Below average — CMS composite of the measures below.
A standard survey is most likely before around September 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 Gulfport Care Center during CMS and state inspections, most recent first.
A resident with a history of hallucinations and dementia exited the facility through an alarmed door, and staff failed to investigate the alarm or promptly report the elopement. The resident was found outside by dietary staff, and the incident was not reported to the State Agency until two days later. The delay in reporting and lack of immediate investigation placed residents at risk and constituted Immediate Jeopardy and Substandard Quality of Care.
A resident with a history of hallucinations and dementia exited the facility unsupervised after staff failed to respond to an audible door alarm. The resident was found outside by a dietary employee, and nursing staff were unaware of the elopement until notified. No immediate investigation was initiated, and key staff were not informed of the incident until days later, resulting in a delayed response to the event.
Two residents experienced significant lapses in supervision and safety interventions: one resident with dementia and hallucinations exited the facility unsupervised after staff failed to respond to an active door alarm, and another resident with a femur fracture was manually transferred by CNAs without the required mechanical lift, resulting in an ankle injury. Staff interviews revealed a lack of adherence to policies regarding alarm response and transfer procedures, and no valid exceptions were documented for the manual transfer.
Staff did not follow care plans for three residents, including failing to provide PEG tube site care resulting in a purulent wound, not ensuring a call light was within reach for a resident at risk for falls, and not using a mechanical lift as directed for a resident requiring assistance with transfers, which led to an ankle sprain.
Two residents receiving enteral feedings did not receive proper care: one had a PEG site with an old, soiled dressing and no physician orders or monitoring for over 20 days, resulting in purulent drainage and infection, while another had a feeding bag that was not properly labeled with required information. Staff confirmed these deficiencies through observation and record review.
A resident with a history of cerebral infarction and severely impaired cognition was found in bed unable to reach her call light, which was wrapped around a light fixture and out of reach. Staff interviews confirmed the resident could not have moved the call light herself and acknowledged it was their responsibility to ensure accessibility, in accordance with facility policy.
A resident's privacy was compromised when personal care instructions related to dialysis were posted on her door, making confidential medical information visible to others. Staff confirmed the sign's presence and acknowledged that such information was already documented in the care plan. The resident, who was cognitively intact and undergoing regular dialysis, had not requested the signage, and facility policy required confidentiality of personal and medical records.
A resident was admitted to hospice services, but staff did not complete a required Significant Change in Status Assessment (SCSA) within 14 days, as mandated by facility policy and the RAI Manual. Interviews and record reviews confirmed the omission, despite staff acknowledging that hospice admission is a qualifying event for an SCSA.
Two residents had inaccurate MDS assessments: one was not coded as receiving hospice care despite being on hospice, and another was incorrectly coded as having bed rails used as a physical restraint, even though staff stated the rails were for mobility assistance. Staff interviews revealed a lack of a system to ensure MDS accuracy, with verification limited to section completion.
Surveyors found that staff failed to store food according to professional standards and facility policy, including the presence of expired milk in a cooler and improper storage of Key Lime juice that required refrigeration. The Dietary Manager and Administrator confirmed these issues and acknowledged that food safety procedures were not followed.
A facility failed to treat a resident with respect and dignity when a CNA used inappropriate language after the resident had an accident in bed. The incident was confirmed by the resident and her roommate, both of whom were cognitively intact. The CNA involved had previously been accused of discourteous behavior and was terminated following the investigation.
Failure to Timely Report and Investigate Resident Elopement
Penalty
Summary
The facility failed to timely report an incident of elopement involving a resident with a history of hallucinations and dementia. The resident, who was cognitively intact at admission with a BIMS score of 15, was last seen inside the facility at approximately 4:00 AM and was later found unsupervised in the facility parking lot by dietary staff at around 4:30 AM. Facility staff were unaware that the resident had left the building through an alarmed door, and staff did not investigate the audible alarm when it sounded. The resident reported feeling threatened by a nurse, which prompted her to leave the facility, and she was found outside by a staff member arriving for work. Despite the incident, the facility did not report the elopement to the State Agency until two days later. Interviews revealed that the LPN on duty heard the alarm but did not investigate, and the Administrator was not fully informed of the circumstances until returning to work after the weekend. The Director of Nursing was also unaware of the incident until after the State Agency began its investigation. The delay in reporting and lack of immediate investigation into the alarm and the resident's whereabouts constituted a failure to follow the facility's policy on incident investigation and reporting, which requires timely reporting of elopements and other reportable incidents. The deficiency was determined to be Immediate Jeopardy and Substandard Quality of Care, as the delay in reporting and failure to investigate placed the resident and others at continued risk for unsupervised exit, increasing the likelihood of serious harm. The facility's own investigation confirmed that staff did not respond appropriately to the alarm and did not account for the resident's whereabouts until notified by dietary staff.
Failure to Timely Investigate Resident Elopement After Alarm Ignored
Penalty
Summary
The facility failed to initiate a timely investigation after a resident with a history of hallucinations and dementia exited the facility unsupervised. The resident was last seen inside the facility at approximately 4:00 AM and was found by dietary staff in the facility parking lot around 4:30 AM. Staff were unaware that the resident had left the building, despite an audible alarm sounding on an exit door, which was not investigated by staff at the time. Interviews revealed that the LPN on duty heard the alarm but did not investigate, and other staff members also failed to respond to the alarm. The resident was discovered outside by a dietary employee arriving for work, who then notified nursing staff. The resident reported leaving the facility due to feeling threatened by a nurse. The LPN and other staff brought the resident back inside but did not conduct an immediate investigation or interview the dietary staff who found the resident. The Administrator was notified of the alarm and the resident's exit but was not made aware of the full circumstances, including that the resident had been found outside by non-nursing staff, until several days later. The Director of Nursing was also not informed of the elopement until the State Agency arrived. As a result, the facility did not begin an internal investigation into the incident until two days after the event, delaying the identification of root causes such as staff failure to respond to alarms and lack of awareness of the resident's whereabouts.
Failure to Prevent Elopement and Ensure Safe Transfer Techniques
Penalty
Summary
The facility failed to ensure adequate supervision and implement safety interventions to prevent accidents for two residents. In the first incident, a resident with Parkinson's disease, dementia, and a history of hallucinations exited the facility unsupervised through an exit door that triggered an alarm. Staff did not immediately investigate the alarm, assuming it was malfunctioning, and did not conduct a room-to-room check to account for all residents. The resident was found outside in the parking lot by a dietary staff member approximately 30 minutes later, appearing confused, tired, and reporting feeling threatened by a nurse. Multiple interviews confirmed that staff heard the alarm but did not respond appropriately, and some staff were unfamiliar with the facility's policies regarding alarms and elopement. In the second incident, another resident with a right femur fracture and a care plan requiring a stand-assist mechanical lift was manually transferred by two CNAs without the use of the required lift. During the transfer, the resident's foot became caught under the wheelchair, resulting in a right ankle sprain. The CNAs involved were agency staff who did not provide a reason for not using the mechanical lift, despite the resident's care plan and room signage indicating its necessity. The resident reported that the lift was available in the room at the time of transfer, and she did not refuse its use. The incident was later reported to therapy staff, and the resident was unable to fully participate in physical therapy for several weeks due to the injury. Interviews with facility staff, including the DON and care plan nurse, confirmed that the use of a mechanical lift was required for the resident and that CNAs are not permitted to determine lift methods. The facility's policy allows for manual transfers only in specific circumstances, such as emergencies or mechanical failure, but no such exception was documented for this incident. The charge nurse also confirmed that the facility operates as a no-manual-lift environment and that the CNAs did not provide justification for their actions.
Failure to Follow Care Plans for PEG Site Care, Safe Transfers, and Call Light Accessibility
Penalty
Summary
Staff failed to follow the comprehensive care plan for three residents, resulting in deficiencies in care. For one resident with a recent PEG tube placement, there was no documented PEG site care order until several weeks after admission, despite the care plan indicating the need for site care and monitoring for infection. The resident reported that no one had performed PEG site care, and observations revealed an old, discolored dressing with purulent, foul-smelling drainage and signs of infection at the site. Another resident, who required staff assistance with transfers and had a care plan specifying the use of a stand-assist mechanical lift, was manually transferred by two CNAs without the lift. This manual transfer resulted in the resident's foot becoming caught under a wheelchair, leading to a right ankle sprain. The resident confirmed that the transfer was not performed according to the care plan and that the injury affected her ability to participate in therapy. A third resident, who was at risk for falls, had a care plan intervention requiring the call light to be within reach. During observation, the call light was found wrapped around a light fixture and not accessible to the resident, who reported being unable to get help when needed. Staff confirmed that ensuring the call light was within reach was their responsibility, but this was not done at the time of observation.
Failure to Provide Proper PEG Site Care and Label Enteral Feeding Equipment
Penalty
Summary
The facility failed to ensure proper care and monitoring of enteral feeding and gastrostomy sites for two residents. One resident, who had recently received a PEG tube prior to admission, reported that no site care had been performed and described the site as draining and unclean. Observations confirmed an old, discolored dressing with green and black purulent drainage and a foul odor, with the dressing dated several days prior. Record review and staff interviews revealed that there were no physician orders for PEG site care or monitoring for approximately 21 days after admission, and the site had not been assessed or the dressing changed as required. The resident continued to receive bolus feedings during this period, and staff confirmed the lack of orders and monitoring. Another resident receiving tube feedings was observed with a feeding bag that was not properly labeled. The bag only included the resident's last name and date, but did not indicate the time it was hung, the type of enteral feeding, or the rate. Staff interviews confirmed that the label was incomplete and did not meet facility policy, which requires the full name, rate, time and date hung, and type of feeding to be included. The family member present was also unaware of the type of enteral feeding being administered. Both residents had relevant medical histories, including recent surgical aftercare and gastrostomy status. The deficiencies were identified through observation, interview, and record review, and were confirmed by staff and facility leadership. The lack of timely physician orders, monitoring, and proper labeling of enteral feeding equipment directly contributed to the deficiencies cited.
Call Light Not Accessible to Resident with Severe Cognitive Impairment
Penalty
Summary
A deficiency occurred when staff failed to ensure that a call light was within reach for a resident with severe cognitive impairment. During an observation, the resident was found lying in bed and stated she needed help but could not get anyone. The call light devices, including a round palm pad call light, were observed wrapped around a light fixture and not accessible to the resident. Staff interviews confirmed that the resident could not have physically wrapped the call lights around the fixture herself, and that it was the responsibility of the certified nurse aide to ensure call lights were within reach during morning rounds. The licensed practical nurse and director of nursing both stated that call lights should always be accessible to residents. The resident involved had a history of cerebral infarction and was assessed as having severely impaired cognition, as indicated by a BIMS score of 00 on the most recent Minimum Data Set assessment. The facility's policy required that call lights be kept within reach of residents at all times to provide a means of communication with staff. Despite this policy, the call light was not accessible, and staff acknowledged the oversight during interviews.
Failure to Maintain Resident Privacy and Confidentiality
Penalty
Summary
The facility failed to maintain the privacy and confidentiality of a resident's personal and medical information by posting signage on the resident's door that disclosed specific care instructions related to dialysis. The sign indicated that the resident was to have a pad placed underneath her on certain days before going to dialysis. This information was visible to anyone passing by the room, including staff, visitors, and other residents. Multiple staff members, including an LPN and a CNA, confirmed the presence of the sign and acknowledged that the information was already documented in the resident's care plan. The resident involved was cognitively intact, as indicated by a BIMS score of 15, and had not requested the signage to be posted. The resident had a history of chronic kidney disease and was dependent on renal dialysis, receiving treatment three times weekly. Facility policies reviewed emphasized the importance of treating residents with dignity and maintaining the confidentiality of personal and medical records. Despite these policies, the signage remained on the door until it was brought to the attention of nursing leadership, who confirmed that such postings were not appropriate.
Failure to Complete Significant Change MDS Assessment After Hospice Admission
Penalty
Summary
The facility failed to complete a Minimum Data Set (MDS) Significant Change in Status Assessment (SCSA) for a resident who was admitted to hospice services. According to the facility's policies and the Resident Assessment Instrument (RAI) Manual, an SCSA is required within 14 days when a terminally ill resident enrolls in a hospice program. Record review showed that the resident was admitted to hospice services on 8/29/24, as confirmed by both the Director of Nursing (DON) and a Licensed Practical Nurse (LPN). However, there was no evidence that an SCSA was completed or submitted within the required 14-day timeframe following the hospice admission. Interviews with facility staff, including the DON and an LPN, confirmed their understanding that hospice admission constitutes a significant change in condition requiring an SCSA. The MDS assessment history for the resident did not show a significant change assessment within the specified period after hospice admission. The resident had a history of cerebral infarction and had been readmitted to the facility earlier in the year. The deficiency was identified through interviews, record reviews, and confirmation of the facility's policies and procedures.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for two of twenty sampled residents. For one resident with a diagnosis of cerebral infarction, records showed she was admitted to hospice services, but her Quarterly MDS assessment did not indicate that she was receiving hospice care during the lookback period. Interviews with nursing staff confirmed that the resident had been on hospice since the previous year, and the omission was not identified or corrected in the MDS documentation. The process for verifying MDS accuracy was limited to staff reviewing their own sections, with no system in place to ensure overall accuracy, and the RN signature only indicated completion, not verification of accuracy. For another resident with a diagnosis of atherosclerotic heart disease, the Quarterly MDS assessment incorrectly coded the use of bed rails as a physical restraint. Facility staff, including an LPN, stated that bed rails were not considered restraints and were used to assist with mobility, and the coding of restraints on the MDS was an error. The administrator confirmed that MDS assessments are expected to accurately reflect residents' status, but the errors in both cases demonstrated a failure to ensure accurate assessment documentation.
Improper Food Storage and Use of Expired Items in Kitchen
Penalty
Summary
During a kitchen observation, surveyors identified that staff failed to store food in a sanitary manner, which did not comply with professional standards and the facility's own food storage policy. Specifically, an opened gallon of reduced-fat milk with an expiration date that had already passed was found inside a reach-in cooler. The Dietary Manager confirmed the milk was expired and was uncertain if it had been served during breakfast. Additionally, a container of Key Lime juice was found stored on a dry goods shelf, despite manufacturer instructions requiring refrigeration after purchase. The Dietary Manager acknowledged the juice was not stored according to these instructions. The facility's policy on food storage and labeling requires routine checks to identify and discard expired foods and to follow manufacturer guidelines for storage. During interviews, both the Dietary Manager and the Administrator confirmed awareness of the findings and acknowledged that the observed practices did not align with facility standards or policy requirements. No information was provided regarding specific residents affected or their medical conditions at the time of the deficiency.
Failure to Treat Resident with Respect and Dignity
Penalty
Summary
The facility failed to treat a resident with respect and dignity during care. An allegation of verbal abuse was reported by a resident's roommate, who stated that a CNA used inappropriate language while addressing the resident after she had an accident in bed. The Social Services Director confirmed the report and initiated an investigation. The resident involved confirmed the incident, stating that the CNA spoke to her in an ugly manner. The Director of Nurses and the Administrator also confirmed the incident, with the Administrator identifying the CNA involved and acknowledging the disrespectful language used. This was the second time the CNA had been accused of discourteous behavior towards residents. The personnel file of the CNA indicated that she had received training on the Vulnerable Adults Act and Resident's Rights. Both the resident involved and the reporting roommate were found to be cognitively intact, as indicated by their BIMS scores. The facility's investigation and interviews confirmed the incident, leading to the termination of the CNA. The deficiency was determined to be past non-compliance, as corrective actions were implemented before the State Agency's entrance.
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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.
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Nursing homes near Gulfport
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Lakeview Nursing Center | 1.6 mi | ★★★★★ | 3 | 0 |
| Coastal Health And Rehabilitation Center | 5.7 mi | ★★★★★ | 2 | 0 |
| Driftwood Nursing Center | 5.8 mi | ★★★★★ | 3 | 0 |
| Pass Christian Health And Rehabiliation Center | 8.9 mi | ★★★★★ | 4 | 0 |
| The Pillars Of Biloxi | 10.3 mi | ★★★★★ | 11 | 0 |
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