a method for private communication without prior arrangements and acknowledged that access to private communication is a guaranteed resident right.
Failure to Provide Adequate ADL Assistance for Personal Hygiene
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) to maintain personal hygiene for one resident who was dependent on staff for care. Facility policy on ADLs, revised March 2018, stated that residents unable to carry out ADLs independently would receive services necessary to maintain good grooming and personal and oral hygiene. Record review showed the resident was admitted with heart failure, chronic kidney disease, and hypertension, had a BIMS score of 12 indicating moderate cognitive impairment, was always incontinent of bowel and bladder, and required substantial/maximal assistance for personal hygiene and was dependent for toilet hygiene. A complainant reported that the resident had expressed difficulty getting staff to provide assistance with ADLs. During an observation and interview with the resident, accompanied by an LPN, the resident reported ongoing difficulty obtaining assistance with ADLs. The surveyor observed that the resident had ten long, dirty fingernails protruding 3.0 to 3.5 millimeters past the fingertips, with a black substance beneath all fingernails; the resident stated they needed cleaning and cutting and were too long. The LPN described the fingernails as too long and dirty, confirmed that nursing staff were responsible for checking fingernails daily during care and weekly during body audits, and acknowledged that staff were responsible for providing fingernail care as part of ADLs. The LPN also confirmed that long, dirty, unkempt fingernails had the potential to cause damage or scratches to the resident’s skin. The DON stated she was not aware of any complaints from the resident but confirmed her expectation that ADLs for residents dependent on staff for personal hygiene would be maintained and provided as needed, and that licensed nurses trimmed fingernails for some residents while any nursing staff could clean under fingernails. The Administrator confirmed that personal hygiene and grooming were part of resident ADLs and were expected to be provided for all dependent residents.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
