Below average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Coastal Health And Rehabilitation Center during CMS and state inspections, most recent first.
Failure to revise fall care plans after resident falls. Two residents had documented falls, one after sliding out of bed onto a floor mat and another after sliding out of a chair onto the floor after returning from the bathroom. Both residents had existing fall-risk care plans, but no new interventions were added after the incidents. An LPN, DON, and Administrator acknowledged the care plans were not updated to reflect the falls or new interventions.
Failure to analyze falls and implement new interventions: Two residents had falls in their rooms, including one resident with severely impaired cognition and hemiplegia/hemiparesis and another resident with moderately impaired cognition after surgical aftercare. In both cases, the fall documentation did not identify measures to reduce hazards or risks, did not determine a root cause, and did not develop an intervention to prevent recurrence. Interviews with the DON and Administrator confirmed that no new interventions were put into place after the falls.
Improper food storage and moldy food products were found during a kitchen observation. Molded Italian sausages were stored in the walk-in cooler, an open undated wing sauce container was also in the cooler, and a sauce product with visible mold was found in dry storage even though the label said to refrigerate after opening. The Dietary Mgr confirmed the items were stored for resident use, and leadership stated dietary staff were expected to check storage areas daily and rotate stock per manufacturer directions.
Resident Council grievances were not properly documented or addressed for repeated complaints about roaches, gnats, linen shortages, and poor food quality. Residents reported ongoing issues with towels, sheets, and meals that were tough, salty, dry, or served in a way that made food soggy, while the SSD said she did not realize the same complaints had to be recorded each month and the Administrator said he knew the complaints were unresolved but was unaware they were not being documented monthly.
Failure to Provide Transfer and Bed-Hold Notifications: The facility failed to give a resident's representative written notice of the reason for hospital transfer in a language they understand and failed to notify the resident and/or representative of the bed-hold policy, including reserve bed payment, when a resident was sent out for unplanned hospital/ER transfers. The resident had a history including cerebral infarction and was transferred multiple times for respiratory distress and evaluation/treatment, but the record contained no transfer or bed-hold letters, and the DON and social services staff confirmed the notices were not completed.
Failure to complete a PASRR Level II determination for a resident with Bipolar Disorder. The resident’s PAS and MDS showed a mental health diagnosis with intact cognition, but the Level II vendor withdrew the request after the facility did not provide requested information. Interviews showed the vendor left messages for an LPN, the LPN notified the hospital, and the admission coordinator did not follow up when the issue was brought to her attention.
QAPI Committee Failed to Sustain Oversight of Multiple Deficiencies: The facility's QAPI program did not remain effective during leadership changes and failed to maintain prior interventions or monitor ongoing issues. Surveyors found unresolved Resident Council grievances about pest control, linen shortages, and food quality, improper transfer/discharge notification for a resident, failure to complete PASRR follow-through for another resident, missed care plan and incontinent care interventions for a resident, and unsafe food storage and sanitation practices in the kitchen.
Failure to Follow Incontinence Care Plan: A resident with bowel and bladder incontinence and intact cognition was found with urine-soaked bed linens and feces on the incontinent pad despite a care plan calling for skin to be kept clean and dry and for prompt care after each incontinent episode. Staff stated the resident was dependent on incontinent care and required checks every two hours, and the DON and an LPN confirmed staff were expected to follow the care plan and provide timely care.
Failure to Provide Timely Incontinence Care: A resident who was dependent on staff for ADL/incontinence care was found in bed soiled with urine and feces, with linens saturated through to the bed. A CNA confirmed the resident needed staff assistance and reported incomplete end-of-shift rounding, while an LPN said there had been repeated complaints that residents, including this cognitively intact resident with frequent bowel and bladder incontinence, were left soiled for long periods, especially on night shift.
A resident with celiac disease and other chronic conditions, and who was cognitively intact, did not receive meals in accordance with documented food preferences and dietary restrictions. The resident reported limited food options and said she relied on oatmeal, boiled eggs, and food brought by her daughter. Surveyors observed a lunch tray that did not match the meal preference ticket, which called for lactose-free meals, chicken breast, and no milk or dairy products; the Dietary Manager, DON, and Administrator all acknowledged the expectation that meal preference tickets be honored.
A resident was observed seated in a reclined Geri-chair in the hallway, complaining of back pain and trying to get out of the chair. CNAs said the chair was used so staff could monitor him because he frequently tried to get out of bed. RN review confirmed there was no physician order or assessment supporting the Geri-chair, and an LPN also found no supporting hospice documentation. The resident had a history of cerebral infarction and was cognitively intact per BIMS.
Care Plan Not Updated After Glasses Broke: A resident with vision impairment and corrective lens needs was observed without glasses after his glasses broke, but the care plan was not revised to reflect the change. The care plan already identified visual impairment and included interventions for properly fitted, clean glasses and PRN ophth consult, and an LPN stated the plan should have been updated once the broken glasses were known.
Missing Physician Order for Hospital Transfer: A resident with COPD had an unplanned transfer to a hospital after the family requested the move, and an NP reportedly gave the order. However, the order was not entered into the EHR or documented in the medical record, and the DON confirmed the resident was discharged without a physician's order on file.
Failure to Provide Independent Leisure Activities: Residents reported that activity carts were removed from the dining rooms, leaving them without access to cards and games in the evenings and on weekends when activity staff were not present. The Activities Director said she was told by the Administrator to remove the games, and the Administrator acknowledged the carts were taken away, leaving residents without access after 4:30 PM until the games were later returned.
Failure to maintain resident vision assistance: A resident with poor vision and corrective lenses was observed unable to see the call light and stated he did not know where his glasses were. Staff interviews showed the resident’s glasses had broken, the CNA did not report it, the DON asked for an eye appt, and the SW received the glasses but forgot to schedule the appt. The resident’s MDS indicated vision impairment and need for corrective lenses.
A resident returned from the hospital with a new Xarelto order, but the order was not entered into the EMR or administered for 14 days. The discharge orders were available to nursing staff, yet an LPN documented no new orders, and the DON confirmed the medication was uploaded but not activated until the resident reported the omission. The resident, who had DVT and cirrhosis of the liver, stated she did not receive the blood thinner during that time and had no complications.
A facility failed to serve meals in a palatable, attractive way when buns were soaked with beet or coleslaw juice, vegetables were mixed with other foods on the same plate, and residents were served watery, overly salty processed turkey. Residents repeatedly complained in council meetings that the food was tough, too salty, repetitive, and soggy, and staff confirmed the night cook had not been trained to separate items such as vegetables and bread. One resident stated she would only eat the meat because the bun was soggy.
The facility failed to maintain a clean, safe, and homelike environment because pest control was limited mainly to common areas and resident rooms were not routinely treated, while residents and staff reported ongoing roach and gnat problems. Residents also reported inadequate towels and linens, and multiple staff confirmed daily shortages, delayed bathing care, and use of wipes when towels were unavailable. Linen closet checks showed very low inventory compared with resident census, and the Administrator acknowledged seeing dead roaches and that the linen supply was not enough to meet resident needs.
Pest control services were limited to common areas, while resident rooms with reported pest activity were not routinely treated and gnat infestations were not addressed with effective chemicals. Residents repeatedly complained in council meetings about roaches and gnats in their rooms and hallways, and the pest control technician, Maintenance Director, Activity Director, and DON confirmed the issue had persisted for months without resolution. The Administrator acknowledged seeing dead roaches and said he had not known pest control was not entering resident rooms or that the chemical used did not work for gnats.
A resident at risk for constipation was hospitalized due to fecal impaction after the facility failed to implement measures outlined in the care plan. Despite the resident's son reporting concerns, the LPN did not document the impaction or notify the NP, leading to a lack of timely intervention. The DON confirmed the absence of documentation and communication prior to the hospitalization.
A facility failed to implement a comprehensive care plan for a resident at risk for constipation due to limited mobility and medication use. An LPN observed signs of possible impaction but did not notify the provider as required, only documenting the issue in a notification book. There was no documentation of the condition or medication administration until after the resident's hospital return. The NP was not informed, and the DON confirmed the care plan was not followed.
A resident with a history of constipation and other health issues was hospitalized due to severe impaction and related conditions after the facility failed to provide adequate care and notify the physician. The LPN observed hard stool but did not inform the NP directly, and there was no documentation of treatment until after hospitalization. The DON confirmed the lack of communication with the NP and Medical Director.
The facility failed to implement wound care interventions for three residents, leading to a deficiency. A resident with Osteomyelitis did not receive documented wound care on multiple days, resulting in a wound infection and hospitalization. Another resident with spinal cord injury and paraplegia had incomplete wound care documentation for sacral and heel wounds. A third resident with diabetes had incomplete wound care documentation for heel and sacral wounds. Staff interviews confirmed the care plans were not followed as required.
A long-term care facility failed to provide consistent pressure ulcer care and documentation for three residents, leading to significant deficiencies in wound management. One resident developed a wound infection and was hospitalized for sepsis due to inadequate care. The facility experienced staff turnover, impacting the consistency of wound documentation.
A facility failed to accurately code an MDS for a resident with a pressure ulcer. Despite a wound care order and documentation of the ulcer, the MDS did not reflect its presence. Interviews revealed the omission was due to missing weekly wound reports in the medical record, leading to inaccurate MDS coding.
A resident with a history of frequent UTIs did not receive timely care due to the facility's failure to follow a physician's order for a urinalysis and delay in administering an antibiotic. Despite the availability of the medication, it was not given until the day after it was ordered. Staff interviews confirmed the delay in both the urine test and antibiotic administration.
Failure to Revise Fall Care Plans After Resident Falls
Penalty
Summary
The facility failed to revise care plans to reflect resident falls and the interventions implemented to prevent recurrence for two residents reviewed for falls. The facility policy for Comprehensive Care Plans required a comprehensive person-centered care plan with measurable objectives and timeframes, and the Fall Prevention Program required each resident’s risk factors and environmental hazards to be evaluated, interventions to be monitored for effectiveness, and the plan of care to be revised as needed after a fall. For one resident, the care plan identified risk for injury related to falls, fractures, skin tears, bruises, unsteady gait, dementia, fragile skin, history of falls, and left-sided hemiplegia, with a goal to remain free from injury/falls. The resident had a fall in the room when observed sliding out of bed onto the floor mat, with no signs or symptoms of injury and no new orders from the MD. The record showed no new intervention was added to the care plan after the fall. The resident’s record also showed severe cognitive impairment with a BIMS score of 0. For the second resident, the care plan identified risk for falls related to impaired balance and muscle weakness/atrophy, with a goal to remain free from injury/falls. The resident had a fall in the room after sliding out of a chair onto the floor after returning from the bathroom. The record showed no new intervention was added to the care plan after the fall. This resident’s MDS showed a BIMS score of 12, indicating moderately impaired cognition. During interviews, the LPN, DON, and Administrator all acknowledged that care plans should be revised after falls and that no new interventions had been implemented following the residents’ April falls.
Failure to Analyze Falls and Implement New Interventions
Penalty
Summary
The facility failed to analyze falls and implement interventions to reduce the risk for recurrence for two residents reviewed for falls. The facility policy, Fall Prevention Program, stated that when any resident experiences a fall, the facility will review the resident's care plan, update it, and document all assessments and actions. For Resident #1, the record showed admission with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side, and a BIMS score of 0, indicating severely impaired cognition. After a fall in the resident's room, the resident was observed sliding out of bed onto the floor mat, with no signs or symptoms of injury and no abnormalities found on full body audit; however, there was no documentation identifying measures to reduce hazards or risks, no root cause identified, and no intervention developed to prevent recurrence. For Resident #2, the record showed admission with diagnoses including encounter for surgical aftercare following surgery on the digestive system, and a BIMS score of 12, indicating moderately impaired cognition. After the resident was found on the floor in her room, lying on her left side, she stated she had slid out of her chair onto the floor after returning from the bathroom. As with Resident #1, there was no documentation identifying measures to reduce hazards or risks, no root cause identified, and no intervention developed to prevent recurrence. Interviews with nursing staff and the DON confirmed that new interventions were expected after each fall, and the DON and Administrator both confirmed that no new interventions were put into place following these falls.
Improper Food Storage and Molded Food Products
Penalty
Summary
The facility failed to store, label, and maintain food in a sanitary manner to prevent contamination and ensure resident safety. During a kitchen observation, molded Italian sausages were found stored inside a box in the walk-in cooler, and an open, undated container of garlic parmesan wing sauce was also observed in the cooler. In the dry goods storage room, a container of [NAME] Sazon salsa mild enchilada sauce had visible mold inside, and the product label indicated it should be refrigerated after opening. The Dietary Manager confirmed and acknowledged that the molded food products were present in both the walk-in cooler and the dry storage area and stated that these items were stored for resident use. Facility policy required food to be received and stored in a manner that complies with safe food handling practices and to be rotated using a first in-first out system, and the Director of Clinical Services and Administrator stated that dietary staff were expected to check food storage daily and rotate stock while following manufacturer storage recommendations.
Resident Council Grievances Not Properly Documented or Addressed
Penalty
Summary
The facility failed to ensure Resident Council grievances were addressed for multiple complaints voiced over several months, including pest control concerns, linen shortages, and food quality issues. The facility policy titled Complaint/Grievance stated that resident complaints would be supported without fear of discrimination or reprisal, that prompt efforts would be made to resolve grievances, and that grievance follow-up should be completed in a reasonable time frame not to exceed 14 days. Review of resident council and food committee minutes showed repeated complaints about roaches, gnats, linen shortages, and food being tough, salty, undercooked, dry, and otherwise unpalatable, with residents also requesting changes in how food was served. Resident council minutes documented that residents on the 200 hall reported seeing roaches in their rooms and hallways, later asked about new linen and requested dietary attendance at a food committee meeting, and then invited the Administrator to discuss resident care, linen shortages, and dietary concerns. Food committee minutes also reflected ongoing complaints about meat texture, salt content, rice, chicken, and bread and rolls becoming soggy, while residents were told to be patient because the kitchen was short staffed. During the survey, residents stated they could not understand why all complaints made during meetings were not recorded in the minutes and reported continued concerns about roaches and gnats in their rooms. Residents also reported not having enough towels to bathe with or enough sheets to change beds, and they described the food as lacking variety and not tasting good. They stated that meals such as Asian chicken, honey chicken, and sweet and sour chicken were served on consecutive days, that processed turkey was watery and salty, and that food was served on one plate causing buns and other items to become saturated with juices. The Social Services Director stated she attended resident council meetings and recorded the minutes, but did not realize the same complaints needed to be documented each month because department heads were already aware of them. The Administrator stated he was aware of the complaints and that they had not been resolved, but he was unaware they were not being recorded monthly. Residents involved in the council included multiple cognitively intact residents, along with some residents with moderate cognitive impairment.
Failure to Provide Transfer and Bed-Hold Notifications
Penalty
Summary
The facility failed to notify a resident's representative in writing of the reason for transfer/discharge to the hospital in a language they understand and failed to notify the resident and/or resident's representative of the facility's bed-hold policy, including reserve bed payment, at the time of transfer for Resident #128. The facility policy titled Transfer/Discharge Notification & Right to Appeal, revised 10/24/2022, required written notice to the resident and resident representative of the transfer or discharge and the reasons for the move in a language and manner they understand. Resident #128 was admitted on 4/22/25 and readmitted on 6/16/25 with diagnoses including cerebral infarction. The record showed unplanned hospital transfers with return anticipated on 5/8/25, 6/8/25, and 7/7/25, and progress notes documented respiratory distress on 5/8/25 and transfers to the emergency room for evaluation and treatment on 6/8/25 and 7/7/25. The clinical record contained no documentation that hospitalization transfer letters or bed-hold letters were provided to the resident or the resident's representative before any of the discharges. The DON stated she could not locate the letters and did not believe they were completed, and social services staff confirmed the letters were not completed for the transfers.
Failure to Complete PASRR Level II Determination
Penalty
Summary
The facility failed to refer and follow through with the appropriate state-designated authority for a Level II PASRR evaluation and determination for one resident. The resident was admitted with a diagnosis of Bipolar Disorder, and the admission MDS showed a BIMS score of 15, indicating the resident was cognitively intact. The pre-admission screening dated before admission identified Bipolar Disorder, psychotropic medication history, and indicated no diagnosis of Alzheimer's disease or dementia, which supported the need for a Level II determination. A notification from the Level II evaluator stated the screening request was withdrawn because requested information was not provided, and a PASRR determination could not be made. The facility matrix listed the resident as having a mental disorder with no PASARR Level II. During interviews, the contracted vendor stated the requested information was never received despite phone calls and voicemails to the facility. An LPN stated she notified the hospital but no further information was provided, and the admission coordinator stated she did not remember being informed of the issue and did not follow up. The administrator stated he expected PASRRs to be completed in a timely manner and concerns with a PASRR II to be followed up.
QAPI Committee Failed to Sustain Oversight of Multiple Deficiencies
Penalty
Summary
The facility's QAPI Committee failed to sustain the program during leadership transitions and did not maintain or monitor the interventions put into place after the November 15, 2023 survey. The report states that the deficiencies involved unresolved grievances, transfers/discharges, PASRR, care plans, ADLs, and kitchen concerns, and that the facility had continued failure during two federal surveys. The facility's QAPI program policy, revised 10/24/2022, stated that the program would be ongoing, multi-level, and facility wide, with the purpose of identifying and analyzing actual or potential quality issues, developing and implementing plans to improve performance, and monitoring the effectiveness of changes. Specific findings showed that Resident Council grievances were not addressed for multiple complaints voiced over several months, including pest control, linen shortages, and food quality, across three meeting minutes reviewed. For Resident #128, the facility did not notify the resident's representative in writing of the reason for transfer/discharge to the hospital in a language they understand and did not notify the resident and/or representative of the bed hold policy at the time of transfer. For Resident #8, the facility did not refer and follow through with the appropriate state-designated authority for Level II PASRR evaluation and determination. For Resident #31, the facility failed to implement care plan interventions for keeping skin clean and dry and providing prompt care after each incontinent episode, and also failed to provide appropriate incontinence care to maintain comfort. The facility also failed to store, label, and maintain food in a sanitary manner during a kitchen observation.
Failure to Follow Incontinence Care Plan
Penalty
Summary
The facility failed to implement care plan interventions for Resident #31 related to keeping skin clean and dry and providing prompt care after each incontinent episode. The resident’s care plan identified a focus of high risk for impaired skin integrity related to bowel and bladder incontinence, with interventions that included keeping skin clean and dry and providing prompt care after each incontinent episode. During observation on 8/6/25, the resident stated he needed assistance being changed and was unsure when night shift staff had last entered his room. At that time, a CNA observed the resident’s bed sheets were saturated with urine and he had feces on the blue incontinent pad. The resident was admitted on 3/1/24 with a diagnosis including cerebral infarction. The quarterly MDS with an ARD of 7/2/25 indicated he was frequently incontinent of bowel and bladder, and the BIMS completed on 7/7/25 showed he was cognitively intact. During interview, the CNA stated the resident was dependent on staff for incontinent care, knew when he had an incontinent episode, and staff were required to check on him every two hours. The DON stated she expected all residents to be changed in a timely manner and that finding a resident soaked through to the bed linens was unacceptable. An LPN stated the purpose of the care plan was to instruct staff on how to provide care and that staff were expected to follow the care plan when providing resident care.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide appropriate incontinence care for a resident who was dependent on staff for ADL assistance. During an observation and interview, the resident was found lying in bed and stated he needed to be changed and was unsure when night shift had last entered his room. A CNA confirmed the resident's bed linens were saturated with urine and that feces was present on the incontinence pad. The CNA also stated the resident was dependent on staff for incontinent care and that she did not always complete incontinent end-of-shift rounding with the off-going shift. The resident was cognitively intact, had diagnoses including cerebral infarction, and the MDS indicated he was frequently incontinent of bowel and bladder, required extensive maximal assistance with toileting, and did not exhibit rejection of care. An LPN reported receiving numerous complaints from day shift CNAs and residents, including the resident, about being left soiled for long periods of time, especially by night shift, and stated the resident had complained about being soiled through his brief to the bed linens. The DON stated she was not aware of the problem but acknowledged that finding a resident saturated through to the bed linens was unacceptable.
Failure to Honor Documented Meal Preferences
Penalty
Summary
The facility failed to honor a resident's documented meal preferences and dietary restrictions for one resident. The resident, who had diagnoses including primary osteoarthritis, unspecified cirrhosis of the liver, celiac disease, and unspecified anemia, was cognitively intact with a BIMS score of 15. The resident stated that due to the food choices available, she was only able to receive oatmeal and boiled eggs, and that since new management began, the cycle of food choices had not improved. She also reported discussing her concerns with the Dietary Director and said her daughter brought refrigerator food weekly so she would have food she could eat. On observation, the resident's lunch tray included baked chicken (leg and thigh), navy beans and rice, chocolate ice cream, and two glasses of water, while the meal preference ticket directed lactose-free meals, a preference for chicken breast, and restrictions excluding milk and dairy products. The Dietary Manager stated he believed staff were capable of reading and honoring resident meal preference tickets, and the DON and Administrator stated their expectation that dietary staff honor resident meal preferences and review meal tickets. The resident also provided photographs of prior meal trays showing that her documented preferences had not been honored.
Unapproved Use of Reclined Geri-Chair as a Physical Restraint
Penalty
Summary
The facility failed to ensure a resident was free from physical restraints without first completing an assessment, documenting a medical symptom, obtaining a physician order, or providing monitoring. Surveyors observed Resident #114 seated in a reclined Geri-chair in the hallway, and the resident stated he had back pain and wanted to sit up. The resident was also observed attempting to get out of the chair. CNA #3 stated the resident was placed in the Geri-chair in the hallway so staff could monitor him because he frequently attempted to get out of bed. Record review and staff interviews showed there was no physician order or assessment supporting the use of the Geri-chair at the time it was being used. RN #1 reviewed the chart and confirmed no order or assessment was present, while LPN #3 stated hospice had provided the chair and that the resident had poor trunk control, but she did not find supporting documentation in the hospice chart. The resident’s record showed diagnoses including cerebral infarction, and the quarterly MDS indicated a BIMS score of 15, showing the resident was cognitively intact. The facility’s Administrator stated the expectation was for nursing staff to obtain orders, assess the resident, document use in the care plan, contact the family, and notify the physician.
Care Plan Not Updated After Glasses Broke
Penalty
Summary
The facility failed to revise the care plan to address a resident's visual impairment needs after his glasses were broken. The resident's care plan, initiated on 4/8/24, identified him as at risk for injury related to visual impairment and stated that he wears glasses, with interventions to make sure the glasses are fitted properly, clean, and of adequate strength and to obtain an ophthalmology consult as needed. On 8/4/25, the resident was observed lying in bed without any glasses and stated that he had poor vision and did not know where his glasses were. A CNA stated that the resident's glasses broke on 7/28/25, and an LPN stated she was not aware the glasses were broken and that the care plan should have been revised to reflect that change. The resident was admitted on 8/14/24 with diagnoses including muscle wasting and atrophy, and the quarterly MDS dated 5/16/25 indicated he was vision impaired and required corrective lenses.
Missing Physician Order for Hospital Transfer
Penalty
Summary
The facility failed to ensure services were provided in accordance with professional standards of practice when a physician's order was not entered for the transfer/discharge of Resident #93 to the hospital. The facility policy stated that physician orders are to be appropriately and timely documented in the medical record, and that a nurse may accept a telephone order from the physician and transcribe it to the appropriate areas of the electronic health record. However, the clinical record showed no physician's order for the resident's transfer/discharge to the hospital on 7/4/2025. Resident #93 was admitted on 12/31/2024 with diagnoses including COPD. The discharge MDS with an ARD of 7/4/2025 showed the resident had an unplanned discharge with return anticipated to a short-term general hospital. During interviews, an LPN stated she contacted the NP after the family requested the resident be sent to the hospital, and the NP ordered the transfer. Another LPN acknowledged she was responsible for entering the physician's orders into the system but forgot to do so for Resident #93. The DON confirmed the resident was discharged to a local hospital without obtaining or entering a physician's order into the medical record.
Failure to Provide Independent Leisure Activities
Penalty
Summary
The facility failed to ensure residents had access to independent leisure activities during all hours, including evenings and weekends, when activity staff were not present. Based on observation, interview, and policy review, activity carts were removed from the dining rooms, leaving no cart available in the large dining room or the smaller dining room on the 300 hall during survey observations. The facility policy, Community Life Overview, stated that community life programming is designed to promote self-esteem, pleasure, comfort, education, creativity, success, and independence. During a resident council meeting, residents reported that the activity carts had been removed from the dining rooms without explanation. They stated they enjoyed playing games after the activity department closed and that weekends offered limited activity options, so they played cards and games. The Activities Director stated she had been instructed by the Administrator to remove the games from the two dining rooms and had told him the carts needed to remain for residents to use in the evenings after she left for the day. The Administrator acknowledged the games were removed, leaving residents without access to activities when activity staff left at 4:30 PM, and later stated the games had been returned to the dining rooms.
Failure to Maintain Resident Vision Assistance
Penalty
Summary
The facility failed to ensure a resident received proper treatment and assistive devices to maintain vision for one of two residents reviewed for vision and hearing. Resident #86 was observed lying in bed and calling out for help while searching for the call light and stating he could not see it. He reported poor vision, said he had asked staff to make an eye appointment, and stated he did not know where his glasses were. The resident’s admission record showed diagnoses including muscle wasting and atrophy, and the quarterly MDS indicated he was vision impaired and required corrective lenses. During interviews, a CNA stated the resident’s glasses broke and acknowledged he did not inform anyone, later believing another staff member may have turned them in. The DON stated she reported the broken glasses to the Social Worker and requested an eye appointment. The Social Worker confirmed he received the broken glasses but forgot to schedule the appointment, and stated the resident needed his glasses. The Administrator stated he expected staff to make appointments to get residents’ glasses fixed in a timely manner and said this should have been discussed in morning meetings.
Missed Anticoagulant Order After Hospital Return
Penalty
Summary
The facility failed to ensure that new physician orders were entered into the electronic medical record and administered when a resident returned from the hospital, resulting in a missed anticoagulant order for 14 consecutive days. Resident #110, who had diagnoses including cirrhosis of the liver and a history of DVT, returned from the hospital with discharge instructions dated 3/27/25 that included a new Xarelto starter pack order. Facility policy required physician orders to be reviewed, verified, transcribed, and documented in the medical record, but the resident’s progress note on 4/4/25 stated, "Resident returned back to facility . no new orders," and the Xarelto order was not entered as an active order until 4/17/25. Interviews confirmed that the discharge orders were uploaded into the system on the day of return and were available to nursing staff, but the order was not processed. The DON confirmed the resident’s Xarelto was uploaded on 4/4/25 but not entered until 4/17/25 and stated she was unsure what happened. The resident stated she was not given the blood thinner for two weeks after discharge and said she had no complications from the missed medication. An LPN stated she first learned of the missed order on 4/17/25 when the resident reported not receiving the blood thinner, and the MAR showed no Xarelto administration until that date.
Food Served in Unappetizing and Improperly Combined Portions
Penalty
Summary
The facility failed to ensure food was prepared and served in a palatable and visually appealing manner. Survey findings showed buns were served saturated with beet juice or coleslaw juice, vegetables were not served separately from bread items, and residents were served watery and overly salty processed turkey. The cited deficiency involved 14 of 14 residents reviewed for food quality, including residents with diagnoses such as diabetes, COPD, CHF, hypertension, osteoarthritis, quadriplegia, cirrhosis, and other chronic conditions; several of the residents were cognitively intact, while others had moderate cognitive impairment. Facility policy titled Quality and Palatability stated that food must be prepared to conserve nutritive value, flavor, and appearance, and that food and liquids must be prepared and served in a manner, form, and texture to meet resident needs. Facility council minutes and food committee minutes documented repeated resident complaints about tough meat, food being too salty, undercooked rice, dry chicken, and bread or rolls becoming soggy when served on the same plate as other foods. Residents also asked that bread be placed in baggies and vegetables be served separately to prevent sogginess. During observation, a test tray showed all food placed on one plate, with juice and English peas mixed with mashed potatoes and turkey. Residents told surveyors the food did not taste good, was repetitive, and that processed turkey was watery and salty. They reported being served barbecue on hamburger buns with beets on the same plate and hot dogs with coleslaw on the same plate, causing the buns to become saturated and soggy. One resident observed eating lunch had a sausage dog with coleslaw on the same plate and stated she would only eat the meat because the bun was soggy. Staff interviews confirmed that all food was being placed on one plate, that vegetables should have been placed in a bowl, and that the night cook had not been taught to separate the vegetables or otherwise prevent the buns from becoming soggy.
Pest Control and Linen Shortages
Penalty
Summary
The facility failed to ensure a safe, clean, and homelike environment by not maintaining adequate pest control access to resident rooms and by not keeping enough clean bath towels and linens available for resident care. The facility policy required a pest control program with inspection, reporting, prevention, quarterly inspections, and treatment as needed, but the pest control technician stated he usually sprayed only common areas and did not enter resident rooms unless requested. He also stated that the chemicals used by the facility were ineffective against gnats and that he had not been informed the facility was having a gnat problem. Residents and staff reported ongoing pest and linen problems. One cognitively intact resident reported gnats in the building had bitten him and caused bumps on his head, while another cognitively intact resident reported roaches and gnats in her room and described seeing roaches at night. During Resident Council, residents complained about inadequate towels and bed linens, as well as roaches and gnats in rooms. The State Agency also observed clutter and boxes in one resident’s room. The Administrator later confirmed he had seen dead roaches in the facility and stated he did not know the technician was not entering resident rooms or that the chemical did not work for gnats. The linen supply was repeatedly found to be insufficient. Linen closet inspections showed very limited bath towels and no face towels in one hall and low towel and linen inventory in another hall, despite census counts of 51 and 54 residents. Multiple CNAs and an LPN confirmed daily towel shortages, said staff sometimes hoarded linens to ensure availability, and reported that care was sometimes delayed until laundry was completed. Staff also stated that when towels were unavailable, wipes were used to clean and bathe residents. Housekeeping/maintenance staff confirmed the shortage was persistent, that additional stock had not been ordered, and that budget restrictions limited linen purchases.
Pest Control Program Not Effectively Addressing Roaches and Gnats
Penalty
Summary
The facility failed to maintain an effective pest control program to prevent and control insects. Review of the facility policy stated that the facility would maintain a pest control program with inspection, reporting, prevention, quarterly inspections, and treatment as required to control insects and vermin. However, the pest control technician reported that he came monthly, usually treated only common areas, and was not routinely taken into resident rooms. He also stated that the chemicals used at the facility did not work for gnats and that the facility had not told him there was a gnat problem. Resident council minutes documented repeated complaints from residents on the 200-hall about seeing roaches in their rooms and hallways, as well as roaches and gnats on the 100 and 200 halls. During the resident council meeting, residents again complained about roaches and gnats in their rooms, and the council members reported that the Administrator appeared defensive when concerns were raised. The Activity Director confirmed that these complaints had continued for several months, were shared with department heads, and that in-services had been done, but the complaints were never resolved. The Maintenance Director confirmed that pest control did not go into resident rooms and only treated common areas. He also stated the facility had previously used another company that provided a drain gel to help with gnats, but the current company did not have that gel. The Administrator confirmed seeing dead roaches in the facility and stated he did not know pest control was not entering resident rooms or that the chemical used did not work for gnats. Residents involved in the council included individuals with diagnoses such as diabetes, COPD, spinal stenosis, hypertension, osteoarthritis, quadriplegia, heart disease, and cirrhosis, and most had BIMS scores indicating they were cognitively intact.
Neglect Leads to Resident Hospitalization Due to Fecal Impaction
Penalty
Summary
The facility failed to protect a resident from neglect, resulting in a hospitalization due to fecal impaction. The resident, who was at risk for constipation due to limited mobility, narcotic medication use, and diuretics, was not properly monitored or treated for constipation. Despite having a care plan that included administering Colace and Senna-S, encouraging fluids, and notifying a provider if no bowel movement occurred within three days, these measures were not effectively implemented. The resident's son reported concerns about his mother's health, including weakness and lack of appetite, but felt no action was taken until the resident was hospitalized. Interviews and record reviews revealed that a Licensed Practical Nurse (LPN) noted hard stool in the resident's rectum and administered MiraLAX and Lactulose, but failed to document the impaction or medication administration. The Nurse Practitioner (NP) was not notified of the impaction, and there was no documentation in the Nurse's Notes or Medication Administration Record (MAR) regarding the issue until after the resident's return from the hospital. The Director of Nursing (DON) confirmed the lack of documentation and communication regarding the resident's condition prior to hospitalization.
Failure to Implement Comprehensive Care Plan for Constipation Risk
Penalty
Summary
The facility failed to implement a comprehensive care plan for a resident who was at risk for constipation due to limited mobility, daily use of narcotic medication, and diuretics. The care plan required staff to observe for signs and symptoms of constipation every shift and notify the provider as needed. However, an LPN noticed the resident had runny and hard stool, indicating a possible impaction, but only documented the issue in the Nurse Practitioner's notification book without directly notifying the provider. This action was contrary to the care plan's requirement to notify the provider directly. Further investigation revealed that there was no documentation in the Progress Notes or Nurse's Notes regarding the observed condition or the administration of MiraLAX and Lactulose until after the resident returned from the hospital. The NP confirmed that she was not informed of the resident's condition, and the DON acknowledged that the LPN failed to follow the care plan. The resident, who was cognitively intact, had a history of constipation, chronic pain, muscle weakness, and heart failure, and had been admitted to the facility since 2014.
Failure to Prevent Impaction and Notify Physician
Penalty
Summary
The facility failed to provide adequate care and services to prevent a severe impaction in a resident, which led to hospitalization and physical decline. The resident, who was admitted with diagnoses including constipation, chronic pain, muscle weakness, and heart failure, was observed by her son to be weak, fatigued, and not eating. Despite these observations and the son's communication with the facility staff, no immediate action was taken. The resident was eventually sent to the hospital, where she was diagnosed with severe constipation, dehydration, and other related conditions. The facility's Licensed Practical Nurse (LPN) observed hard stool in the resident's rectum on two occasions but failed to notify the Nurse Practitioner (NP) directly, instead documenting the issue in a notification book that the NP did not review. There was no documentation of the administration of MiraLAX and Lactulose in the resident's records until after the resident returned from the hospital. The Director of Nursing confirmed that the NP and Medical Director were not informed of the resident's condition, which was a requirement according to the facility's policy on notification of change in condition.
Failure to Implement Wound Care Plans
Penalty
Summary
The facility failed to implement care plan interventions related to wound care for three of four sampled residents, resulting in a deficiency. Resident #1, who was admitted with a diagnosis of Osteomyelitis, had a care plan that included daily wound care for impaired skin integrity. However, the Electronic Treatment Administration Record (E-TAR) showed that wound care was not documented as completed on multiple days in July and August 2024. This failure led to Resident #1 acquiring a wound infection that required hospitalization. Resident #3, admitted with diagnoses including an unspecified injury to the cervical spine cord and paraplegia, also had a care plan focusing on high risk for impaired skin integrity. The care plan required daily wound care for the sacrum, right buttocks, and heels. However, the E-TAR revealed that wound care was not documented as completed on several days in July and August 2024 for these areas. The lack of documentation indicates that the care plan interventions were not consistently followed. Resident #4, admitted with Type 2 Diabetes Mellitus, had a care plan for wound care on the right heel and sacrum. The care plan required wound care every other day for the heel and every 12 hours for the sacrum. The E-TAR showed that wound care was not documented as completed on several days in July and August 2024. Interviews with facility staff, including an LPN and the Interim Director of Nursing, confirmed that the care plans were not followed as required, emphasizing the importance of adhering to individualized care plans to ensure consistent resident care.
Inconsistent Wound Care and Documentation in LTC Facility
Penalty
Summary
The facility failed to provide consistent pressure ulcer care and treatment for three residents, leading to significant deficiencies in wound management. Resident #1, who had a physician's order for daily wound care to the sacrum, did not receive documented wound care on multiple days in July and August 2024. Additionally, there was a significant gap in weekly wound documentation, with no assessments or measurements recorded for several weeks. This lack of consistent care and documentation resulted in the deterioration of Resident #1's sacral wound, leading to a wound infection and subsequent hospitalization for sepsis and surgical debridement. Resident #3 also experienced inadequate wound care and documentation. The resident had multiple wounds, including those on the sacrum, right buttocks, left heel, and right heel, with physician's orders for daily care. However, wound care was not documented as completed on numerous days across July and August 2024. Furthermore, there were significant gaps in weekly wound assessments and documentation, with no records of wound measurements or progression for several weeks. This lack of consistent care and documentation compromised the resident's wound management. Resident #4 faced similar issues with wound care and documentation. The resident had wounds on the right heel, sacrum, and left heel, with physician's orders for daily or every-other-day care. However, wound care was not documented as completed on several days in July and August 2024. Additionally, there were no weekly wound reports documented until mid-August, resulting in a lack of consistent assessments and documentation of wound progression. The facility's failure to maintain consistent wound care and documentation was attributed to staff turnover, including the resignation of the Director of Nursing and the wound nurse, which impacted the consistency of wound documentation during this period.
Inaccurate MDS Coding for Resident with Pressure Ulcer
Penalty
Summary
The facility failed to accurately code a Minimum Data Set (MDS) for a resident with an unhealed pressure ulcer. The deficiency was identified through staff interviews, record reviews, and a review of the facility's policy on MDS assessments. The facility's policy requires comprehensive and reproducible assessments for each resident at least every three months, using the federal and/or state-required Resident Assessment Instrument (RAI). However, the MDS for a resident with a sacral pressure ulcer did not reflect the presence of the ulcer, despite a wound care order being in place and documentation of the ulcer on a Weekly Observation Tool. The resident was admitted with diagnoses including Osteomyelitis and had a wound care order for the sacrum. The Comprehensive MDS, with an Assessment Reference Date (ARD) of 07/15/24, incorrectly indicated that the resident did not have a pressure ulcer. Interviews with a Licensed Practical Nurse (LPN) and the Interim Director of Nursing (I-DON) revealed that the wound was not addressed on the MDS due to the absence of a weekly wound report in the medical record corresponding with the lookback period. The I-DON confirmed that the MDS did not accurately reflect the resident's condition, as the necessary charting and wound assessment tools were not completed in the resident's chart.
Failure to Follow Physician's Orders and Delay in Treatment
Penalty
Summary
The facility failed to provide care and treatment in accordance with professional standards by not following a physician's order for a urinalysis and delaying the administration of an antibiotic for a resident. The resident, who had a history of frequent urinary tract infections, was admitted with a diagnosis of Metabolic Encephalopathy. On a specific date, a physician's order was given for a urinalysis with culture and sensitivity, but there was no documentation that the urine sample was collected or sent to the laboratory. Consequently, there were no urinalysis results in the resident's medical record. Additionally, an order for the antibiotic Levaquin was received two days later, but the medication was not administered until the following day, despite being available at the facility. Interviews with staff, including a registered nurse, a licensed practical nurse, the interim director of nursing, and the infection preventionist, confirmed the delay in both the collection of the urine sample and the administration of the antibiotic. The nurse practitioner also confirmed that the antibiotic should have been administered on the day it was ordered.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 52 citations issued within 25 miles in the last 12 months — including the 6 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Gulfport
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Driftwood Nursing Center | 0.1 mi | ★★★★★ | 3 | 0 |
| Gulfport Care Center | 5.7 mi | ★★★★★ | 0 | 0 |
| Pass Christian Health And Rehabiliation Center | 6.2 mi | ★★★★★ | 4 | 0 |
| Lakeview Nursing Center | 6.6 mi | ★★★★★ | 3 | 0 |
| The Pillars Of Biloxi | 9.3 mi | ★★★★★ | 11 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.