Below average — CMS composite of the measures below.
The next survey window likely opens around March 2027
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 Diversicare Of Moss Point during CMS and state inspections, most recent first.
Wet dishware used during tray prep. A Dietary Mgr was observed using wet plate dome covers and wet serving bowls with visible water dripping while preparing lunch trays, despite facility policy requiring dishware to be air dried and properly stored. The Dietary Mgr later confirmed the items were wet and described the practice as wet nesting; the IP and Admin also acknowledged that wet nesting can allow bacterial growth and increase the risk of foodborne illness.
Surveyors found that the facility failed to maintain a safe, clean, and homelike environment when a resident’s room contained odorous soiled linens left on the floor and later placed on furniture with clean clothing, and the bed was made with torn linens exposing the mattress. Other residents reported that housekeeping did not clean under beds, and multiple large dead roaches were repeatedly observed under several beds, with one resident stating he often disposed of dead roaches himself. Residents also reported refusing to use the north shower room due to dirty clothing, feces, and residue on shower chairs and floors; an observation confirmed the presence of soiled clothing, a soiled brief, and unidentified substances on the shower chair and floor, despite staff acknowledging that CNAs were expected to clean and sanitize the shower room after each use.
The facility failed to maintain an effective pest control program, as evidenced by repeated observations of roaches and other insects in multiple resident rooms and common areas. Surveyors found gnats and dead roaches under beds, while several residents reported seeing roaches on ceilings, walls, and floors, including roaches falling onto them at night and having to remove dead roaches themselves. A family member reported bringing her own roach spray due to concerns about roaches in a loved one’s room. During a Resident Council meeting, roaches were seen crawling across the floor, and residents stated that roaches were commonly observed throughout the building. Although the contracted pest control provider reported monthly service focused mainly on entry points and exterior areas and facility staff described processes for reporting pests, the persistent roach activity showed the program was not effectively preventing or controlling pests.
Failure to provide consistent weekend activities for a cognitively intact resident with expressed preferences for music, group activities, going outside, and religious services. The resident reported there were no activities for men on Saturdays and none on Sundays, while the AD confirmed activities were mainly provided Monday through Friday, Sunday staff did not work, Saturday staff were assigned to transportation and dining duties, and there was no system to monitor weekend activities. Other staff confirmed RCNAs were not assigned to activities on weekends, and the Administrator acknowledged weekend activities were not consistently provided.
Food was not consistently palatable, attractive, or served at an appetizing temperature. During meal observations, a resident could not eat a hard grilled cheese sandwich with unmelted cheese, and a test tray showed salty green beans and meatballs that lacked taste and appeared as loose ground meat in gravy. Residents reported ongoing concerns about food quality, taste, salt content, texture, and temperature during food committee meetings, and some said they bought snacks with personal funds instead of eating facility meals.
Staff failed to follow infection control practices during resident care. A resident on EBP for a wound and indwelling catheter received hands-on care from three CNAs who wore gloves and used hand sanitizer but did not wear gowns. In a separate event, an LPN carried uncovered meds and water into one resident’s room, touched the resident and the resident’s environment, then gave the same meds to another resident without hand hygiene. The DON and IP confirmed the expected PPE and hand hygiene practices.
Missing Foley Catheter Securement Device: A resident with an indwelling catheter for neurogenic bladder was observed without a catheter securement device in place, including during catheter care. CNAs confirmed the device was not present, one CNA said the nurse applies the devices and they were kept in central supply, and another said the nurse had been notified. RN and DON stated residents with indwelling catheters are expected to have securement devices in place to prevent pulling and trauma.
Unlabeled PEG Feeding Supplies: A resident receiving enteral nutrition via a PEG tube had a feeding bag, water flush bag, and syringes in the room that were not properly labeled or dated. An LPN confirmed the feeding bag lacked the required information, and the DON stated all tube feeding solutions and supplies should be labeled with the resident’s name, date, time, and rate; the facility also did not have a PEG-specific labeling policy.
An LPN prepared Entresto and Metoprolol for a resident even after a CNA reported low BP and the chart showed BP 88/56. The resident had orders to hold Entresto if systolic BP was less than 100, but the nurse did not identify that parameter and stated she would have given both meds if the concern had not been raised. The DON and pharmacist confirmed the meds can lower BP and that clinical judgment should be used before administering antihypertensives when BP is low.
Medication administration errors occurred when an LPN prepared antihypertensive medications for a resident with a low BP despite a hold parameter on the order and the resident’s BP reading of 88/56. The LPN initially intended to give both Metoprolol and Entresto, then removed them only after the concern was raised. In a separate event, ordered Vancomycin for a resident with recurrent C. difficile was not given for two scheduled doses because the medication was unavailable, and staff did not notify supervisory personnel.
A resident with hemiplegia and hemiparesis following a cerebral infarction, and with severely impaired cognition, had a physician order for sacral pressure ulcer wound care. The TAR showed multiple blank entries with no nurse signature or documentation for wound care on several dates, and the DON, an RN, and the Administrator acknowledged that wound care was being completed but not documented.
QAPI failed to sustain corrective actions after a prior F880 infection control citation involving EBP for a resident at high risk for MDROs. The facility was cited again when staff failed to use appropriate PPE during high-contact resident care for a resident on EBP, despite prior monitoring and review by the QAPI committee.
The facility failed to provide written notification of transfers to residents or their representatives, as required by policy and regulations. A receptionist, instructed by a consultant, stopped mailing notifications, opting to call instead. This affected three residents who were hospitalized, including one with Sepsis, another with Acute Respiratory Failure, and a third with Paraplegia. The administrator was unaware of this procedural change.
The facility failed to provide written notifications of its bed hold policies to residents or their representatives during transfers to hospitals. This deficiency affected three residents with serious medical conditions, including sepsis, acute respiratory failure, and paraplegia. The Social Services Director stopped mailing notifications based on company policy, which was not aligned with the facility's Bed Hold Policy. The Administrator was unaware of this practice change.
A facility failed to transmit a discharge MDS assessment in a timely manner for a resident with Spastic Hemiplegia. The resident was admitted with specific diagnoses and discharged home, but the discharge MDS was not submitted. An LPN confirmed the corporate nurse completed but did not submit the MDS, and an RN acknowledged missing the submission. The DON was unaware of the oversight and expected timely submissions.
The facility failed to develop and implement comprehensive care plans for two residents, leading to deficiencies in care. A resident with PTSD had a care plan that did not identify specific triggers, while another resident with a tracheostomy did not receive care with the required enhanced barrier precautions. Staff were unaware of the need to list PTSD triggers, and an OT did not wear a gown as required, despite clear signage and availability of PPE.
A facility failed to provide trauma-informed care for a resident with PTSD by not identifying or documenting triggers and specific interventions. The resident, with a history of PTSD from Vietnam War service, had known triggers like gunfire, but these were not included in care plans. Staff interviews revealed a lack of awareness and communication about the resident's needs, with conflicting responsibilities between the SSD and DON, leading to a gap in care.
The facility failed to maintain food safety standards, with issues including an unclean ice machine, undated and exposed foods, and improper storage practices. The Dietary Director confirmed these deficiencies, admitting challenges in cleaning and monitoring. Despite monthly food safety training, these problems persisted, prompting the Administrator to acknowledge the need for improved oversight.
A facility failed to implement Enhanced Barrier Precautions (EBP) for a resident at high risk for MDRO. The resident, with a tracheostomy and feeding pump, required EBP, but an OT provided care without a gown, despite signage and available PPE. Staff interviews confirmed the expectation for gown use, highlighting a lapse in infection control practices.
Wet dishware used during tray preparation
Penalty
Summary
The facility failed to ensure dishware was properly air-dried before use during meal service. During observation of tray preparation for the [NAME] Wing, the Dietary Manager was assisting the cook when plate dome covers were seen on a table behind the tray line with visible moisture and water dripping from the surfaces. Ten dome covers were observed to be wet, and the Dietary Manager and District Dietary Manager were present and continued preparing trays while using the wet dome covers. During the same observation, a staff member brought five serving bowls that were wet with water dripping from them, and the Dietary Manager used those bowls for tray preparation. At the end of the tray preparation observation, water droplets were still visible on the dome cover of the sample tray. The facility policy, Warewashing, stated that all dishware would be air dried and properly stored after cleaning and sanitizing. During interview, the Dietary Manager confirmed the dome covers and serving bowls used during tray preparation were wet and that staff used them while preparing trays, describing the practice as wet nesting and stating dishware should be allowed to dry completely before stacking or use. The Infection Preventionist and Administrator also acknowledged that wet nesting could allow bacterial growth and increase the risk of foodborne illness, and the Administrator stated staff are expected to ensure all dishware is properly dried prior to stacking and use.
Failure to Maintain Clean Resident Rooms and Shower Facilities
Penalty
Summary
The deficiency involves the facility’s failure to provide a safe, clean, comfortable, and homelike environment, as required by its Resident Rights & Quality of Life Policy. For one resident, surveyors observed a bag of odorous soiled linens resting on the floor of the room, and the resident’s bed was made with a bedspread that had a football-sized hole exposing the mattress. The resident, who was cognitively intact with a BIMS score of 14 and had Type 2 Diabetes Mellitus, reported that it was not unusual for bags of soiled linens to be left on the floor and for bedding to be damaged. A CNA confirmed that soiled linens were commonly left in bags on the floor after morning care and that torn bedding should not be used, and later placed the bag of soiled linens on the resident’s furniture where his clean clothing was hanging. The resident remained upset the following day, and a dead roach was observed under his bed near the headboard. Additional deficiencies were identified in other resident rooms. One resident with End Stage Renal Disease and a severely impaired cognition (BIMS score of 5) reported that housekeeping did not clean under the bed; surveyors observed three large dead roaches under the bed, which remained there the following day. When the Housekeeping Supervisor later observed the room, five dead roaches were present under the bed, and he stated the area should not have been in that condition. Another resident, with a diffuse traumatic brain injury and a moderately impaired cognition (BIMS score of 10), reported frequently picking up and disposing of dead roaches himself because staff did not remove them, and a large dead roach was observed under his bed. The facility also failed to maintain a clean and sanitary north shower room. During a Resident Council interview, multiple cognitively intact and moderately impaired residents reported refusing to use the shower room due to cleanliness concerns, including observations of dirty clothing, feces, and residue on shower chairs and floors. A housekeeper stated that while she cleaned the shower rooms multiple times a day, CNAs were responsible for cleaning and sanitizing the shower room after each use and that she had observed occasions when CNAs failed to do so. A subsequent observation of the north shower room revealed soiled clothing, including a soiled brief, on a shower chair, a yellow fluid-like substance on the floor and shower chair, and a white powdery substance on the floor, with no staff present. The Social Services Assistant, DON, and Administrator each acknowledged that staff were expected to clean and sanitize the shower room after each use.
Ongoing Roach Activity Demonstrates Ineffective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program as required by its pest control policy dated 9/1/2014, which states the center will maintain an ongoing program to keep the building free of insects and rodents. Surveyors observed multiple instances of roach and insect activity in resident rooms and common areas. In one cognitively intact resident’s room, gnats were seen flying and a dead roach was later found under the bed near the headboard. Another resident’s room contained three large dead roaches under the bed on two consecutive days; this resident reported that roaches were regularly seen in the room, especially at night, crawling on the ceiling and falling onto him and his roommate, and that staff had been notified but he had not seen staff respond to assess or treat the issue. A third resident reported seeing roaches on the ceiling and under the bed and stated he often removed dead roaches himself because staff did not; a large dead roach was observed under his bed. A family member of another resident reported feeling it was necessary to bring her own roach spray due to concerns about roaches in the resident’s room and stated she was told she could not keep the spray in the room, expressing concern that the roach problem needed to be addressed. During a Resident Council meeting, two large roaches were observed crawling across the floor, and residents reported that roaches were commonly seen in rooms and common areas, including on walls, ceilings, and floors, particularly at night. The contracted pest control provider reported he provides monthly services, focusing on different areas each visit, primarily treating entry points and exterior areas, and stated he had not personally observed roaches and received only occasional complaints. Facility leadership, including the housekeeping supervisor, DON, and Maintenance Director, described expectations that staff report pest sightings and that pest control services are available monthly and as needed, but the ongoing presence of roaches and dead insects in resident rooms and common areas demonstrated that the pest control program was not effectively preventing or controlling pests.
Failure to Provide Consistent Weekend Activities
Penalty
Summary
The facility failed to ensure an ongoing activities program that met the interests and preferences of Resident #70. The resident was originally admitted with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side and was readmitted by the facility on 7/3/2021. The Comprehensive MDS with an ARD of 11/20/25 showed the resident had a BIMS score of 15, indicating he was cognitively intact, and that he identified multiple activity preferences as very important, including listening to music, participating in group activities, engaging in favorite activities, going outside, and participating in religious services. Record review showed the Activity Participation Review dated 02/19/26 documented participation in small group and large group activities as varying, individual activities as daily, and family/friends and other residents as varying. The resident's favorite activities included cognitive activities, entertainment, games, and spiritual activities, with bingo specifically identified. The April 2026 activity calendar listed weekend activities such as puzzles, word search, coloring, and watching TV in the resident room, but these were limited in variety and did not demonstrate individualized or structured programming specific to the resident's interests. During interview, the resident stated there were no activities for men on Saturdays and no activities on Sundays, and that he usually stayed in his room, went into the hallway, or went to the kitchen. The AD confirmed activities were provided Monday through Friday, that Sunday activity staff did not work, that Saturday staff were primarily assigned to transportation and dining duties, and that there was no system in place to monitor whether weekend activities occurred. Other staff confirmed the RCNAs were not assigned to provide activities on weekends and did not have time to do so, and the Administrator acknowledged activities were not consistently provided on weekends.
Food Not Palatable or Appealing
Penalty
Summary
Food and drink were not ensured to be palatable, attractive, and served at a safe and appetizing temperature. During a lunch tray observation for one resident, the resident asked the surveyor to touch a grilled cheese sandwich because she could not eat it; the sandwich was hard and the cheese was not melted, and a bowl of thick red tomato soup was present. The resident stated she could not eat the meal due to its condition. A facility policy titled Food: Quality and Palatability stated food would be prepared by methods that conserve nutritive value, flavor, and appearance and would be palatable, attractive, and served at safe and appetizing temperatures. During a test lunch meal tray observation, the green beans were salty and the meatballs lacked taste, were not formed, and appeared as loose ground meat in gravy. During an interview with 13 Resident Council members, residents reported the food was not palatable, said they had raised concerns about food quality during monthly food committee meetings, and stated they used personal funds to buy snacks instead of eating facility meals. Staff interviews reflected awareness of resident complaints about taste, salt content, texture, and temperature, and the Social Services Director stated the Dietary Manager documented food committee meeting minutes but those minutes did not reflect resident complaints. The Dietary Manager reported she was not aware of recent complaints about food palatability, and the Administrator stated he had observed thick tomato soup and relied on the Dietary Manager to address food-related concerns.
Failure to Use PPE and Perform Hand Hygiene During Resident Care
Penalty
Summary
The facility failed to prevent the possible spread of infection when staff did not use appropriate PPE during high-contact care for a resident on Enhanced Barrier Precautions. On 4/21/26, three CNAs were observed in Resident #89’s room providing catheter care and other hands-on care while wearing gloves and using hand sanitizer, but no gowns were worn. All three CNAs confirmed the resident was on Enhanced Barrier Precautions because of a wound and an indwelling catheter, acknowledged gowns were not worn, and stated they had been educated on the precautions. Enhanced Barrier Precaution signage was posted on the resident’s door, and the DON and Infection Preventionist both stated gowns and gloves were expected for high-contact care for residents with wounds, catheters, or PEG tubes. The facility also failed to ensure hand hygiene and medication handling practices were followed when an LPN carried uncovered medications and water into one resident’s room, touched the resident and the resident’s environment, and then administered the same medications to another resident without performing hand hygiene. On 4/19/26, LPN #6 entered an unsampled resident’s room with an uncovered cup of medications and an uncovered cup of water intended for another resident, adjusted the resident’s nasal cannula, repositioned the resident in bed, then left and administered the medications to another resident without hand hygiene. The LPN acknowledged she should not have taken the medications into another resident’s room and stated she believed hand hygiene was only required after every third resident. The DON confirmed medications should be taken directly to the intended resident and that staff are expected to perform hand hygiene after contact with a resident or the resident’s environment.
Missing Foley Catheter Securement Device
Penalty
Summary
The facility failed to ensure a Foley catheter securement device was in place for Resident #89, who had a physician's order for an indwelling catheter for neurogenic bladder. During an observation and interview, the resident was seen sitting in a wheelchair in the hallway with catheter tubing visible, and no securement device was observed in place. The resident stated he did not have anything to hold the catheter in place. During a later observation of catheter care with CNAs #4, #2, and #3, no catheter securement device was in place for the resident, and all three CNAs confirmed this. CNA #3 stated the nurse must apply the securement devices and that they were locked in the central supply closet. CNA #4 reported the resident had not had a securement device in place all morning and that she had notified the nurse. RN #4 stated residents with indwelling catheters are required to have a securement device in place at all times, and LPN #1 reported she had not been informed that one was needed for the resident. The DON confirmed residents with indwelling catheters are expected to have a securement device in place to prevent trauma or pulling.
Unlabeled PEG Feeding Supplies
Penalty
Summary
The facility failed to ensure a resident receiving enteral nutrition via a PEG tube received care and services to prevent complications when the tube feeding solution, water flush bag, and syringes were not labeled for Resident #90. On 4/19/26, the resident was observed in bed with the head of the bed elevated while tube feeding was infusing at 55 ml per hour. The feeding bag contained formula but was not labeled with the type of feeding, date, time, or rate. A water flush bag in the room was labeled with the resident’s name and the date, but no time or additional information was noted. Two syringes were also observed in the room, and neither was labeled or dated. During interviews, the CNA confirmed the feeding bag was not labeled and stated the resident received tube feeding only and nothing by mouth. The LPN stated she had hung the tube feeding earlier that day and confirmed the feeding bag was not labeled with the type of feeding, date, time, or rate; she also acknowledged that neither syringe was labeled or dated. The DON later confirmed that all tube feeding solutions and supplies should be labeled with the resident’s name, date, time, and rate, and stated the facility did not have a policy specific to PEG feeding labeling. Resident #90 was admitted with diagnoses including unspecified severe protein-calorie malnutrition and dysphagia, had severely impaired cognitive skills for daily decision making, and had physician orders for NPO status and Jevity 1.5 at 55 ml per hour.
Medication error rate exceeded 5% after antihypertensives were prepared despite low blood pressure
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5% when two medications were prepared for administration to a resident without an appropriate clinical assessment. During morning medication administration, an LPN prepared Entresto 24-26 mg and Metoprolol 100 mg for a resident and placed them in a medication cup with the resident’s scheduled medications. A CNA then informed the LPN that the resident’s blood pressure was low, and the LPN reviewed the electronic record and found the blood pressure was 88/56. The LPN secured the medication cart and proceeded toward the resident’s room with the prepared medications, and later confirmed she intended to administer both medications and did not have parameters to hold them. The resident had been admitted with a diagnosis of metabolic encephalopathy and had physician orders for Metoprolol tartrate twice daily and Sacubitril-Valsartan (Entresto) twice daily with instructions to hold for systolic blood pressure less than 100. The record showed the resident’s blood pressure was 88/56 at the time of the medication pass. The DON later confirmed the Entresto order included a hold parameter for systolic blood pressure less than 100 and that the nurse did not identify this parameter. The pharmacist also confirmed both medications can lower blood pressure and that nursing staff are expected to use clinical judgment and contact the physician when blood pressure is low before administering antihypertensive medications.
Medication Administration Errors
Penalty
Summary
The facility failed to ensure medications were administered safely when an LPN prepared morning antihypertensive medications for a resident whose blood pressure had been documented as 88/56. The resident had diagnoses including metabolic encephalopathy and a BIMS score of 8, indicating moderately impaired cognition. During medication administration, the LPN prepared Entresto and Metoprolol, placed them in a cup, and proceeded toward the resident’s room after being told the blood pressure was low. She initially stated she intended to give both medications and said she did not have parameters to hold them, despite the resident’s low blood pressure and the order for Entresto to be held if systolic blood pressure was less than 100. The DON later confirmed the nurse failed to identify and follow the hold parameter. The record review showed the resident had active orders for Metoprolol tartrate twice daily and Sacubitril-Valsartan (Entresto) twice daily with instructions to hold for systolic blood pressure less than 100. The facility policy required medications to be administered as prescribed and stated that if a dose seemed excessive considering the resident’s age and condition, the physician should be contacted before administration. The pharmacist reported both medications can lower blood pressure and staff are expected to use clinical judgment and notify the provider when blood pressure is low before giving them. The NP also stated that giving these medications could have caused the blood pressure to drop to an unsafe level and that nursing staff were expected to notify the provider when abnormal vital signs were identified. The facility also failed to administer ordered antibiotic therapy as prescribed for another resident with recurrent C. difficile. The resident had an order for Vancomycin oral suspension every 6 hours for 7 days, but two scheduled doses were coded as not given because the medication was unavailable. Progress notes documented medication on order, and the packing slip showed the Vancomycin was delivered after those doses were due. An RN confirmed the doses were not administered because the medication was not available and that supervisory staff were not notified. The DON later stated staff were expected to notify appropriate personnel when medications were unavailable and confirmed she was not aware of the missed doses until identified during the survey.
Incomplete TAR Documentation for Wound Care
Penalty
Summary
The facility failed to ensure accurate and complete medical records when nursing staff did not document wound care on the Treatment Administration Record (TAR) for Resident #14, who was admitted with diagnoses including hemiplegia and hemiparesis following cerebral infarction. The resident’s Quarterly MDS showed a BIMS score of 2, indicating severely impaired cognition. The record also showed a physician’s order dated 2/2/26 for wound care to a sacral pressure ulcer. A review of the March 2026 TAR showed no nurse signature or documentation indicating wound care was completed on multiple dates, and the April 2026 TAR also showed no nurse signature or documentation on two additional dates. During interview, the DON acknowledged there were multiple blank entries on the TAR and stated nurses were completing wound care but not documenting it. RN #1 acknowledged she did not always document wound care after completing treatments and said she was responsible for ensuring documentation was completed. The Administrator stated staff were expected to document treatments after providing care.
Failure to Sustain Infection Control Monitoring
Penalty
Summary
The facility’s QAPI Committee failed to sustain corrective actions after a prior F880 infection control citation for not implementing Enhanced Barrier Precautions (EBP) for a resident at high risk for MDROs. The facility had previously been cited during an annual recertification survey on 12/05/2024 for failing to follow infection control practices by not implementing EBP for one of 21 sampled residents. During the current recertification survey, the facility was again cited for F880 after staff failed to use appropriate PPE during high-contact resident care for a resident on EBP on 4/21/26. The Administrator stated that after the earlier citation, the QAPI team developed a plan of correction that was monitored for 13 weeks, with the QAPI committee reviewing the citation monthly for three months and using a spreadsheet to track monitoring findings. The Administrator also stated that no relapses occurred during the monitoring period.
Failure to Provide Written Notification of Resident Transfers
Penalty
Summary
The facility failed to provide written notification of resident transfers to the residents or their representatives for three residents who were hospitalized. The facility's policy, revised in November 2016, mandates that residents and their representatives be notified in writing of any transfer or discharge, in a language and manner they understand. However, the receptionist, following instructions from the Regional Business Office Consultant, ceased mailing written notifications approximately six months prior to the survey, opting instead to call the representatives. This practice was contrary to the facility's policy and federal and state regulations. The deficiency was identified during a review of records and interviews with staff. Resident #47, who was initially admitted in March 2020 with a diagnosis of Sepsis, was discharged to an acute hospital without written notification. Similarly, Resident #65, admitted in May 2023 with Acute Respiratory Failure, and Resident #69, admitted in May 2024 with Paraplegia, were also discharged to acute hospitals without receiving the required written notifications. The facility administrator was unaware of the change in procedure and acknowledged the requirement for written notifications.
Failure to Provide Written Bed Hold Notifications
Penalty
Summary
The facility failed to provide written notification of its bed hold policies to residents or their representatives at the time of transfer to a hospital or during therapeutic leave. This deficiency was identified for three residents who were reviewed for hospitalizations. The facility's Bed Hold Policy, revised in 2016, mandates that residents and their representatives be notified in a language and manner they understand before any transfer or discharge. However, the Social Services Director disclosed that she had ceased mailing these notifications six months prior, following instructions from the Regional Business Office Consultant, who indicated that company policy did not require written notifications and that phone contact was sufficient. The deficiency was further highlighted during interviews with facility staff. The Social Services Director confirmed the cessation of mailing notifications, while the Administrator was unaware of this change in practice. The residents involved in this deficiency included one with a diagnosis of sepsis, another with acute respiratory failure, and a third with paraplegia, all of whom were discharged to acute hospitals without receiving the required written bed hold notifications. This lack of compliance with the facility's policy and federal and state laws resulted in a failure to properly inform residents and their representatives about the bed hold policy during critical transitions.
Failure to Timely Transmit Discharge MDS Assessment
Penalty
Summary
The facility failed to transmit a discharge Minimum Data Set (MDS) assessment in a timely manner for one of the twenty-one MDS assessments reviewed, specifically for Resident #86. The facility's policy, effective August 2019, requires that care plans and MDS be developed and maintained per Resident Assessment Instrument (RAI) Guidelines. Resident #86 was admitted on July 2, 2024, with a diagnosis of Spastic Hemiplegia Affecting the Left Non-Dominant Side and was discharged home with an Assessment Reference Date (ARD) of August 6, 2024. However, the discharge MDS was not electronically submitted. During interviews, an LPN stated that the corporate nurse was responsible for submitting the discharge MDS, and confirmed that the corporate nurse completed the discharge MDS but failed to submit it to the Centers for Medicare and Medicaid Services (CMS). An RN also confirmed she failed to submit the discharge MDS for Resident #86, stating she did not know how she missed it. The Director of Nursing (DON) was unaware that the MDS was not submitted and expected MDS assessments to be submitted timely.
Failure to Develop and Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for two residents, leading to deficiencies in care. For a resident diagnosed with PTSD, the care plan included forgetfulness and memory loss but did not identify specific triggers related to the resident's PTSD, such as gunfire and hearing people in distress. This oversight was confirmed by an LPN and the Care Plan nurse, who were unaware of the need to list PTSD triggers in the care plan. The Director of Nursing acknowledged that identifying triggers is essential to prevent re-traumatization and provide quality care. Additionally, the facility did not implement care plan interventions for enhanced barrier precautions for another resident with a tracheostomy. The care plan required staff to wear gowns and gloves when providing care, but an Occupational Therapist was observed providing therapy without wearing a gown, despite the presence of a sign indicating the need for enhanced barrier precautions. The OT admitted to not wearing a gown, and the Care Plan nurse confirmed the requirement for gown use. The Director of Nursing also confirmed the failure to implement the care plan intervention.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide trauma-informed care for a resident diagnosed with Post-Traumatic Stress Disorder (PTSD), as they did not identify or document triggers and resident-specific interventions. The resident, who was admitted in 2016 and had a diagnosis of PTSD stemming from service in the Vietnam War, had triggers such as gunfire and hearing people in distress. Despite this, the facility's records, including the Certified Nurse Aide (CNA) Kardex and care plan, did not list any PTSD triggers or interventions tailored to the resident's needs. Interviews with staff, including a CNA, LPN, Social Services Director (SSD), Director of Nursing (DON), and the Administrator, revealed a lack of awareness and communication regarding the resident's PTSD triggers. The SSD and DON had conflicting views on who was responsible for evaluating PTSD and identifying triggers, leading to a gap in care. The Administrator acknowledged the expectation for trauma-informed care to prevent re-traumatization, but the deficiency highlighted a failure in the facility's processes to ensure such care was provided.
Food Safety Deficiencies in Kitchen Storage and Sanitation
Penalty
Summary
The facility failed to adhere to professional standards for food safety, as observed during a kitchen inspection. The ice machine was found with dirt-like stains on the interior, which transferred onto a towel when wiped, indicating a lack of cleanliness. Refrigerator #2 contained six trays of portioned liquids without labels or dates, and Freezer #1 had an opened bag of breaded chicken strips that were exposed and undated. In the pantry, an opened bag of hamburger buns and dehydrated onions were left exposed, and a scoop was improperly stored in the flour bin, touching the flour. Additionally, three spice jars were left open, and a bottle of lemon juice was not refrigerated as required by the manufacturer's instructions. The Dietary Director (DD) confirmed the presence of the dirt-like stains, undated and exposed foods, and the scoop left in the flour bin. The DD admitted responsibility for monitoring food safety but acknowledged difficulty in cleaning the ice machine and a lack of testing for bio-growth, which was the Maintenance Director's responsibility. The cook confirmed that staff are trained monthly on food safety, yet these issues persisted. The Administrator was informed of the deficiencies and acknowledged the need for self-monitoring to ensure food quality and sanitation.
Failure to Implement Enhanced Barrier Precautions for High-Risk Resident
Penalty
Summary
The facility failed to adhere to infection control practices by not implementing Enhanced Barrier Precautions (EBP) for a resident at high risk for Multidrug-resistant Organisms (MDRO). The resident, who was non-verbal and had a tracheostomy and a feeding pump, was admitted with diagnoses including Gastrostomy Status and Encounter for Attention to Tracheostomy. Despite the presence of a sign on the resident's door indicating the need for EBP, an Occupational Therapist (OT) was observed providing care without wearing a gown, although gloves and a surgical mask were used. This was contrary to the facility's policy, which requires the use of gowns and gloves during high-contact care activities for residents with wounds and indwelling medical devices. Interviews with staff, including a Registered Nurse (RN) and the Director of Nursing (DON), confirmed that all staff had been in-serviced on EBP and that the OT should have worn a gown while providing care. The OT admitted to not wearing a gown and stated that she only wears PPE when it is located on the resident's door, despite PPE being readily available in the hallway. The DON reiterated that the absence of PPE on the door was not a valid reason to omit proper precautions, emphasizing the expectation for staff to follow infection control measures.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 31 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
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Moss Point
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Singing River Skilled Nursing Facility | 1 mi | ★★★★★ | 0 | 0 |
| Plaza Community Living Center | 1.1 mi | ★★★★★ | 1 | 0 |
| River Chase Village | 7.2 mi | ★★★★★ | 0 | 0 |
| Sunplex Sub-acute Center | 11.2 mi | ★★★★★ | 15 | 6 |
| Ocean Springs Health & Rehabilitation Center | 11.7 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.