Inspection Reports for
Coastal Health & Rehabilitation Center
1530 Broad Avenue, Gulfport, MS, 39501
Back to Facility Profile7 Reports
Inspection Report — Aug 7, 2025
Routine CMS
Date: Aug 7, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, pest control, and facility environment, including complaints about pest infestations and linen shortages.
Findings
The facility failed to maintain a safe, clean, and homelike environment due to inadequate pest control limited to common areas, persistent roach and gnat infestations, and insufficient linen supply causing care delays. Additionally, care plan interventions for incontinence and timely resident care were not consistently implemented.
Deficiencies (4)
Failed to ensure a safe, clean, and homelike environment due to limited pest control access to resident rooms and lack of clean bath towels.
Failed to develop and implement a complete care plan meeting all resident needs, specifically related to skin care and prompt incontinence care for Resident #31.
Failed to provide appropriate incontinence care for Resident #31, resulting in prolonged exposure to soiled linens and delayed care.
Failed to maintain an effective pest control program, with pest control services limited to common areas and ineffective treatment for gnats, affecting 13 of 14 residents interviewed.
Report Facts
Days of survey with pest control issues: 4
Residents interviewed with pest issues: 14
Residents affected by pest control deficiency: 13
Residents reviewed for care plan: 27
Residents reviewed for ADL care: 7
Bath towels in 200 Hall linen closet: 5
Bath towels in 100 Hall linen closet: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Confirmed lack of awareness of pest complaints and linen shortages; stated expectations for timely resident care |
| Maintenance Director | Maintenance Director | Confirmed pest control limited to common areas, inadequate linen supply, and budget restrictions |
| Administrator | Administrator | Acknowledged pest control issues and linen shortages; committed to improving pest treatment and linen supply |
| Certified Nursing Assistant #1 | CNA | Confirmed linen shortages and staff hoarding linens |
| Certified Nursing Assistant #2 | CNA | Confirmed linen hoarding and care delays due to shortages |
| Certified Nursing Assistant #4 | CNA | Confirmed daily towel shortages and use of wipes for resident care |
| Licensed Practical Nurse #2 | LPN, Unit Manager | Reported daily towel shortages and care delays awaiting laundry and linen restocking |
| Certified Nursing Assistant #5 | CNA | Observed Resident #31's soiled linens and confirmed care dependency |
| Licensed Practical Nurse #5 | LPN | Reported expectation for staff to follow care plans for resident care |
| Pest Control Technician | Pest Control Technician | Reported monthly visits limited to common areas, ineffective chemicals for gnats, and lack of notification about gnat problems |
| Activity Director | Activity Director | Confirmed ongoing resident complaints about pests and unresolved grievances |
Inspection Report — Aug 7, 2025
Annual Inspection CMS
Date: Aug 7, 2025
Visit Reason
The inspection was conducted as an annual recertification survey to assess compliance with federal regulations related to resident care, safety, and facility operations.
Findings
The facility was found deficient in multiple areas including failure to honor resident meal preferences, unresolved resident council grievances, inadequate pest control, insufficient linen supply, improper use of physical restraints, failure to notify resident representatives of hospital transfers, incomplete PASRR evaluations, failure to implement care plans, medication errors, poor food quality and presentation, and ineffective quality assurance processes.
Deficiencies (15)
Failed to honor a resident's documented meal preferences for one of 27 sampled residents.
Failed to ensure Resident Council grievances were addressed for multiple complaints including pest control, linen shortages, and food quality.
Failed to ensure a safe, clean, and homelike environment due to limited pest control access and linen shortages.
Failed to ensure a resident was free from physical restraints without proper assessment or physician orders.
Failed to notify resident's representative in writing of hospital transfer/discharge and bed hold policies for one resident.
Failed to refer and follow through with appropriate PASRR Level II evaluation for one resident.
Failed to implement care plan interventions related to skin care and prompt care after incontinence for one resident.
Failed to provide appropriate incontinence care for a resident dependent on staff for ADLs.
Failed to revise care plan to address resident's visual impairment after glasses were broken.
Failed to ensure services met professional standards as a nurse did not enter physician's order for hospital transfer.
Failed to ensure new physician orders were entered and administered upon resident's return from hospital, resulting in missed anticoagulant medication for 14 days.
Failed to ensure meals were visually appealing and palatable; food was served with buns saturated with juices, vegetables not served separately, and processed turkey was watery and salty.
Failed to store, label, and maintain food in a sanitary manner; observed molded food products in walk-in cooler and dry storage.
Failed to maintain an effective pest control program; pest control limited to common areas, resident rooms with pest activity not routinely treated, and gnat infestations not addressed.
Failed to sustain an effective Quality Assurance and Performance Improvement (QAPI) program; prior deficiencies remained uncorrected and unmonitored.
Report Facts
Residents sampled: 27
Residents affected by meal preference deficiency: 1
Residents affected by Resident Council grievances: 3
Residents affected by pest control deficiency: 13
Residents affected by physical restraint deficiency: 1
Residents affected by transfer notification deficiency: 1
Residents affected by PASRR deficiency: 1
Residents affected by care plan deficiencies: 2
Residents affected by medication error: 1
Residents affected by food quality deficiency: 14
Residents affected by pest control program deficiency: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Manager | Named in meal preference and food quality deficiencies | |
| Director of Nursing | DON | Named in multiple interviews related to deficiencies and expectations |
| Administrator | Named in multiple interviews related to deficiencies and expectations | |
| Certified Nursing Assistant #3 | CNA | Named in physical restraint deficiency |
| Registered Nurse #1 | RN | Named in physical restraint deficiency |
| Licensed Practical Nurse #3 | LPN | Named in physical restraint deficiency |
| Social Services Director | SSD | Named in Resident Council grievance deficiency |
| Licensed Practical Nurse #4 | LPN | Named in PASRR deficiency |
| Admission Coordinator | Named in PASRR and medication order deficiencies | |
| Licensed Practical Nurse #1 | LPN | Named in medication order deficiency |
| Licensed Practical Nurse #2 | LPN | Named in medication order deficiency |
| Advanced Registered Nurse Practitioner | ARNP | Named in medication order deficiency |
| Certified Nurse Aide #5 | CNA | Named in incontinence care deficiency |
| Licensed Practical Nurse #6 | LPN | Named in medication order deficiency |
| Dietary #1 | Named in food quality deficiency | |
| Dietary #2 | Named in food quality deficiency | |
| Pest Control Technician | Named in pest control deficiency | |
| Maintenance Director | Named in pest control deficiency |
Inspection Report — Nov 26, 2024
Complaint Investigation CMS
Date: Nov 26, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to protect a resident from neglect, specifically failing to prevent fecal impaction that led to hospitalization and failing to communicate the condition to the physician.
Complaint Details
The complaint investigation found substantiated neglect when the facility failed to prevent fecal impaction for Resident #1, leading to hospitalization. Interviews with the resident's son, nursing staff, and review of records confirmed failure to notify the provider and inadequate documentation.
Findings
The facility failed to implement measures to prevent fecal impaction for Resident #1, resulting in hospitalization for dis-impaction and intravenous fluids. The care plan was not properly followed, and staff failed to notify the Nurse Practitioner or Medical Director about the resident's condition. Documentation of medication administration and impaction was missing prior to hospitalization.
Deficiencies (3)
Failed to protect resident from neglect leading to fecal impaction and hospitalization.
Failed to develop and implement a complete care plan that meets all resident's needs.
Failed to provide appropriate treatment and care according to orders and resident preferences, resulting in physical decline and hospitalization.
Report Facts
Residents reviewed: 4
Residents affected: 1
BIMS score: 15
Potassium level: 2.5
Hospital admission date: 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | LPN | Noted hard stool in Resident #1's rectum, administered MiraLAX and Lactulose, but failed to notify NP directly |
| Nurse Practitioner | NP | Did not receive notification about Resident #1's impaction |
| Director of Nursing | DON | Confirmed no documentation or notification of impaction and acknowledged LPN #1 failed to follow care plan |
| Registered Nurse #1 | RN | Confirmed LPN #1 failed to notify Medical Director or NP as required by care plan |
| Resident #1's son | Reported concerns about resident's condition and requested hospitalization |
Inspection Report — Oct 2, 2024
Routine CMS
Date: Oct 2, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident assessments, care planning, treatment, and wound care management at Coastal Health and Rehabilitation Center.
Findings
The facility failed to accurately code Minimum Data Set (MDS) assessments, implement complete care plans, provide timely treatment according to physician orders, and ensure consistent pressure ulcer care and documentation. These failures resulted in actual harm, including wound infections and hospitalization for some residents.
Deficiencies (4)
Failed to accurately code a Minimum Data Set (MDS) for a resident with an unhealed pressure ulcer.
Failed to implement care plan interventions related to wound care for three residents, resulting in wound infection and hospitalization.
Failed to provide care and treatment in accordance with physician orders, including delay in obtaining urinalysis and administering antibiotics.
Failed to ensure consistent pressure ulcer care and weekly wound documentation for three residents, resulting in wound deterioration and infection.
Report Facts
Days wound care not documented as completed: 10
Days wound care not documented as completed: 7
Days wound care not documented as completed: 9
Days wound care not documented as completed: 9
Days wound care not documented as completed: 9
Days wound care not documented as completed: 10
Days wound care not documented as completed: 7
Days wound care not documented as completed: 5
Days wound care not documented as completed: 3
Days wound care not documented as completed: 8
Days wound care not documented as completed: 7
Days wound care not documented as completed: 5
Days wound care not documented as completed: 4
Days wound care not documented as completed: 10
Days wound care not documented as completed: 7
Days wound care not documented as completed: 10
Days wound care not documented as completed: 7
Days wound care not documented as completed: 10
Days wound care not documented as completed: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #2 | LPN | Confirmed significant change in Resident #1's condition and MDS coding issue |
| Interim Director of Nursing | I-DON | Confirmed MDS inaccuracies and wound care documentation issues |
| Registered Nurse #1 | RN | Received physician order for urinalysis and antibiotic for Resident #2; admitted failure to follow up |
| Licensed Practical Nurse #1 | LPN/Supervisor | Confirmed delay in urine sample collection and antibiotic administration for Resident #2 |
| Nurse Practitioner | NP | Prescribed antibiotic for Resident #2 and confirmed expectations for timely administration |
| Administrator | Acknowledged staff turnover and delays in wound care and treatment | |
| Infection Preventionist | IP | Confirmed delay in urine test and antibiotic administration for Resident #2 |
| Licensed Practical Nurse #1 | LPN | Manager of several halls; expected nursing staff to follow care plans |
| Wound Nurse | Confirmed importance of weekly wound assessments and documentation | |
| Wound Care Nurse Practitioner | NP | Evaluates residents weekly and recommends wound measurements |
| Physician | Confirmed requirement for weekly wound reports and noted impact of staff changes |
Inspection Report — Nov 15, 2023
Routine CMS
Date: Nov 15, 2023
Visit Reason
The inspection was conducted as a routine regulatory survey to assess compliance with federal and state regulations for nursing home care.
Findings
The facility was found deficient in multiple areas including failure to honor resident rights regarding wound care timing, failure to promptly resolve food grievances, failure to notify residents and representatives of hospital transfers and bed hold policies, inaccurate PASRR screening, incomplete care plans for several residents, failure to provide adequate activities of daily living care, failure to provide appropriate incontinent care, failure to administer pain medication as ordered, lack of RN coverage for at least 8 hours on one day, and unsanitary conditions in the dietary department.
Deficiencies (11)
Failed to honor resident's right to timely wound care to support resident choice and activities.
Failed to promptly resolve food grievances and inform residents of progress.
Failed to notify residents and representatives in writing of hospital transfers.
Failed to notify residents or representatives in writing of bed hold policy at time of transfer.
Failed to accurately complete PASRR screening resulting in no Level II referral for evaluation.
Failed to develop and implement comprehensive care plans addressing incontinent care, ADLs, and pain management.
Failed to provide activities of daily living related to nail care and bathing/showers.
Failed to provide incontinent care in a manner to prevent infection.
Failed to administer pain medication as ordered resulting in resident experiencing severe pain.
Failed to provide Registered Nurse coverage for at least 8 hours on one day.
Failed to maintain a clean and sanitary dietary department including dirty ice machine and expired/unlabeled foods.
Report Facts
Residents affected: 1
Residents affected: 4
Residents affected: 2
Residents affected: 2
Residents affected: 1
Residents affected: 4
Residents affected: 2
Residents affected: 1
Residents affected: 1
Staffing days reviewed: 25
Staffing days with no RN coverage: 1
Expired food items: 2
Unlabeled/undated food items: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #5 | Wound Care Coordinator | Interviewed regarding wound care timing for Resident #32 |
| Certified Nurse Aide #5 | CNA | Interviewed regarding Resident #32 wound care and social activities |
| Registered Nurse #1 | RN | Interviewed regarding Resident #32 wound care timing |
| Director of Nursing | DON | Interviewed regarding wound care timing, food grievances, care plans, pain management, RN coverage |
| Social Services #1 | Social Services | Interviewed regarding resident council grievances |
| Social Services #2 | Social Services | Interviewed regarding resident council grievances |
| Dietary Manager | Dietary Manager | Interviewed regarding food complaints and dietary sanitation |
| Licensed Social Worker | LSW | Interviewed regarding hospital transfer and bed hold notifications |
| Business Office Manager | BOM | Interviewed regarding hospital transfer and bed hold notifications |
| Administrator | Administrator | Interviewed regarding wound care, food grievances, hospital transfer and bed hold notifications, pain management, dietary sanitation |
| Certified Nursing Assistant #3 | CNA | Interviewed regarding Resident #1 nail care |
| Certified Nursing Assistant #2 | CNA | Observed and interviewed regarding incontinent care for Resident #109 |
| Licensed Practical Nurse #4 | LPN | Interviewed regarding care plans and incontinent care |
| Registered Nurse #1 | RN | Interviewed regarding pain management for Resident #127 |
| Licensed Practical Nurse #6 | LPN | Interviewed regarding pain management for Resident #127 |
| Maintenance Staff #1 | Maintenance | Interviewed regarding ice machine cleaning |
| Dietary Staff #1 | Dietary Staff | Interviewed regarding dietary sanitation |
| Dietary Staff #2 | Dietary Staff | Interviewed regarding dietary sanitation |
Inspection Report — Mar 6, 2023
Complaint Investigation CMS
Date: Mar 6, 2023
Visit Reason
The inspection was conducted due to complaints and concerns regarding failure to implement comprehensive care plans, improper use of mechanical lifts, inadequate wound care and assessments, and unsafe environmental conditions including broken beds.
Complaint Details
The complaint investigation was triggered by observations of unsafe mechanical lift use and inadequate wound care, including a resident with a foot injury caused by a broken bed and multiple residents with untreated pressure ulcers. The investigation identified immediate jeopardy conditions related to these issues.
Findings
The facility failed to implement care plan interventions for mechanical lift use and pressure ulcer treatments, failed to assess and treat bleeding in a timely manner for a resident on anticoagulants, and failed to maintain safe equipment such as beds and mechanical lifts. These failures placed residents at immediate jeopardy of serious harm. The facility provided removal plans and education to staff, and the immediate jeopardy was removed prior to exit.
Deficiencies (4)
Failure to implement comprehensive care plan interventions related to mechanical lift use and pressure ulcer treatments for multiple residents.
Failure to promptly assess and treat bleeding for a resident on anticoagulant therapy.
Failure to provide routine and consistent wound care, assessments, and documentation for residents with pressure ulcers.
Failure to maintain safe environment including broken bed with improperly fitting footboard causing injury and improper use of mechanical lift without required staff assistance.
Report Facts
Missed wound treatments: 20
Missed wound treatments: 9
Missed wound treatments: 17
Missed wound treatments: 16
Residents on anticoagulant therapy: 29
Beds audited: 124
Beds with motor not working: 2
Residents needing full body lift transfer: 49
Residents with skin concerns: 17
Residents at risk for skin concerns: 61
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nurse Aide | Observed using mechanical lift without required assistance; received corrective termination. |
| LPN #1 | Licensed Practical Nurse | Failed to reassess resident for active bleeding; educated on anticoagulant therapy reassessment. |
| RN #1 | Registered Nurse | Assessed resident for active bleeding; provided education on anticoagulant therapy reassessment. |
| RN #11 | Registered Nurse | Assessed Resident #1's foot injury and completed treatment per physician orders. |
| DON | Director of Nursing | Notified of immediate jeopardy; provided education and oversight of care plan compliance. |
| ADON | Assistant Director of Nursing | Participated in QAPI meetings and education; resigned during investigation period. |
| Maintenance Director | Conducted bed audits; identified and replaced broken beds. | |
| WCNP | Wound Care Nurse Practitioner | Provided wound care orders that were not executed by facility. |
Inspection Report — Apr 23, 2021
Routine CMS
Date: Apr 23, 2021
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident care, including abuse prevention, personal hygiene, foot care, food safety, social work staffing, and infection control.
Findings
The facility was found deficient in providing adequate personal hygiene and abuse prevention for residents unable to perform ADLs, appropriate foot care for diabetic and non-diabetic residents, safe food handling practices, employment of a qualified social worker, and infection prevention and control practices including proper wound care, oxygen therapy equipment handling, and perineal care.
Deficiencies (5)
Failure to provide necessary services to maintain good personal hygiene for residents unable to carry out ADLs, including residents #17, #101, #16, and #55.
Failure to provide appropriate foot care and podiatry services for residents #26, #35, and #103, including untrimmed, thick, and discolored toenails.
Failure to distribute meals in a safe manner, with food temperatures above safe levels for Resident #26.
Failure to employ a qualified full-time social worker in a facility licensed for more than 120 beds.
Failure to provide and implement an effective infection prevention and control program, including improper glove use during wound and perineal care, improper handling of oxygen therapy equipment, and failure to prevent cross contamination.
Report Facts
Residents observed for hygiene deficiency: 4
Residents affected by foot care deficiency: 3
Residents affected by infection control deficiency: 5
Facility licensed beds: 180
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #2 | Licensed Practical Nurse | Made CNA assignments and confirmed residents could develop complications from inadequate ADL care |
| DON | Director of Nursing | Confirmed unacceptable care practices and infection control deficiencies |
| PCA #1 | Personal Care Attendant | Assigned to front hall, involved in inadequate ADL care for residents |
| CNA #5 | Certified Nursing Assistant | Observed providing inadequate perineal care and improper glove use |
| RN #2 | Registered Nurse | Observed performing wound care with improper glove and hand hygiene |
| LPN #1 | Licensed Practical Nurse | Commented on podiatry services and nail care practices |
| Administrator | Discussed social worker staffing and podiatry contract status | |
| Social Services Director | Discussed social worker qualifications and podiatry appointment process | |
| RN #4 | Registered Nurse | Discussed oxygen tubing handling and infection control |
| CNA #4 | Certified Nursing Assistant | Observed replacing oxygen cannula and assisting resident |
| CNA #1 | Certified Nursing Assistant | Observed improper glove use during wound care |
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