Inspection Reports for
Ocean Springs Health and Rehabilitation Center
1199 Ocean Springs Road, Ocean Springs, MS, 39564
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Inspection Report — Sep 11, 2025
Annual Inspection CMS
Date: Sep 11, 2025
Visit Reason
The inspection was conducted as part of the annual recertification survey to assess compliance with federal regulations and facility policies related to resident rights, care, staffing, infection control, and food safety.
Findings
The facility was found deficient in multiple areas including failure to honor resident dignity and preferences, delays in assisting residents with personal identification, failure to provide admission documents, breaches of resident privacy, delayed reporting of misappropriation allegations, inadequate assistance with activities of daily living, failure to post nurse staffing information properly, unsanitary food handling practices, inaccurate payroll-based journal staffing data submission, failure to sustain quality assurance improvements, and lapses in infection prevention and control protocols.
Deficiencies (11)
Failed to ensure a resident's right to dignity and respect when staff required her to wear a brief against her preference instead of providing a bedpan or bathroom assistance.
Failed to honor a resident's request for assistance in obtaining personal identification, resulting in a delay of more than one year without follow-up.
Failed to provide residents or their representatives with copies of Resident Rights and admission documents at the time of admission.
Failed to ensure a resident's right to personal privacy by posting identifying hospice information on a resident's door.
Failed to implement abuse prevention policy by not reporting and investigating an allegation of misappropriation of resident property in a timely manner.
Failed to provide assistance with activities of daily living for residents dependent on staff, including incontinence care and shaving.
Failed to post daily nurse staffing information in a prominent place readily accessible to residents, staff, and visitors.
Failed to maintain food quality and hygienic practices in accordance with professional standards, including overly ripened produce, improperly stored food, exposed and expired food, and unsanitary handling of ready-to-eat food.
Failed to accurately report staffing data to CMS using payroll and other verifiable sources, resulting in triggering for excessively low weekend staffing and no licensed nursing coverage.
Failed to sustain corrective actions to prevent recurrence of previously cited deficiencies related to Payroll Based Journal reporting and QAPI program effectiveness.
Failed to prevent possible spread of infection by not implementing contact isolation precautions timely and not using enhanced barrier precautions during wound care.
Report Facts
Residents sampled: 22
Residents affected: 1
Staffing days without posting: 4
PBJ quarters reviewed: 4
PBJ quarters with deficiencies: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | LPN | Interviewed regarding Resident #109's care and use of briefs |
| Director of Nursing | DON | Interviewed regarding resident care expectations and infection control |
| Licensed Practical Nurse #2 | LPN | Interviewed regarding wound care and abuse reporting |
| Administrator | Administrator | Interviewed regarding facility policies, staffing, and QAPI |
| Licensed Practical Nurse #4 | LPN | Responsible for staffing schedule and PBJ data submission |
| Registered Nurse #2 | RN | Interviewed regarding infection control and Resident #47 isolation |
Inspection Report — Feb 8, 2025
Complaint Investigation CMS
Date: Feb 8, 2025
Visit Reason
The inspection was conducted due to a complaint investigation following an incident where Resident #1, identified as an elopement and wandering risk, exited the facility unsupervised while wearing a malfunctioning wander alarm device.
Complaint Details
The complaint investigation was triggered by the elopement of Resident #1 on 2/08/25 at approximately 3:00 PM. The resident exited the facility unsupervised wearing a wander alarm device that was found to be inoperable. The resident walked approximately 0.7 miles for about 30 minutes before being located and returned safely. Immediate Jeopardy was declared and later removed after corrective actions.
Findings
The facility failed to implement care plan interventions and adequately monitor the wander guard device for Resident #1, resulting in the resident eloping and walking approximately 0.7 miles unsupervised. Immediate Jeopardy was identified but removed after corrective actions were implemented, including staff education, system repairs, and enhanced monitoring protocols.
Deficiencies (2)
Failure to implement care plan interventions for Resident #1 related to wandering and elopement risk.
Failure to provide adequate supervision and assessment and monitoring of a wandering alarm device to prevent Resident #1 from exiting the facility unnoticed and unsupervised.
Report Facts
Distance walked by resident during elopement: 0.7
Time unsupervised: 30
Date of elopement incident: Feb 8, 2025
Date Immediate Jeopardy removed: Feb 10, 2025
Number of residents reviewed: 4
Number of residents wearing wander guards: 5
Speed limit near facility: 15
Temperature at time of incident: 75
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Working on 2/08/25, failed to check wander guard transmitter functionality for Resident #1. |
| CNA #1 | Certified Nursing Assistant | Reported seeing Resident #1 walking along highway and assisted in locating him. |
| Director of Nursing | Director of Nursing | Confirmed importance of care plan implementation and monitoring of wander guard devices. |
| Administrator | Facility Administrator | Confirmed expectations for staff to follow care plans and reported on incident and corrective actions. |
| Maintenance Director | Maintenance Director | Tested wander guard system and confirmed malfunction; ordered replacement transmitters. |
| DON | Director of Nursing | Demonstrated wander guard system function and confirmed staff education and monitoring. |
| CNA #3 | Certified Nursing Assistant | Witnessed resident missing and assisted visitor in locating Resident #1. |
Inspection Report — Apr 18, 2024
Annual Inspection CMS
Date: Apr 18, 2024
Visit Reason
The inspection was conducted as part of the annual recertification survey to assess compliance with regulatory requirements related to resident care, safety, infection control, staffing, and quality assurance.
Findings
The facility was found deficient in multiple areas including failure to ensure residents' rights to dignified care, inadequate care plan development and implementation, failure to assess and intervene for substance use disorder, inadequate incontinence care leading to skin excoriations, inaccurate submission of staffing data to CMS, failure to sustain quality assurance and performance improvement activities, and lapses in infection prevention and control practices.
Deficiencies (7)
Failed to ensure a resident's right for a dignified dining experience when staff did not provide timely incontinence care, resulting in odors and discomfort for Resident #38.
Failed to develop and implement care plans for residents with UTI (Resident #55), Substance Use Disorder (Resident #57), and failed to implement care plan intervention for low air loss mattress (Resident #261).
Failed to assess risk and develop interventions for a resident with known substance use disorder (Resident #57).
Failed to provide timely incontinence care for six residents, resulting in skin excoriations for Resident #57 and improper use of multiple briefs for Resident #55.
Failed to accurately submit Payroll Based Journal (PBJ) staffing data to CMS for Quarter 1 FY 2023, resulting in a trigger for excessively low weekend staffing.
Failed to sustain Quality Assurance and Performance Improvement (QAPI) program during leadership transitions, resulting in repeated deficiencies related to residents' rights and wound care.
Failed to prevent possible spread of infection as evidenced by a nurse touching medications with bare hands and CNAs discarding soiled linens and briefs on the floor during care.
Report Facts
Residents sampled: 22
Residents affected: 1
Residents affected: 3
Residents affected: 6
PBJ quarters reviewed: 5
BIMS scores: 14
BIMS scores: 15
BIMS scores: 0
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #2 | Certified Nurse Aide | Named in failure to provide timely incontinence care for Resident #38 |
| CNA #10 | Certified Nurse Aide | Named in failure to provide timely incontinence care for Resident #38 and Resident #1 |
| CNA #1 | Certified Nurse Aide | Named in failure to provide timely incontinence care for Resident #38 |
| CNA #3 | Certified Nurse Assistant | Named in incontinence care deficiencies for Resident #57 |
| CNA #4 | Certified Nurse Assistant | Named in incontinence care deficiencies for Resident #57 |
| CNA #5 | Certified Nurse Assistant | Named in incontinence care deficiencies for Resident #57 |
| LPN #1 | Licensed Practical Nurse | Responsible for resident care plans, confirmed lack of care plan for Resident #55 |
| LPN #2 | Licensed Practical Nurse | Care plan nurse, confirmed lack of care plan for Resident #57 and explained infection control practices |
| DON | Director of Nursing | Interviewed multiple times regarding care deficiencies, infection control, and staffing |
| Administrator | Facility Administrator | Interviewed regarding staffing data submission and QAPI program |
| RN #3 | Registered Nurse | Observed touching medication with bare hands |
| RN #2 | Registered Nurse/Infection Preventionist Nurse | Interviewed regarding infection control and incontinence care |
| Human Resource Coordinator | Explained corporate responsibility for PBJ staffing data submission | |
| Medical Director | Medical Director | Confirmed need for substance abuse program referral for Resident #57 |
Inspection Report — Jul 26, 2023
Complaint Investigation CMS
Date: Jul 26, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to notify a family member of a resident's death and failure to implement baseline care plan interventions related to Cardiopulmonary Resuscitation (CPR) for a resident who was found unresponsive.
Complaint Details
The complaint investigation was triggered by allegations that the facility failed to notify the correct family member of a resident's death and failed to provide CPR to a resident with a Full Code status who was found unresponsive. The investigation confirmed these failures and identified errors in chart review and notification processes.
Findings
The facility failed to notify the correct family member of a resident's death and failed to initiate CPR for a resident with a Full Code status who was found unresponsive, resulting in the resident's death. The nurse pulled the wrong resident's chart, leading to incorrect notifications and lack of emergency care. The facility implemented corrective actions including staff education, audits, and policy reviews.
Deficiencies (3)
Failed to notify a family member of a resident's death for one of four sampled residents.
Failed to implement baseline care plan interventions related to Cardiopulmonary Resuscitation (CPR) for a resident who was found unresponsive.
Failed to initiate Cardiopulmonary Resuscitation (CPR) and provide emergency services to an unresponsive resident with a Full Code status.
Report Facts
Residents sampled: 4
Residents affected: 1
Certified Nursing Assistants educated: 50
Licensed Practical Nurses educated: 26
Registered Nurses educated: 12
Non-nursing staff educated: 35
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Named in the finding related to pulling the wrong resident's chart and failing to initiate CPR |
| LPN #2 | Licensed Practical Nurse | Interviewed regarding the incident and confirmation of resident status |
| RN #1 | Registered Nurse | Made death pronouncement and involved in the incident without verifying resident identity |
| Director of Nursing (DON) | Director of Nursing | Investigated the incident and provided statements on expectations and findings |
| Executive Director (ED) | Executive Director | Involved in investigation and corrective action planning |
Inspection Report — Apr 19, 2023
Complaint Investigation CMS
Date: Apr 19, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding an incident involving Resident #1 and a Certified Nurse Aide (CNA #1) related to alleged abuse and verbal altercation.
Complaint Details
The complaint investigation was substantiated. Resident #1 was involved in a verbal and physical altercation with CNA #1 on 2/18/23, including a struggle over the resident's cane and verbal insults. The CNA was suspended immediately and terminated on 2/24/23 for violation of facility policy.
Findings
The facility failed to ensure residents were free from abuse for one of four sampled residents. The investigation revealed a verbal altercation and physical struggle over a cane between Resident #1 and CNA #1, resulting in the CNA's suspension and subsequent termination for unprofessional conduct.
Deficiencies (1)
Failure to protect residents from all types of abuse including physical and verbal abuse.
Report Facts
Residents sampled: 4
Residents affected: 1
Incident duration: 15
Admission date: Jan 31, 2022
BIMS assessment date: Apr 6, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Witnessed and reported the incident involving Resident #1 and CNA #1 |
| CNA #1 | Certified Nurse Aide | Involved in the verbal and physical altercation with Resident #1; suspended and terminated |
| Director of Nursing | Director of Nursing | Conducted investigation and reported on the incident; involved in disciplinary actions |
| RN #2 | Registered Nurse | Confirmed details of the incident and verbal altercation |
| Administrator | Facility Administrator | Provided statements on facility policy and disciplinary actions |
Inspection Report — Apr 29, 2022
CMS
Date: Apr 29, 2022
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, grievance resolution, activities of daily living assistance, wound care, medication administration, and food safety at Ocean Springs Health & Rehabilitation Center.
Findings
The facility was found deficient in multiple areas including failure to maintain resident dignity during care, failure to resolve and investigate resident grievances regarding missing personal property, inadequate assistance with activities of daily living such as showering and nail care, improper wound care techniques, failure to prevent significant medication errors related to sliding scale insulin administration, and failure to properly store and handle food items in the kitchen.
Deficiencies (7)
Failed to treat a resident in a dignified manner by not covering the resident during incontinence/catheter care.
Failed to resolve a resident's grievance regarding personal property.
Failed to thoroughly investigate a resident's allegation of misappropriation of personal property.
Failed to ensure residents dependent on staff for showering, shaving, and nail care received those services.
Failed to clean residents' wounds according to professional standards.
Failed to prevent a significant medication error when a resident did not receive sliding scale insulin per physician's orders.
Failed to remove expired food items from the pantry, failed to date open food items, and failed to reseal a hamburger bun package.
Report Facts
Resident affected count: 1
Resident affected count: 1
Resident affected count: 5
Resident affected count: 2
Resident affected count: 1
Expired food items: 2
Value of missing ring: 1735
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #8 | Certified Nursing Assistant | Failed to cover resident during catheter care |
| Director of Nursing | Director of Nursing (DON) | Confirmed CNA #8 failed to follow policy; involved in interviews and findings |
| Social Services Designee | Social Services Designee (SSD) | Involved in grievance investigation and communication with resident and family |
| Interim Administrator | Interim Administrator | Interviewed regarding grievance resolution discrepancies |
| LPN #4 | Licensed Practical Nurse | Failed to enter sliding scale insulin order correctly |
| RN #2 | Registered Nurse | Performed improper wound care technique |
| Chef | Chef | Responsible for food storage and expiration checks |
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