Inspection Report
Complaint Investigation
Census: 74
Capacity: 90
Deficiencies: 0
Dec 4, 2025
Visit Reason
The State Agency conducted a complaint investigation related to quality of care and accidents at the facility.
Findings
The facility was found to be in compliance with Medicare and Medicaid requirements, and no deficiencies were cited during the investigation.
Complaint Details
Complaint Investigation (CI), MS #2572025 was investigated related to quality of care and accidents. No deficiencies were cited.
Report Facts
Licensed beds: 90
Census: 74
Inspection Report
Complaint Investigation
Deficiencies: 0
Dec 4, 2025
Visit Reason
The State Agency conducted a Complaint Investigation (CI), MS #2572025, related to quality of care and accidents at the facility.
Findings
The facility was found to be in compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirements. There were no deficiencies cited.
Complaint Details
Complaint Investigation MS #2572025 was related to quality of care and accidents. The complaint was investigated and found to be unsubstantiated as no deficiencies were cited.
Inspection Report
Complaint Investigation
Deficiencies: 0
Jul 7, 2025
Visit Reason
The State Agency conducted a Complaint Investigation (CI), MS #29413, at the facility on 7/7/25 regarding resident left wet, call bells not answered, injury of unknown origin, verbal abuse (employee to resident), and resident not treated with dignity.
Findings
No deficiencies were cited during this survey; however, the facility remains out of compliance with state licensure requirements due to deficiencies cited on the 06/05/25 survey.
Complaint Details
Complaint investigation MS #29413 was substantiated with no deficiencies cited during this visit, but prior deficiencies from 06/05/25 remain.
Inspection Report
Complaint Investigation
Census: 66
Capacity: 90
Deficiencies: 0
Jul 7, 2025
Visit Reason
The State Agency conducted a Complaint Investigation (CI), MS #29413, at the facility on 7/7/25 regarding resident left wet, call bells not answered, injury of unknown origin, verbal abuse (employee to resident), and resident not treated with dignity.
Findings
No deficiencies were cited during this complaint investigation survey; however, the facility remains out of compliance due to deficiencies cited on the 06/05/25 survey.
Complaint Details
Complaint Investigation MS #29413 was for resident left wet, call bells not answered, injury of unknown origin, verbal abuse (employee to resident), and resident not treated with dignity. No deficiencies were cited during this investigation.
Report Facts
Licensed beds: 90
Census: 66
Inspection Report
Follow-Up
Deficiencies: 0
Jul 7, 2025
Visit Reason
The State Agency conducted a follow-up revisit at the facility on 7/7/25 related to the Annual and Complaint Survey conducted from 6/2/25 through 6/5/25.
Findings
The State Agency found the facility to be in compliance with the requirements of participation with the Minimum Standards for Institutions for the Aged or Infirm, State Licensure Requirement, and recommends the facility be placed back in compliance effective 7/7/25.
Inspection Report
Follow-Up
Census: 66
Capacity: 90
Deficiencies: 0
Jul 7, 2025
Visit Reason
The State Agency conducted a follow-up revisit at the facility on 7/7/25 related to the Annual and Complaint Survey conducted 6/2/25 through 6/5/25.
Findings
The State Agency found the facility to be in compliance with the requirements of participation in Medicare and Medicaid and recommends the facility be placed back in compliance effective 7/7/25.
Inspection Report
Annual Inspection
Census: 67
Capacity: 90
Deficiencies: 9
Jun 5, 2025
Visit Reason
The State Agency conducted an annual recertification survey along with complaint investigations at the facility from 6/2/25 through 6/5/25.
Findings
The facility was found not in compliance with Medicare and Medicaid participation requirements, citing multiple deficiencies including failure to prevent elopement, timely reporting and investigation of incidents, inaccurate assessments, failure to follow care plans, and food safety violations. Immediate Jeopardy was identified related to Resident #55's elopement but was removed after corrective actions.
Complaint Details
Complaint Investigations MS #27770 and MS #28507 were conducted related to nursing services, no hot water, food palatability, quality of care/treatment, dignity/respect, and misappropriation. No deficiencies were related to the complaints.
Severity Breakdown
Level J: 4
Level G: 2
Level D: 3
Deficiencies (9)
| Description | Severity |
|---|---|
| Failure to provide supervision to prevent Resident #55 from leaving the facility through an alarmed door and failure to investigate the event timely. | Level J |
| Failure to timely report an instance of elopement involving Resident #55. | Level J |
| Failure to initiate a timely investigation of Resident #55's elopement. | Level J |
| Failure to complete a Significant Change Minimum Data Set (MDS) assessment within 14 days for Resident #7 admitted to hospice services. | Level D |
| Failure to ensure accuracy of MDS assessments for Residents #7 and #5. | Level D |
| Failure to follow comprehensive care plans for Residents #164, #47, and #7 including PEG tube site care, call light accessibility, and use of mechanical lift. | Level G |
| Failure to ensure adequate supervision and safety interventions to prevent accidents for Residents #55 and #47, including failure to respond to door alarms and improper transfer techniques. | Level J |
| Failure to ensure proper care and monitoring of enteral feeding and gastrostomy sites for Residents #164 and #6, including unlabeled feeding equipment and delayed PEG site care. | Level G |
| Failure to store food in a sanitary manner, including use of expired milk and improper storage of key lime juice. | Level D |
Report Facts
Deficiencies cited: 7
Census: 67
Total Capacity: 90
Incident reports audited: 66
Wandering drills: 65
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Named in relation to Immediate Jeopardy notification, investigation, and corrective actions for Resident #55 elopement. | |
| Director of Nursing | Named in relation to investigation, care plan review, and corrective actions for multiple deficiencies. | |
| Certified Nursing Assistant #1 | CNA | Named in relation to call light placement deficiency for Resident #7. |
| Licensed Practical Nurse #1 | LPN | Named in relation to Resident #55 elopement event and investigation. |
| Licensed Practical Nurse #2 | LPN | Named in relation to MDS assessment and care plan accuracy. |
| Dietary #1 | Named in relation to discovering Resident #55 outside the facility. | |
| Staff Development Nurse | Named in relation to staff in-service training on call light placement, incident reporting, and care plan process. |
Inspection Report
Annual Inspection
Deficiencies: 5
Jun 5, 2025
Visit Reason
The State Agency conducted an annual recertification survey along with complaint investigations related to nursing services, hot water, food quality, dignity/respect, and misappropriation from 2025-06-02 through 2025-06-05.
Findings
The facility was found not in compliance with state licensure requirements, citing deficiencies including failure to supervise a resident who eloped, residents' rights violations, improper care of enteral feeding sites, unsafe accident prevention, and unsafe food handling practices. Immediate Jeopardy was identified related to the elopement incident but was removed after corrective actions.
Complaint Details
Complaint investigations MS #27770 and MS #28507 were conducted related to nursing services, hot water, food quality, dignity/respect, and misappropriation. No deficiencies were found related to the complaints.
Severity Breakdown
Level IV: 2
Level III: 1
Level II: 2
Deficiencies (5)
| Description | Severity |
|---|---|
| Failure to provide supervision to prevent Resident #55 from eloping through an alarmed door, resulting in Immediate Jeopardy. | Level IV |
| Failure to ensure call light was within reach for Resident #7 and failure to maintain residents' privacy and confidentiality with personal care signage on Resident #14's door. | Level II |
| Failure to provide timely physician orders and proper care for PEG site resulting in infection (Resident #164) and unlabeled enteral feeding equipment (Resident #6). | Level III |
| Failure to ensure adequate supervision and safety interventions to prevent accidents, including failure to investigate an active exit alarm and improper manual transfer causing injury (Resident #47). | Level IV |
| Failure to store food in a sanitary manner, including expired milk and improperly stored key lime juice. | Level II |
Report Facts
Deficiencies cited: 5
Residents reviewed for accidents and hazards: 4
Residents sampled for call light and privacy: 20
Residents reviewed for tube feeding and site care: 2
Residents in facility head count during code drill: 65
Incident/accident reports audited: 66
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Named in failure to investigate exit alarm and elopement incident involving Resident #55. |
| Director of Nursing | Director of Nursing | Involved in investigation and corrective actions related to Resident #55 elopement and Resident #47 injury. |
| Administrator | Facility Administrator | Notified of Immediate Jeopardy and involved in corrective action plan for Resident #55 elopement. |
| Certified Nursing Assistant #5 | Certified Nursing Assistant | Involved in Resident #55 elopement incident response. |
| Licensed Practical Nurse #5 | Licensed Practical Nurse | Involved in Resident #55 elopement incident response. |
| Physical Therapy Assistant | Physical Therapy Assistant | Reported Resident #47 injury due to improper manual transfer. |
| Agency CNA #1 | Certified Nursing Assistant | Admitted to manually transferring Resident #47 without mechanical lift. |
| Dietary Manager | Dietary Manager | Noted expired milk and improperly stored key lime juice. |
Inspection Report
Annual Inspection
Census: 67
Capacity: 90
Deficiencies: 3
Jun 5, 2025
Visit Reason
The State Agency conducted an annual recertification survey along with complaint investigations related to nursing services, no hot water, food quality, quality of care, dignity/respect, and misappropriation from 2025-06-02 through 2025-06-05.
Findings
The facility was found not in compliance with Medicare and Medicaid requirements, citing multiple deficiencies including failure to provide supervision that led to a resident elopement. Immediate Jeopardy and Substandard Quality of Care were identified but removed by 2025-06-05 after corrective actions were implemented.
Complaint Details
Complaint investigations MS #27770 and MS #28507 were conducted for nursing services, no hot water, food quality, quality of care, dignity/respect, and misappropriation. No deficiencies were found related to the complaints.
Severity Breakdown
J: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to provide supervision to prevent Resident #55 from leaving the facility through an alarmed door and failure to investigate the alarm promptly. | J |
| Failure to report the elopement event to the State Agency in a timely manner. | J |
| Failure to investigate the alleged violation internally as required. | J |
Report Facts
Census: 67
Total licensed capacity: 90
Deficiency citations: 7
Inspection Report
Annual Inspection
Deficiencies: 2
Jun 5, 2025
Visit Reason
The State Agency conducted an annual recertification survey along with complaint investigations related to nursing services, no hot water, food quality, dignity/respect, and misappropriation from 6/2/25 through 6/5/25.
Findings
No deficiencies were found related to the complaint investigations. However, the facility was found non-compliant with state licensure requirements, including failure to provide supervision to prevent a resident from eloping, resulting in an Immediate Jeopardy and Substandard Quality of Care that began on 5/31/25 and was removed on 6/5/25 after corrective actions.
Complaint Details
Complaint investigations MS #27770 and MS #28507 were conducted for nursing services, no hot water, food not palatable, quality of care/treatment, residents not treated with dignity/respect, and misappropriation. No deficiencies were found related to these complaints.
Severity Breakdown
Level IV: 1
Level II: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to provide supervision to prevent Resident #55 from leaving the facility through an alarmed door, which staff failed to investigate despite hearing the alarm. | Level IV |
| Scope and severity for Rule 45.21.8 - Accidents (M640) lowered to Level II after removal of Immediate Jeopardy. | Level II |
Report Facts
Complaint Investigations: 2
Dates of survey: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Named in relation to being unaware of the elopement and failure to initiate internal investigation |
Inspection Report
Life Safety
Deficiencies: 0
Jun 2, 2025
Visit Reason
The survey was conducted to assess the facility's compliance with Federal, State, and local emergency preparedness requirements.
Findings
The facility met all applicable emergency preparedness requirements with no deficiencies cited during the survey.
Inspection Report
Life Safety
Deficiencies: 0
Jun 2, 2025
Visit Reason
The inspection was conducted to assess the facility's compliance with the 2012 Edition of the Life Safety Code (LSC) of the National Fire Protection Association (NFPA).
Findings
The facility met the applicable provisions of the 2012 Edition of the Life Safety Code. No deficiencies were cited during this inspection.
Inspection Report
Complaint Investigation
Census: 65
Capacity: 90
Deficiencies: 0
Oct 14, 2024
Visit Reason
The State Agency conducted a Complaint Investigation related to discharge rights, resident safety, and neglect.
Findings
The facility was found to be in compliance with Medicare and Medicaid requirements, and no deficiencies were cited.
Complaint Details
Complaint Investigation (CI MS #26733) related to discharge rights, resident safety, and neglect; no deficiencies cited.
Report Facts
Licensed beds: 90
Census: 65
Inspection Report
Complaint Investigation
Deficiencies: 0
Oct 14, 2024
Visit Reason
The State Agency conducted a Complaint Investigation (CI), MS #26733, related to discharge rights, resident safety, and neglect at the facility.
Findings
During the survey, the State Agency determined the facility was in compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirement. There were no deficiencies cited.
Complaint Details
Complaint Investigation MS #26733 was related to discharge rights, resident safety, and neglect. The complaint was not substantiated as no deficiencies were cited.
Inspection Report
Complaint Investigation
Census: 67
Capacity: 90
Deficiencies: 0
Oct 7, 2024
Visit Reason
The State Agency conducted a Complaint Investigation (CI MS #25892) related to quality of care, facility cleanliness, and resident discharge.
Findings
The facility was found to be in compliance with Medicare and Medicaid requirements, and no deficiencies were cited during the investigation.
Complaint Details
Complaint Investigation (CI MS #25892) was related to quality of care, facility cleanliness, and resident discharge. The complaint was not substantiated as no deficiencies were cited.
Report Facts
Licensed beds: 90
Census: 67
Inspection Report
Complaint Investigation
Deficiencies: 0
Oct 7, 2024
Visit Reason
The State Agency conducted a Complaint Investigation (CI), MS #25892, related to quality of care, facility cleanliness, and resident discharge at the facility.
Findings
The facility was found to be in compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirement, with no deficiencies cited.
Complaint Details
Complaint Investigation MS #25892 was substantiated by the survey, which found no deficiencies.
Report Facts
Complaint Investigation Number: 25892
Inspection Report
Complaint Investigation
Census: 66
Capacity: 90
Deficiencies: 1
May 2, 2024
Visit Reason
The State Agency conducted complaint investigations related to allegations of abuse and resident rights violations at the facility from 4/30/24 through 5/2/24.
Findings
The facility was found to have failed to treat a resident with respect and dignity during care, specifically involving verbal abuse by a Certified Nurse Aide (CNA) toward Resident #2. The CNA was terminated following the incident, and corrective actions including staff in-services and a Quality Assurance Performance Improvement meeting were implemented. The deficiency was cited as Past Non-Compliance and was corrected prior to the survey.
Complaint Details
The complaint investigations included CI MS #24570 related to abuse, CI MS #24603 related to verbal abuse, and CI MS #24912 related to resident rights. The verbal abuse allegation was substantiated as disrespectful treatment but not rising to verbal abuse level. The facility reported the incident to the State Agency and Attorney General Office on 3/22/24.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to treat a resident with respect and dignity during care, involving verbal abuse by a CNA toward Resident #2. | SS=D |
Report Facts
Licensed beds: 90
Resident census: 66
BIMS score: 15
BIMS score: 15
Date of incident report: Mar 22, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nurse Aide | Named in verbal abuse finding and terminated after second incident of discourteous behavior |
| Social Services Director | Interviewed regarding the incident and investigation | |
| Director of Nurses | Interviewed and confirmed resident statements and staff conduct | |
| Administrator | Conducted investigation, confirmed findings, and implemented corrective actions |
Inspection Report
Complaint Investigation
Deficiencies: 1
May 2, 2024
Visit Reason
The State Agency conducted Complaint Investigations at Gulfport Care Center from 2024-04-30 through 2024-05-02 related to allegations of abuse and resident rights violations.
Findings
The facility was found to be in compliance with state licensure requirements based on corrective actions implemented prior to the survey. However, a Level II deficiency was cited for failure to treat a resident with respect and dignity during care, involving verbal abuse by a Certified Nurse Aide (CNA). The CNA was terminated following the incident, and the facility conducted in-services on resident rights and abuse/neglect.
Complaint Details
The complaint investigations included MS #24570 related to abuse, MS #24603 related to verbal abuse, and MS #24912 related to resident rights. The verbal abuse allegation involved a CNA telling Resident #2 to 'get her expletive up and go to the bathroom' after an accident. The allegation was substantiated as disrespectful but not threatening. The CNA was terminated after a second similar accusation. The facility reported the abuse to the State Agency and Attorney General Office on 2024-03-22.
Severity Breakdown
Level II: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to treat a resident with respect and dignity during care, involving verbal abuse by a CNA towards Resident #2. | Level II |
Report Facts
Complaint Investigations: 3
BIMS score: 15
BIMS score: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nurse Aide | Named in verbal abuse finding and terminated following the incident |
| Social Services Director | Confirmed verbal abuse allegation and participated in investigation | |
| Director of Nurses | DON | Confirmed verbal abuse allegation and staff conduct expectations |
| Administrator | Conducted investigation, confirmed findings, and reported abuse to authorities |
Inspection Report
Follow-Up
Deficiencies: 0
Mar 18, 2024
Visit Reason
The State Agency conducted a follow-up revisit at the facility on 3/18/24 related to an Annual Recertification survey and Complaint Investigation (CI MS #23919), which took place from 1/29/24 through 2/1/24.
Findings
The facility was found to be back in compliance with Minimum Standards for Institutions for the Aged or Infirm and state licensure requirements, effective 3/13/24.
Complaint Details
Complaint Investigation (CI MS #23919) was part of the visit.
Inspection Report
Annual Inspection
Census: 72
Capacity: 90
Deficiencies: 11
Feb 1, 2024
Visit Reason
The State Agency conducted an annual recertification survey and a complaint investigation related to infection control at the facility from January 29, 2024 through February 1, 2024.
Findings
No deficiencies were cited related to the complaint investigation on infection control. However, during the annual recertification survey, the facility was found not in compliance with Medicare and Medicaid participation requirements and was cited for multiple deficiencies.
Complaint Details
Complaint Investigation MS #23919 was related to infection control and no deficiencies were cited related to the complaint.
Deficiencies (11)
| Description |
|---|
| Deficiency F561 cited |
| Deficiency F567 cited |
| Deficiency F585 cited |
| Deficiency F623 cited |
| Deficiency F625 cited |
| Deficiency F725 cited |
| Deficiency F758 cited |
| Deficiency F761 cited |
| Deficiency F812 cited |
| Deficiency F851 cited |
| Deficiency F919 cited |
Report Facts
Licensed beds: 90
Census: 72
Inspection Report
Annual Inspection
Census: 72
Capacity: 180
Deficiencies: 3
Feb 1, 2024
Visit Reason
The State Agency conducted an annual recertification survey and a complaint investigation related to infection control at the facility from 2024-01-29 through 2024-02-01.
Findings
The facility was found not in compliance with state licensure requirements, citing deficiencies in nursing staffing resulting in residents not receiving showers and call lights not answered timely, failure to ensure residents' rights regarding access to personal funds on weekends, and unsafe food handling practices including unlabeled and undated food items.
Complaint Details
Complaint Investigation MS #23919 related to infection control was conducted with no deficiencies cited.
Severity Breakdown
Level II: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to provide sufficient nursing staff resulting in residents not receiving showers and call lights not answered timely for 5 of 18 sampled residents. | Level II |
| Failed to ensure residents had access to their personal fund accounts on weekends for 9 of 18 sampled residents. | Level II |
| Failed to store food in accordance with professional standards for food service safety related to food items not dated with a use-by-date, food items without an identifying label, and food items opened and exposed. | Level II |
Report Facts
Residents sampled for nursing staffing deficiency: 18
Residents affected by nursing staffing deficiency: 72
Residents sampled for personal fund access deficiency: 18
Residents potentially affected by personal fund access deficiency: 40
Facility licensed capacity: 180
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse #1 | Registered Nurse | Confirmed failure to document resident showers and in-serviced staff on documentation. |
| Director of Nursing | Director of Nursing | Confirmed staffing issues and failure to document showers; planned corrective actions. |
| Administrator | Administrator | Confirmed staffing expectations and lack of weekend staff for personal fund distribution. |
| Dietary Manager | Dietary Manager | Acknowledged food storage deficiencies and responsibility for food labeling and dating. |
| CNA #4 | Certified Nursing Assistant | Reported working alone on night shift and inability to provide showers due to lack of assistance. |
| CNA #5 | Certified Nursing Assistant | Reported giving bed baths instead of showers due to lack of assistance. |
| CNA #6 | Certified Nursing Assistant | Reported inability to provide showers alone and complaints to DON and Staff Development Nurse. |
Inspection Report
Annual Inspection
Census: 72
Capacity: 90
Deficiencies: 11
Feb 1, 2024
Visit Reason
The State Agency conducted an annual recertification survey and Complaint Investigation related to infection control from 1/29/24 through 2/1/24.
Findings
The facility was found not in compliance with Medicare and Medicaid participation requirements, citing multiple deficiencies including resident self-determination, personal funds management, grievances, transfer notices, nursing staffing, psychotropic medication use, medication storage, food safety, payroll staffing data, and resident call system functionality.
Complaint Details
Complaint Investigation (CI MS #23919) was related to infection control and no deficiencies were cited related to the complaint.
Severity Breakdown
SS=D: 5
SS=E: 3
SS=F: 3
Deficiencies (11)
| Description | Severity |
|---|---|
| Failed to ensure resident rights were honored by not consistently providing residents with their choice of receiving showers for 3 of 18 residents reviewed. | SS=D |
| Failed to ensure residents had access to their personal fund accounts on weekends for 9 of 18 sampled residents. | SS=E |
| Failed to provide resolution to grievances related to call lights not being answered and CNAs turning off call lights and not returning for 3 of 6 months of Resident Council grievance logs reviewed. | SS=E |
| Failed to include the reason for resident transfers in a manner they could understand in the written notification of transfer for 2 of 2 sampled residents reviewed for hospitalization. | SS=D |
| Failed to provide resident and Resident Representative written information at the time of resident transfer to hospital regarding bed hold policies for 1 of 2 sampled residents reviewed for hospitalization. | SS=D |
| Failed to provide sufficient nursing staff resulting in residents not receiving showers and call lights not answered timely for 5 of 18 sampled residents and potentially affecting all 72 residents. | SS=F |
| Failed to ensure an as needed (PRN) psychotropic medication was limited to a 14-day duration without clinical rationale documentation for 1 of 5 residents reviewed. | SS=D |
| Failed to discard insulin vials after discard date for 1 of 3 medication carts reviewed. | SS=D |
| Failed to store food in accordance with professional standards for food service safety related to food items not dated with a use-by-date, food items without an identifying label, and food items opened and exposed for 1 of 3 kitchen observations. | SS=F |
| Failed to ensure Payroll Based Journal staffing data was accurately submitted to CMS for 1 of 4 quarters reviewed due to omission of contract staff hours. | SS=F |
| Failed to ensure call lights were functioning for 2 of 14 resident rooms on the 300 Hall. | SS=D |
Report Facts
Deficiencies cited: 11
Licensed beds: 90
Resident census: 72
Residents reviewed for choice of showers: 18
Residents affected by personal funds access issue: 40
Residents reviewed for personal funds access: 18
Resident council grievance logs reviewed: 6
Residents reviewed for hospitalization transfer notices: 2
Medication carts reviewed: 3
Kitchen observations: 3
Quarters reviewed for PBJ data: 4
Contract staff missing from PBJ: 4
Resident rooms with non-functioning call lights: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Named in shower documentation and provision deficiency. |
| CNA #4 | Certified Nursing Assistant | Named in shower provision deficiency. |
| CNA #5 | Certified Nursing Assistant | Named in shower provision deficiency. |
| CNA #6 | Certified Nursing Assistant | Named in shower provision deficiency. |
| DON | Director of Nursing | Named in shower documentation, staffing, and call light deficiencies. |
| Administrator | Facility Administrator | Named in multiple deficiencies including shower documentation, grievance resolution, transfer notices, staffing, and call light deficiencies. |
| Activity #1 | Activity Staff | Named in personal funds access deficiency. |
| Activity #2 | Activity Staff | Named in personal funds access deficiency. |
| Business Office Manager | Business Office Manager | Named in personal funds access deficiency. |
| Psychiatric NP | Nurse Practitioner | Named in psychotropic medication deficiency. |
| LPN #3 | Licensed Practical Nurse | Named in medication storage deficiency. |
| Dietary Manager | Dietary Manager | Named in food storage deficiency. |
| Maintenance Director | Maintenance Director | Named in call light deficiency. |
Inspection Report
Annual Inspection
Deficiencies: 1
Feb 1, 2024
Visit Reason
The State Agency conducted an annual recertification survey and a complaint investigation related to infection control at the facility from January 29, 2024 through February 1, 2024.
Findings
No deficiencies were cited related to the complaint investigation on infection control. However, during the annual recertification survey, the facility was found not in compliance with state licensure requirements and cited for deficiencies M225, M500, and M815.
Complaint Details
Complaint Investigation MS #23919 related to infection control was investigated and no deficiencies were cited.
Deficiencies (1)
| Description |
|---|
| Facility was not in compliance with Minimum Standards for Institutions for the Aged or Infirm, state licensure requirements, citing M225, M500, and M815. |
Inspection Report
Life Safety
Deficiencies: 1
Jan 30, 2024
Visit Reason
The inspection was conducted to assess compliance with the Life Safety Code (LSC) requirements, specifically focusing on the maintenance and testing of the facility's essential electric system including the generator.
Findings
The facility failed to maintain the generator in a condition capable of automatically transferring power within 10 seconds during a power failure. On the day of the survey, the generator controls were found in the 'off' position, rendering the generator incapable of automatic transfer. The issue was corrected by placing the generator in 'automatic' mode and repairs were made to ensure compliance.
Severity Breakdown
SS=F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Generator controls were in the 'off' position and the generator was incapable of automatically transferring power to the facility in the event of a power failure. | SS=F |
Report Facts
Scheduled generator exercise frequency: 12
Scheduled generator exercise duration: 4
Date of survey: Jan 30, 2024
Plan of correction completion date: Mar 13, 2024
Inspection Report
Life Safety
Deficiencies: 1
Jan 30, 2024
Visit Reason
The inspection was conducted to assess compliance with Life Safety Code regulations, specifically regarding the facility's generator and essential electric system.
Findings
The facility failed to maintain the generator in an automatic mode capable of transferring power during an outage, posing a potential risk to all residents. The generator was found in the 'off' position and was manually switched to 'automatic' during the survey; corrective actions and monitoring plans were implemented.
Deficiencies (1)
| Description |
|---|
| Facility failed to provide the generator as directed by NFPA 110 section 8.4.2 and NFPA 99 sections 6.4.4.1.1.3 and 6.4.4.2, with generator controls in the 'off' position and incapable of automatic power transfer. |
Report Facts
Date of generator repair: Feb 1, 2024
Monitoring period: 12
Monitoring period: 3
Date of Quality Assessment and Assurance Committee meeting: Mar 12, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Put generator in automatic position and responsible for ongoing monitoring. | |
| Administrator | Acknowledged the finding during exit interview. | |
| Maintenance Supervisor | Verified the generator observation during exit interview. | |
| Regional Supervisor | Provided in-service training on essential electric system maintenance and testing. |
Inspection Report
Deficiencies: 0
Jan 30, 2024
Visit Reason
The survey was conducted to assess the facility's compliance with emergency preparedness requirements.
Findings
The facility met all applicable Federal, State, and local emergency preparedness requirements with no deficiencies noted.
Inspection Report
Complaint Investigation
Deficiencies: 0
Aug 1, 2023
Visit Reason
The State Agency conducted a Complaint Investigation at the facility from 7/31/23 to 8/1/23 regarding allegations of Infection Control and Physical Environment.
Findings
The State Agency did not substantiate the complaint allegations and determined the facility was in compliance with Mississippi Regulations for Minimum Standards for Institutions for Aged or Infirm with no deficiencies cited.
Complaint Details
Complaint MS# 22101 was investigated and not substantiated for allegations of Infection Control and Physical Environment.
Inspection Report
Complaint Investigation
Census: 79
Capacity: 90
Deficiencies: 0
Aug 1, 2023
Visit Reason
The State Agency conducted a complaint investigation (CI MS# 22101) at the facility from 7/31/23 through 8/1/23 regarding allegations of Infection Control and Physical Environment.
Findings
The facility was found to be in compliance with Medicare and Medicaid requirements with no deficiencies cited related to the complaint investigation.
Complaint Details
Complaint investigation CI MS# 22101 was not substantiated; no deficiencies were cited for allegations of Infection Control and Physical Environment.
Report Facts
Census: 79
Total Capacity: 90
Inspection Report
Complaint Investigation
Deficiencies: 0
Jul 12, 2023
Visit Reason
The State Agency conducted a desk review of information related to a complaint survey completed on 2023-05-18.
Findings
The information provided by the facility confirmed compliance with the Minimum Standards of Operation for Institutions for the Aged or Infirm.
Complaint Details
The visit was complaint-related, and the facility was found to be in compliance based on the desk review.
Inspection Report
Plan of Correction
Deficiencies: 0
Jul 12, 2023
Visit Reason
The State Agency conducted a desk review of information related to a complaint survey completed on 2023-05-18 to verify corrective measures taken by the facility.
Findings
The facility provided information confirming that measures were implemented to correct the deficient practice and sustain compliance with Medicare and Medicaid requirements. The State Agency recommended the facility be placed back in compliance effective 2023-06-30.
Complaint Details
The visit was related to a complaint survey completed on 2023-05-18. The review confirmed corrective actions were taken and compliance was restored.
Inspection Report
Complaint Investigation
Census: 75
Capacity: 90
Deficiencies: 0
Jul 6, 2023
Visit Reason
The State Agency conducted a Complaint Investigation and a Focused Infection Control survey at the facility from 07/05/23 through 07/06/23 related to infection control, improper disposal of biohazard waste, and failure to conduct COVID-19 testing for staff.
Findings
The facility was found to be in compliance with Medicare and Medicaid participation requirements with no deficiencies cited during this survey. However, the facility remains Out of Compliance due to deficiencies cited on the 5/18/2023 survey.
Complaint Details
The complaint investigation involved MS #21942 related to Infection Control and MS #21949 related to improper disposal of biohazard waste and not conducting COVID-19 testing for staff. No deficiencies were cited in this investigation.
Report Facts
Census: 75
Total licensed capacity: 90
Inspection Report
Abbreviated Survey
Deficiencies: 0
Jul 6, 2023
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey was conducted by the State Agency from 07/05/2023 through 07/06/2023.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to E-0024 (b) (6). However, the facility remains out of compliance due to deficiencies cited on the 5/18/2023 survey.
Inspection Report
Complaint Investigation
Deficiencies: 0
Jul 6, 2023
Visit Reason
The State Agency conducted a Complaint Investigation and a Focused Infection Control survey at the facility from 07/05/23 through 07/06/23. The investigation was related to Infection Control and improper disposal of biohazard waste and failure to conduct COVID-19 testing for staff.
Findings
During the survey, the facility was found to be in compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirements. No deficiencies were cited during this investigation, but the facility remains Out of Compliance due to deficiencies cited on a prior survey dated 5/18/2023.
Complaint Details
The complaint investigation involved MS #21942 related to Infection Control and MS #21949 related to improper disposal of biohazard waste and not conducting COVID-19 testing for staff. No deficiencies were cited during this investigation.
Report Facts
Complaint Investigation IDs: MS #21942 and MS #21949
Prior survey date: 5/18/2023
Inspection Report
Complaint Investigation
Census: 75
Capacity: 90
Deficiencies: 0
Jul 6, 2023
Visit Reason
The State Agency conducted a Complaint Investigation and a Focused Infection Control survey at the facility from 07/05/23 through 07/06/23 related to Infection Control and improper disposal of biohazard waste and not conducting COVID-19 testing for staff.
Findings
The facility was found to be in compliance with Medicare and Medicaid participation requirements with no deficiencies cited during this survey. However, the facility remains Out of Compliance due to deficiencies cited on the 5/18/2023 survey.
Complaint Details
The investigation involved MS #21942 related to Infection Control and MS #21949 related to improper disposal of biohazard waste and failure to conduct COVID-19 testing for staff. No deficiencies were cited in this investigation.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Jul 6, 2023
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey was conducted by the State Agency from 07/05/2023 through 07/06/2023.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to E-0024 (b) (6). However, the facility remains Out of Compliance due to deficiencies cited on the 5/18/2023 survey.
Inspection Report
Complaint Investigation
Deficiencies: 0
Jul 6, 2023
Visit Reason
The State Agency conducted a Complaint Investigation and a Focused Infection Control survey at the facility from 07/05/23 through 07/06/23 related to infection control, improper disposal of biohazard waste, and failure to conduct COVID-19 testing for staff.
Findings
The survey determined the facility was in compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirements, with no deficiencies cited during this investigation. However, the facility remains Out of Compliance due to deficiencies cited on the 5/18/2023 survey.
Complaint Details
The complaint investigation involved MS #21942 related to Infection Control and MS #21949 related to improper disposal of biohazard waste and not conducting COVID-19 testing for staff. No deficiencies were cited during this investigation.
Inspection Report
Complaint Investigation
Census: 72
Capacity: 90
Deficiencies: 2
May 18, 2023
Visit Reason
The State Agency conducted three complaint investigations at the facility from 05/16/23 through 05/18/23 related to infection control, dietary, discharge rights, accidents, resident assessment, environment, resident care, staffing, and abuse allegations.
Findings
The facility was found non-compliant with Medicare and Medicaid participation requirements due to failure to timely report an allegation of abuse and failure to protect a resident from further abuse during investigation. No deficiencies were cited for infection control, dietary, discharge rights, accidents, resident assessment, environment, resident care, or staffing.
Complaint Details
The complaint investigations included MS #21107 related to abuse, MS #20900 related to infection control, dietary, and discharge rights, and MS #20690 related to accidents, resident assessment, environment, resident left wet, and staffing. Deficiencies were cited only for MS #21107 related to abuse. The facility failed to timely report an abuse allegation involving Resident #3 and failed to protect Resident #3 from further abuse during the investigation. The allegation involved CNA #1 pushing Resident #3 in the face on 3/25/23. Staff did not report the incident immediately, and CNA #1 was allowed to work the full shift after the allegation. The facility took corrective actions including staff in-service and monitoring.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to report an allegation of abuse to the facility Administrator and State Agency in a timely manner for one resident. | SS=D |
| Failure to protect a resident from further abuse while the investigation was in progress. | SS=D |
Report Facts
Facility license capacity: 90
Resident census: 72
Complaint Investigations: 3
Incident report date: Mar 28, 2023
Incident date: Mar 25, 2023
CNA #1 shift hours: CNA #1 clocked in at 7:00 PM and clocked out at 6:30 AM the next morning
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse Supervisor #1 | Registered Nurse Supervisor | Assessed Resident #3 on 3/26/23 with no adverse findings; reported abuse allegation to Administrator |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Did not report abuse allegation immediately; in-serviced on abuse reporting on 3/27/23 |
| Licensed Practical Nurse #2 | Licensed Practical Nurse | Did not report abuse allegation immediately; left letter under Administrator's door; in-serviced on abuse reporting |
| Administrator | Facility Administrator | Notified of abuse allegation on 3/26/23; initiated investigation and staff in-service; reported to State Agency and resident's family |
| Registered Nurse #1 | Registered Nurse | Weekend supervisor; notified Administrator of abuse allegation on 3/26/23 |
| Director of Nursing | Director of Nursing | Confirmed CNA #1 was allowed to work full shift after abuse allegation |
Inspection Report
Complaint Investigation
Deficiencies: 0
May 16, 2023
Visit Reason
The State Agency conducted complaint investigations at the facility from 05/16/23 through 05/18/23 related to infection control, dietary, discharge rights, accidents, resident assessment, environment, resident left wet for extended periods, facility staffing, and abuse.
Findings
The facility was found to be in compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirements. No state licensure deficiencies were cited.
Complaint Details
Investigations were conducted for MS #21107 (Abuse), MS #20900 (Infection control, Dietary, Discharge Rights), and MS #20690 (Accidents, Resident Assessment, Environment, Resident left wet for extended periods, Facility Staffing). No deficiencies were cited.
Inspection Report
Complaint Investigation
Deficiencies: 0
Sep 9, 2022
Visit Reason
The State Agency conducted a complaint investigation at the facility from 9/7/22 through 9/9/22 related to a resident's death due to choking.
Findings
The facility was found to be in compliance with Mississippi Regulations for Minimum Standards for Institutions for the Aged or Infirm and state licensure requirements. The complaint was not substantiated and no deficiencies were cited.
Complaint Details
Complaint related to a resident's death due to choking was investigated and not substantiated.
Inspection Report
Complaint Investigation
Census: 61
Capacity: 90
Deficiencies: 0
Sep 9, 2022
Visit Reason
The State Agency conducted a Complaint Investigation (CI), MS #19552, at the facility from 9/7/22 through 9/9/22 to investigate a complaint regarding a resident's death due to choking.
Findings
The facility was found to be in compliance with Medicare and Medicaid participation requirements. The complaint was not substantiated and no deficiencies were cited.
Complaint Details
Complaint investigation MS #19552 regarding a resident's death due to choking was not substantiated.
Report Facts
Licensed beds: 90
Resident census: 61
Inspection Report
Complaint Investigation
Deficiencies: 0
Apr 12, 2022
Visit Reason
The State Agency conducted a complaint investigation at the facility from 4/7/22 through 4/12/22 regarding allegations of neglect, residents left wet, pressure sores, and not following physician orders related to dialysis transportation.
Findings
The complaint was not substantiated. The facility was found to be in compliance with the Mississippi Regulations Minimum Standards for Institutions for the Aged or Infirm, and no deficiencies were cited.
Complaint Details
Complaint investigation MS #18698 was conducted and the complaint was not substantiated.
Inspection Report
Complaint Investigation
Census: 65
Capacity: 90
Deficiencies: 0
Apr 12, 2022
Visit Reason
The State Agency conducted a complaint investigation at the facility from 4/7/22 through 4/12/22 regarding allegations of neglect, residents left wet, pressure sores, and not following physician orders related to dialysis transportation.
Findings
The facility was found to be in compliance with Medicare and Medicaid requirements. The complaint was not substantiated and no deficiencies were cited.
Complaint Details
Complaint investigation MS #18698 was conducted; the complaint was not substantiated.
Inspection Report
Complaint Investigation
Deficiencies: 0
Dec 21, 2021
Visit Reason
The inspection was conducted as a complaint survey (CI: 18257) from 12/20/2021 to 12/21/2021.
Findings
The State Agency determined the facility was in compliance with the Minimum Standards of Operation for Institutions for the Aged or Infirm and state licensure requirements, with no deficiencies cited.
Complaint Details
Complaint survey CI: 18257 was conducted and found no deficiencies; the facility was in compliance.
Inspection Report
Complaint Investigation
Deficiencies: 0
Dec 21, 2021
Visit Reason
The inspection was conducted as a complaint survey from 12/20/2021 to 12/21/2021 to determine compliance with state licensure requirements.
Findings
The State Agency determined the facility was in compliance with the Minimum Standards of Operation for Institutions for the Aged or Infirm and state licensure requirements, with no deficiencies cited.
Complaint Details
Complaint survey CI: 18257 was conducted; no deficiencies were found and the facility was in compliance.
Inspection Report
Complaint Investigation
Census: 71
Capacity: 90
Deficiencies: 0
Dec 21, 2021
Visit Reason
The State Agency conducted a complaint investigation at the facility from 12/20/21 to 12/21/21 regarding allegations of violating residents' rights, failure to assess a resident after a fall, and failure to provide quality of care.
Findings
The investigation determined the facility was in compliance with Medicare and Medicaid participation requirements. The complaint was not substantiated due to lack of sufficient evidence, and no deficiencies were cited.
Complaint Details
Complaint MS #18257 was investigated and found unsubstantiated due to insufficient evidence of violating residents' rights, failure to assess Resident #1 after a fall, and failure to provide quality of care.
Report Facts
Licensed beds: 90
Census: 71
Inspection Report
Annual Inspection
Deficiencies: 0
Oct 21, 2021
Visit Reason
The State Agency conducted an annual and complaint investigation survey for multiple complaints at the facility from 2021-10-18 to 2021-10-21.
Findings
The State Agency did not substantiate the complaints related to Quality of Care/Treatment, Resident/Patient/Client Abuse, and Infection Control. The facility was found to be in compliance with Mississippi Regulations for Minimum Standards for Institutions for Aged or Infirm with no deficiencies cited.
Complaint Details
Complaints MS #17383, MS #17426, MS #17463, MS #17961, and MS #18132 were investigated and not substantiated.
Inspection Report
Annual Inspection
Census: 67
Capacity: 90
Deficiencies: 0
Oct 21, 2021
Visit Reason
An annual survey and multiple complaint investigations were conducted by the State Agency from 10/18/2021 through 10/21/2021 to assess compliance with Medicare and Medicaid participation requirements.
Findings
The facility was found to be in compliance with Medicare and Medicaid requirements. The State Agency did not substantiate the complaints related to call light response times, resident care issues, notification of family, physician follow-up, oxygen and IV fluid administration, bathing, skin breakdown, quality of care, and infection control.
Complaint Details
Complaints investigated included issues such as untimely response to call lights, residents not receiving water, lack of family notification of condition changes, physician follow-up failures, oxygen and IV fluid administration omissions, missed baths, skin breakdown upon discharge, and quality of care concerns. None of these complaints were substantiated.
Report Facts
Complaint Investigations: 5
Inspection Report
Annual Inspection
Deficiencies: 0
Oct 21, 2021
Visit Reason
The State Agency conducted an annual and complaint investigation survey for complaints MS #17383, MS #17426, MS #17463, MS #17961, and MS #18132 at the facility from 10/18/2021 to 10/21/2021.
Findings
The State Agency did not substantiate the complaints for Quality of Care/Treatment, Resident/Patient/Client Abuse, and Infection Control. The facility was found to be in compliance with Mississippi Regulations for Minimum Standards for Institutions for Aged or Infirm with no deficiencies cited.
Complaint Details
Complaints MS #17383, MS #17426, MS #17463, MS #17961, and MS #18132 were investigated and not substantiated.
Inspection Report
Annual Inspection
Census: 67
Capacity: 90
Deficiencies: 0
Oct 21, 2021
Visit Reason
An annual survey and multiple complaint investigations were conducted by the State Agency from 10/18/2021 through 10/21/2021.
Findings
The facility was found to be in compliance with Medicare and Medicaid requirements. The complaints related to call light response, resident care, notification of family, physician follow-up, oxygen and IV fluid administration, bathing, skin breakdown, quality of care, and infection control were not substantiated.
Complaint Details
Complaints investigated included issues with call light response, resident hydration, family notification of condition changes, physician follow-up, oxygen and IV fluid administration, bathing, skin breakdown upon discharge, quality of care, and infection control. None of these complaints were substantiated by the State Agency.
Report Facts
Complaint Investigations: 5
Inspection Report
Annual Inspection
Census: 67
Capacity: 90
Deficiencies: 0
Oct 21, 2021
Visit Reason
An annual survey and multiple complaint investigations were conducted by the State Agency from 10/18/2021 through 10/21/2021.
Findings
The facility was found to be in compliance with Medicare and Medicaid participation requirements. The State Agency did not substantiate the complaints related to call light response times, resident care issues, notification of family, physician follow-up, oxygen and IV fluid administration, bathing, skin breakdown, quality of care, and infection control.
Complaint Details
Complaints investigated included issues with call light response, resident hydration, family notification, physician follow-up, oxygen and IV fluid administration, bathing, skin breakdown upon discharge, quality of care, and infection control. None of these complaints were substantiated.
Report Facts
Licensed beds: 90
Resident census: 67
Inspection Report
Life Safety
Deficiencies: 0
Oct 19, 2021
Visit Reason
The facility was surveyed under the Centers for Medicare Medicaid Services (CMS) COVID-19 Emergency Declaration Blanket 1135 Waivers for Health Care Provider to assess compliance with the Life Safety Code (LSC).
Findings
The facility met the applicable provisions of the 2012 Edition of the Life Safety Code (LSC) of the National Fire Protection Association (NFPA). No LSC deficiencies were cited during this survey.
Inspection Report
Deficiencies: 0
Oct 19, 2021
Visit Reason
The survey was conducted to assess the facility's compliance with Federal, State, and local emergency preparedness requirements.
Findings
The facility met all applicable Federal, State, and local emergency preparedness requirements with no deficiencies cited.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Dec 10, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey was conducted by the State Agency on 12/10/2020.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness requirements.
Inspection Report
Routine
Census: 55
Capacity: 90
Deficiencies: 0
Dec 10, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the State Agency to assess compliance with infection control regulations and implementation of CDC recommended practices for COVID-19 preparation.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and had implemented CMS and CDC recommended practices to prepare for COVID-19.
Inspection Report
Abbreviated Survey
Census: 67
Capacity: 90
Deficiencies: 0
Nov 18, 2020
Visit Reason
The State Agency conducted a COVID-19 Focused Infection Control Survey to assess the facility's compliance with infection control regulations and implementation of recommended practices by CMS and CDC.
Findings
The facility was found in compliance with infection control regulations and had implemented the recommended practices to prepare for COVID-19. No deficiencies were cited.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Nov 18, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey was conducted by the Centers for Medicare & Medicaid Services (CMS).
Findings
The facility was found to be in compliance with 42 CFR §483.73 related to E-0024 (b)(6).
Inspection Report
Complaint Investigation
Deficiencies: 0
Jul 30, 2020
Visit Reason
The State Survey Agency conducted complaint investigations related to Quality of Care, Resident Neglect, and Nursing Services at Gulfport Care Center on 7/30/2020.
Findings
All three complaint investigations were unsubstantiated with no deficiencies cited. The facility was found to be in compliance with Medicare and Medicaid requirements for participation.
Complaint Details
Three complaint investigations (CI MS #16638, CI MS #16765, CI MS #16779) were conducted and all were unsubstantiated with no deficiencies cited related to pressure sore precautions, water offered to residents, resident neglect, and nursing services.
Inspection Report
Routine
Census: 67
Capacity: 90
Deficiencies: 0
Jul 28, 2020
Visit Reason
A Covid-19 Focused Infection Control Survey was conducted by the State Agency to assess compliance with infection control regulations and preparedness for COVID-19.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and had implemented CMS and CDC recommended practices to prepare for COVID-19.
Inspection Report
Abbreviated Survey
Census: 67
Capacity: 90
Deficiencies: 0
Jul 28, 2020
Visit Reason
A Covid-19 Focused Infection Control Survey was conducted by the State Agency to assess compliance with infection control regulations and preparedness for COVID-19.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and had implemented CMS and CDC recommended practices to prepare for COVID-19.
Inspection Report
Routine
Census: 65
Capacity: 90
Deficiencies: 0
May 22, 2020
Visit Reason
A Covid-19 Focused Infection Control Survey was conducted by the State Agency to assess compliance with infection control regulations and preparedness for COVID-19.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and had implemented CMS and CDC recommended practices to prepare for COVID-19.
Inspection Report
Abbreviated Survey
Census: 65
Capacity: 90
Deficiencies: 0
May 22, 2020
Visit Reason
A Covid-19 Focused Infection Control Survey was conducted by the State Agency to assess compliance with infection control regulations and preparedness for COVID-19.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and had implemented CMS and CDC recommended practices to prepare for COVID-19.
Inspection Report
Annual Inspection
Census: 81
Capacity: 90
Deficiencies: 4
Dec 19, 2019
Visit Reason
The State Agency conducted an annual recertification survey from 12/16/19 through 12/19/19 to determine compliance with the Minimum Standards for the Aged and Infirm.
Findings
The facility was found not in compliance with several state statutes including criminal history record checks, residents' rights, urinary incontinence care, and medical record services. Deficiencies included missing background check documentation for new hires, failure to ensure dignity for residents with catheters, improper incontinent care, and incomplete medical records for residents with indwelling catheters.
Severity Breakdown
Level II: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to provide background checks/fingerprint letters for two of five new hires reviewed. | Level II |
| Failed to ensure resident's right to dignity by leaving urinary catheter drainage bag uncovered for one resident. | Level II |
| Failed to provide incontinent care in a manner to prevent infection for one resident. | Level II |
| Failed to accurately complete medical record for one resident by not having a physician's order for an indwelling catheter. | Level II |
Report Facts
Census: 81
Total Capacity: 90
New hire charts reviewed: 5
Residents with indwelling catheters: 6
Medical records reviewed: 21
Inspection Report
Annual Inspection
Census: 81
Capacity: 90
Deficiencies: 6
Dec 19, 2019
Visit Reason
The State Agency conducted an annual recertification survey to determine compliance with Medicare and Medicaid participation requirements.
Findings
The facility was found not in substantial compliance with participation requirements, citing deficiencies related to resident rights, baseline care plans, comprehensive care plans, incontinent care, medical record accuracy, and infection control.
Severity Breakdown
SS=D: 6
Deficiencies (6)
| Description | Severity |
|---|---|
| Failure to ensure a resident's right to dignity by leaving a urinary catheter drainage bag uncovered. | SS=D |
| Failure to develop a baseline care plan for an indwelling catheter upon resident readmission. | SS=D |
| Failure to follow the comprehensive care plan while providing incontinent care. | SS=D |
| Failure to provide incontinent care in a manner to prevent infection, including improper glove and towel use. | SS=D |
| Failure to maintain accurate medical records, specifically lacking a physician's order for an indwelling catheter. | SS=D |
| Failure to follow infection prevention and control standards during incontinent care, including improper handling of soiled linen and gloves. | SS=D |
Report Facts
Deficiencies cited: 6
Census: 81
Total Capacity: 90
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant #1 | CNA | Named in findings related to improper incontinent care and infection control violations. |
| Certified Nursing Assistant #4 | CNA | Named in findings related to improper handling of soiled linen and infection control violations. |
| Certified Nursing Assistant #5 | CNA | Interviewed regarding catheter dignity bag policy and infection control. |
| Registered Nurse Director of Nursing | Director of Nursing | Conducted audits, provided in-service training, and responsible for monitoring compliance related to deficiencies. |
| Assistant Director of Nursing | Assistant Director of Nursing | Interviewed regarding catheter dignity bag policy and infection control. |
| Registered Nurse #1 | RN / Minimum Data Set Coordinator | Interviewed regarding care plan compliance and incontinent care. |
| Director of Nursing | Director of Nursing | Confirmed issues with medical record accuracy and infection control violations. |
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