Below average — CMS composite of the measures below.
A standard survey is most likely before around December 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 Ocean Springs Health & Rehabilitation Center during CMS and state inspections, most recent first.
Improper Food Storage and Unsanitary Food Handling: Kitchen observations found dated and undated produce stored with overly ripe, slimy, and biologically grown items, an opened flour bin, and opened sauces that required refrigeration after opening. Staff also handled ready-to-eat foods with gloved hands and reused a serving spoon across foods during tray service, and the DM and Administrator acknowledged the food safety concerns.
Inaccurate PBJ Staffing Data Submission: The facility failed to accurately submit PBJ staffing data to CMS using payroll and other verifiable sources. The PBJ report triggered for excessively low weekend staffing, no RN hours, and no licensed nursing coverage 24 hours/day, even though the staffing grid and time sheets showed RN and licensed nursing coverage and eight hours of RN coverage daily. An LPN, HR Coordinator, and Administrator stated they were unaware of the inaccurate submission, and the Administrator said the errors occurred under prior corporate ownership.
QAPI failed to sustain oversight and corrective actions for repeat deficiencies involving PBJ staffing data reporting and the QAPI program itself. The facility was cited again for inaccurately submitting direct care staffing information to CMS and for not maintaining the QAPI program during leadership transitions, after having been cited for the same issues on a prior survey. The Administrator said QAPI meetings occur quarterly and as needed, and acknowledged the repeat PBJ issue continued, attributing the discrepancy to a possible IT processing glitch.
Resident Required to Wear Brief Against Preference: A resident who was cognitively intact and admitted for aftercare following joint replacement surgery reported that night shift staff told her she had to wear a brief instead of being assisted to the bathroom or provided a bedpan. She stated she does not wear briefs, had been admitted in panties with an incontinence pad, and felt degraded by the request. An LPN reported that evening shift staff used a bedpan and assisted the resident without issue, while the DON stated staff should not place a brief or pull-up on a continent resident.
A resident’s request for help obtaining a state ID was not honored, and the issue remained unresolved for more than a year. Staff reported the resident’s out-of-state driver’s license and state ID were expired, and multiple trips to the DMV were unsuccessful because she did not have a birth certificate. The resident was cognitively intact with a BIMS score of 15 and had diagnoses including hemiplegia and hemiparesis following CVA.
Failure to provide admission rights and documents: The facility did not give a resident or the resident’s RR copies of the Resident Rights, Resident Handbook, or other admission materials at admission, even though the admission agreement required acknowledgment of receipt. The admissions Coordinator said the materials were not available, and the Admissions Director said she only verbally explained the paperwork and did not provide physical copies. The resident, who had a BIMS of 14 and was cognitively intact, did not recall receiving the admission information, and the resident’s relative stated no paperwork was sent home.
A resident’s privacy was not protected when a hospice sign displaying the hospice provider’s name and the resident’s identifying information was posted on the room door. The resident had dementia and severe cognitive impairment, and interviews with the RR, hospice coordinator, DON, and administrator confirmed the sign was visible to passersby, was not authorized by the RR, and should not have been posted with resident-specific health information.
Delayed reporting of misappropriation allegation: A resident with Type 2 DM and intact cognition reported that a CNA was handling her change purse and that coins were missing. An LPN observed quarters on the resident and a change purse tucked in her gown, and the allegation was reported up the chain, but the DON and Administrator delayed reporting because they questioned the credibility of the claim and the resident did not want to make a big deal about it.
Failure to provide timely ADL assistance: A resident dependent on staff for incontinence care reported being left in a soiled brief for hours, with CNA confirmation that the resident had not been checked and was saturated when finally assessed. Another resident who was dependent on staff for personal hygiene was repeatedly observed with long facial hair despite stating she wanted to be shaved; CNA and LPN interviews confirmed shaving was expected during shower care but was not consistently provided.
Failure to implement isolation and EBP precautions timely affected two residents. One resident admitted with COVID-19 did not have contact isolation signage, PPE, or biohazard barrels in place at admission, and an RN confirmed the protocol was not followed. Another resident with a wound-related EBP order had wound care performed without gowns, and there was no EBP sign on the door; the DON and RN confirmed gowns and gloves should have been used.
Failure to Post Daily Nurse Staffing Information: Surveyors found that daily nurse staffing information was not posted in a prominent area accessible to residents, staff, and visitors. An LPN stated the staffing sheet was usually taped on a table in the entrance hallway, but residents did not go there and a sign directed staff and family not to allow residents beyond the double doors. The Administrator and DON confirmed the posting location did not meet regulatory requirements.
A resident with severe cognitive impairment and identified as an elopement risk exited the facility unsupervised due to a malfunctioning wander guard device. The care plan required daily checks of the device's functionality, but staff failed to perform these checks, leading to the resident walking 0.7 miles and crossing a highway before being found. The resident had diagnoses including aphasia and legal blindness, highlighting the critical need for adherence to care plan interventions.
A resident identified as an elopement risk exited the facility unnoticed due to an inoperable wander alarm device. The resident, with cognitive impairments, walked 0.7 miles and crossed a highway before being located by staff. The facility's policy required daily checks of the wander monitoring system, but this was not adhered to, leading to the incident.
The facility failed to provide timely incontinence care for six residents, leading to skin excoriations and other issues. One resident was left in a saturated and soiled brief, resulting in redness and excoriations. Another resident was found wearing two incontinence briefs, against facility policy, and had a current diagnosis of a UTI. Other residents also experienced delays in incontinence care, highlighting a systemic issue with timely care and adherence to policies.
The facility failed to accurately submit direct care staffing information to CMS for Quarter 1 of FY 2023, leading to the Metric of Excessively Low Weekend Staffing being triggered. The Human Resource Coordinator, an LPN, and the Administrator were unaware of the inaccuracies until an audit revealed that salaried staff working weekends were not properly reported.
A resident at risk for pressure ulcers did not have their low air loss mattress transferred when moved from the skilled unit to the LTC unit, despite a physician's order. This oversight was confirmed by the resident's family, the MD, and the DON.
A resident's right to a dignified dining experience was compromised when staff failed to provide timely incontinence care, resulting in the resident eating lunch in a soiled brief. The resident's request for assistance was acknowledged but not acted upon, leading to discomfort and an unappetizing meal due to the odor in the room.
A facility failed to ensure the safety of a cognitively intact resident with a known substance use disorder by not assessing the risk of substance use and not developing appropriate interventions. The resident frequently left the facility to consume alcohol and returned impaired, but no care plan or interventions were in place to address his SUD. Interviews with the resident, his family, and facility staff confirmed the lack of assessment and intervention, despite the resident's need for help with alcohol abuse.
The facility's QAPI Committee failed to sustain its program during leadership transitions, leading to deficiencies in residents' rights and wound care. Specifically, the facility did not provide incontinence care, resulting in odors during a meal, and failed to continue a PU intervention after a room change.
The facility failed to prevent the spread of infection due to improper medication handling and incontinence care practices. A nurse placed a pill into her ungloved hand before transferring it to a medication cup, and CNAs discarded soiled linens and briefs directly onto the floor during care for two residents, contrary to facility policies.
The facility failed to develop and implement care plans for three residents, including one with a UTI, one with SUD, and one requiring a low air loss mattress. Despite being cognitively intact, these residents did not receive appropriate care plan interventions, as confirmed by staff and family members.
Improper Food Storage and Unsanitary Food Handling
Penalty
Summary
Food was not maintained in accordance with professional standards for food safety during kitchen observations, as multiple items were found improperly stored or in poor condition. On 09/08/2025, Refrigerator #1 contained two small plates with individual portions of lettuce, tomato, and onions that were not dated, along with one cut piece of overly ripe cucumber with dark spots. Refrigerator #2 contained four bunches of overly ripe celery with withered leaves that were soft and flexible, one opened bag of salad mix with a manufacturer's Best if Used By date of 9/4/25, and five heads of iceberg lettuce with slimy dark leaves and visible white biological growth. The pantry also had a flour bin with the lid left open, exposing the flour, and opened gallon-sized bottles of teriyaki sauce and soy sauce that required refrigeration after opening. The Dietary Manager acknowledged the overly ripe produce, exposed and expired food, and improper storage, and stated he and the cook were responsible for maintaining food quality. During a follow-up kitchen observation on 09/09/2025, staff were observed handling ready-to-eat food with gloved hands instead of using sanitary utensils. The Baker was observed preparing resident trays while picking up bread rolls and pieces of fried fish with her gloved hands and arranging chicken and potatoes on plates with her gloved hands. A Dietary Aide was observed using a serving spoon from potatoes to push chicken from one plate to another, then using the same spoon to serve carrots, and also placing bread rolls and pieces of fried fish on plates with her gloved hands. Both staff acknowledged the improper handling of food and stated they knew food should be handled with proper utensils. The Dietary Manager acknowledged the unsanitary handling of food during tray service, and the Administrator later confirmed awareness of the observations of overly ripe produce, exposed food, expired food, and unsanitary food handling practices.
Inaccurate PBJ Staffing Data Submission
Penalty
Summary
The facility failed to accurately submit direct care staffing information to CMS using payroll and other verifiable, auditable data for FY Quarter 3 2025. Based on record review, the PBJ Staffing Data Report for the quarter triggered for excessively low weekend staffing, no RN hours, and no licensed nursing coverage 24 hours/day. The infraction dates for no RN hours and failure to have licensed nursing coverage 24 hours/day were identified as 4/1/25 through 4/30/25 and 5/1/25 through 5/31/25. Record review of the staffing grid completed by an HR staff member who was also an LPN showed RN and nursing coverage on all days in April and May 2025. Review of the facility’s time sheets also showed the facility was not excessively low on staff on weekends, had licensed nursing coverage 24 hours per day, and had eight hours of RN coverage daily. During interviews, the LPN stated she was unaware the facility failed to electronically submit PBJ staffing data accurately and said salaried staff helped cover the schedule as needed. The HR Coordinator stated the corporate office was responsible for submitting PBJ staffing data and she was unaware the information submitted for the facility was inaccurate until notified by the State Agency. The Administrator stated he was not aware of the inaccurate submission, acknowledged the facility’s responsibility for accuracy, and stated the errors occurred under prior corporate ownership before the change on 6/1/25.
QAPI Failed to Sustain Oversight of PBJ Reporting and Prior Deficiencies
Penalty
Summary
The facility's QAPI Committee failed to sustain corrective actions to prevent recurrence of previously cited deficiencies. Based on record review, staff interview, and facility policy review, the facility was cited again for failing to accurately submit direct care staffing information and for failing to ensure the QAPI program was sustained during transitions in leadership, after having been cited for the same issues during an annual recertification survey on 4/18/24. The current survey found that QAPI did not maintain ongoing monitoring and oversight to prevent recurrence for 2 of 11 deficiencies cited, specifically F851 and F865/867. Review of the facility's QAPI policy dated 6/1/25 showed that the program was intended to be ongoing and comprehensive, with the Executive Director accountable for implementation and the QAPI Committee responsible for reviewing proposed activities and identifying priorities. The Provider History Profile and CMS-2567 showed prior citations for F851 and F865. During interview on 9/11/25, the Administrator stated that QAPI meetings occur quarterly and as needed, that concerns are reported to him or the DON, and that he compiles information for QAPI review. He acknowledged that the repeat deficient practice related to PBJ reporting had continued and attributed the discrepancy to a possible IT processing glitch when information is transmitted to CMS.
Resident Required to Wear Brief Against Preference
Penalty
Summary
The facility failed to ensure a resident's right to dignity and respect when staff required her to wear a brief instead of providing a bedpan or assistance to the bathroom. Resident #109 reported that night shift staff told her she would need to wear a brief even though she stated she does not wear briefs. She explained that she never requested a brief or pull-up and objected when staff attempted to place a brief on her, stating that if staff insisted, a pull-up would be preferable to a brief. Her daughter confirmed that the resident was admitted wearing panties with an incontinence pad, not a brief or pull-up, and the resident said she continues to wear panties and did not want to feel degraded or disrespected by being asked to wear a brief. During interview, an LPN stated that evening shift staff, including herself, used a bedpan for the resident and that she personally assisted the resident onto the bedpan, which the resident tolerated well. The LPN said she did not know why night shift staff chose not to use the bedpan and instead placed the resident in a brief. The DON stated she does not expect staff to place a brief or pull-up on a resident who is continent, identifying this as a resident rights and dignity issue. The resident was admitted with diagnoses including aftercare following joint replacement surgery, and her BIMS indicated she was cognitively intact.
Failure to Assist Resident With Obtaining Personal Identification
Penalty
Summary
The facility failed to honor a resident’s request for assistance in obtaining personal identification, and the request remained unresolved for more than one year. Resident #48 stated she had asked the facility for help completing paperwork and obtaining a state ID card, but the request was not fulfilled. The Social Services Director stated she had no knowledge of the request, while the Social Services Assistant recalled that the resident had previously requested transportation to the DMV to renew her license and obtain a state ID. The assistant reported that the resident’s out-of-state driver’s license and state ID were expired and that she was told a birth certificate was required. The resident was transported to multiple DMV locations, but each attempt was unsuccessful because she did not have a birth certificate. The Social Services Assistant stated the matter was not resolved because of turnover in the social services department and lack of follow-up from the prior Social Worker. The Social Services Director later confirmed that the assistant knew the process to obtain a birth certificate and acknowledged that the issue had not been resolved for the resident. Resident #48 was admitted with diagnoses including hemiplegia and hemiparesis following cerebral infarction, and her MDS showed a BIMS score of 15, indicating she was cognitively intact.
Failure to Provide Admission Rights and Documents
Penalty
Summary
The facility failed to provide residents or their resident representatives with copies of the Resident Rights and admission documents at the time of admission. The admission agreement revised 5/25 required residents or their representatives to sign acknowledging receipt of documents including the Resident Rights, Resident Handbook, and other admission materials, but the admissions Coordinator stated she had not been providing these items during the admission process because the facility had not been able to order resident handbooks and the resident rights documents were not available to distribute. She acknowledged that residents and representatives signed the admission agreement even though she had no materials available to provide. Resident #26 was admitted on 8/30/2025 with diagnoses including Surgical Aftercare following Surgery on the Nervous System. During the resident council meeting, Resident #26 stated she did not recall receiving admission information during the admission process. The resident later stated she did not recall receiving a folder with signed admission documents unless her daughter may have taken it, and the emergency contact/relative stated that no admission paperwork was sent home following the admission. The Admissions Director stated she completed the admission paperwork face-to-face on a Saturday, verbally explained the documents, but did not provide physical copies because she did not have access to a copier in the field. The resident's MDS with ARD 9/6/2025 showed a BIMS score of 14, indicating the resident was cognitively intact.
Resident Privacy Breach Involving Hospice Signage
Penalty
Summary
The facility failed to protect a resident’s personal privacy by allowing identifying hospice information to be posted on the resident’s door. During observation, a sign on the door displayed the hospice provider’s name along with the resident’s first initial and last name highlighted in yellow and instructed visitors to call the hospice provider first. The resident was lying in bed and was unable to verbalize awareness of hospice services or knowledge of the sign posted on the door. Interviews confirmed the sign had been placed without authorization. The resident’s representative stated she had not requested the sign, and the hospice coordinator acknowledged the sign was posted, was clearly visible to anyone passing the room, and had not been authorized or reported to her. The DON stated she was not aware of the sign and that resident-specific health information should not be displayed. The administrator confirmed hospice had placed a sign on the door. Record review showed the resident was admitted with dementia, had a BIMS score of 03 indicating severe cognitive impairment, and was receiving hospice care under a physician’s order.
Delayed Reporting of Misappropriation Allegation
Penalty
Summary
The facility failed to implement its abuse prevention policy when it did not report and investigate an allegation of misappropriation of resident property in a timely manner for one resident. The facility policy required any employee or contracted service provider with knowledge of an allegation of misappropriation of resident property to report it immediately, and no later than 2 hours after the allegation if the events involved abuse. The policy also required the Executive Director to ensure reporting was completed timely and appropriately to the proper officials, including the State Agency within 5 working days of the incident. Resident #106, who was admitted to the facility with a diagnosis of Type 2 Diabetes Mellitus and had a BIMS score of 15 indicating cognitive intactness, reported that a CNA was seen handling her change purse and that coins were missing. During wound care, an LPN noticed quarters stuck to the resident’s back and a small red change purse tucked inside her gown; the resident stated she had been napping, awoke to a noise, and saw the CNA at her bedside with the purse open and removing quarters. The LPN immediately reported the allegation to the charge nurse, who reported it to the DON, but leadership delayed reporting because they debated the credibility of the allegation and the Administrator stated he did not initially report it because the resident did not want to make a big deal about it.
Failure to Provide Timely ADL Assistance
Penalty
Summary
The facility failed to provide assistance with activities of daily living for residents who were dependent on staff, specifically related to incontinence care and shaving. The facility policy for Activities of Daily Living stated that CNAs were to provide needed assistance to residents. Resident #109, admitted with diagnoses including aftercare following joint replacement surgery, reported that she had been left in a soiled brief since 6:00 AM and said she pushed the call light several times, but staff turned it off without returning to provide care. Her daughter confirmed the resident was not checked on or changed during the time she was present. CNA #1 later stated she had not checked or changed the resident during her shift and believed the resident had gone to the bathroom independently, but when she checked the resident, the brief was saturated and the bed was soiled, requiring a complete bed change. Resident #91, admitted with diagnoses including paraplegia, was observed with thick facial hair on the chin and neck and stated she liked to have it shaved but staff often forgot. On a later observation, the resident still had long facial hair and said she disliked it but staff forgot to shave her. CNA #2 stated female residents were supposed to be shaved on shower days, but whether Resident #91 was shaved depended on the CNA assigned. LPN #2 stated she had noticed the resident with long facial hair on consecutive days and confirmed CNAs had been instructed and in-serviced to provide shaving during bathing or shower care. The DON and Administrator both stated that residents left in urine or not receiving timely care was unacceptable and that residents dependent on staff for ADLs were expected to be treated in a dignified manner.
Failure to Implement Isolation and EBP Precautions
Penalty
Summary
The facility failed to prevent the possible spread of infection by not implementing contact isolation precautions timely for one resident and enhanced barrier precautions (EBP) when providing care for another resident. The facility’s infection control policy stated that its procedures were intended to help prevent and manage transmission of disease and infections, and its EBP policy stated that gowns and gloves are to be used during high-contact resident care activities when contact precautions do not otherwise apply. Resident #47 was admitted with a diagnosis of COVID-19 and had a BIMS score of 10, indicating moderate cognitive impairment. On observation, there was no contact isolation signage on the resident’s door on the day after admission, and the resident was in bed in the room. The following day, signage, PPE, and biohazard barrels were present in the room. RN #2 stated the resident had tested positive for COVID-19 in the hospital and confirmed the facility failed to follow infection control protocol at the time of admission by not placing the resident on isolation precautions. Resident #4 was admitted with a diagnosis of left femur fracture and had a BIMS score of 13, indicating cognitive intactness. The resident had a physician’s order for EBP related to wounds, but during observed wound care, staff washed their hands and wore gloves but did not wear gowns, and there was no EBP signage on the door. LPN #2 and CNA #4 confirmed they did not wear gowns and stated they normally looked for a sign on the door stating EBP. The DON and RN #2 stated gowns and gloves should have been used for wound care and that an EBP sign should have been placed on the door.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post daily nurse staffing information in a prominent place readily accessible to residents, staff, and visitors for 4 of 4 days of survey. During an initial tour on 9/8/25 at 10:00 AM, surveyors observed that no daily staffing information was posted throughout the building, and there was a stop sign on the entranceway door asking staff and family not to allow residents beyond the double doors into the entrance hall. On 9/9/25 at 8:00 AM and 9/10/25 at 9:00 AM, surveyors again did not observe the required daily staffing posting during walkthroughs of the facility. During an interview on 9/11/25 at 11:55 AM, an LPN stated the staffing information was usually taped on the table in the entrance hallway next to the visitor sign-in book. The LPN confirmed she failed to tape the staffing information on the table on 9/8/25, but did so on 9/9/25 through 9/11/25. She also confirmed residents did not frequent the entrance hallway and acknowledged the sign on the door indicating not to allow residents beyond that door. During a later interview, the Administrator and DON confirmed the daily staffing postings did not meet regulatory requirements because the area was not accessible to residents, and they stated residents did not frequent the entrance hall. The DON stated the Staff Development Nurse was responsible for posting the daily staffing information and ensuring it was posted where everyone could see it.
Failure to Implement Elopement Prevention Measures
Penalty
Summary
The facility failed to implement care plan interventions for a resident identified as an elopement and wandering risk. On February 8, 2025, at approximately 3:00 PM, the resident exited the facility unsupervised while wearing a wander alarm device that was found to be inoperable. The resident was out of the facility for about thirty minutes and walked approximately 0.7 miles, crossing a four-lane highway before being located by facility staff and returned to the facility. The care plan for the resident included interventions to ensure the wander guard was functioning properly daily, with the responsibility assigned to the nursing staff. However, interviews revealed that the Licensed Practical Nurse (LPN) on duty did not check the functionality of the wander guard transmitter, only verifying its placement. This oversight was a critical lapse in following the care plan, which was designed to prevent elopement and ensure the resident's safety. The resident had been admitted to the facility with diagnoses including aphasia following cerebral infarction, cognitive communication deficit, and legal blindness. The Minimum Data Set (MDS) assessment indicated severe cognitive impairment, with long and short-term memory problems and impaired decision-making skills. Despite these known risks, the failure to monitor the wander guard's functionality as per the care plan led to the resident's unsupervised exit, putting them at risk for serious harm.
Removal Plan
- Resident was assessed upon return to the facility and had no injuries, the wander guard device was found to be inoperable, and Resident was placed on one-on-one supervision.
- The facility reviewed the wandering/missing resident policy, educated staff on the wandering/missing resident policy and held a quality assurance meeting.
- Staff checked all exit doors out of the facility and all wander guards currently being utilized in the building, placing any not working on 1:1 supervision.
- A complete headcount was performed, and the door codes were changed.
- LPN #1 was notified that Resident #1 could not be accounted for, and the Director of Nursing, Executive Director, Social Services Director, Medical Director, and Regional Director of Clinical Services were notified.
- Resident was located and safely returned to the facility.
- Once Resident was back inside the center, a head-to-toe body audit was completed with no injuries noted.
- The Assistant Maintenance Director performed checks on all exterior doors and windows, along with the wander guard system.
- Resident was immediately placed on 1:1 supervision and a 24-hour door monitor was put in place at the front.
- RN #2/Unit Manager began educating staff on elopement wandering risk policy, missing resident policy, following care plans, abuse and neglect, and resident's rights.
- The Director of Social Services reassessed Resident #1's Brief Interview for Mental Status.
- Wandering risk evaluation was completed on all residents.
- Elopement binders were updated and located at both nurses' stations and up front.
- An Ad hoc QAPI was held to discuss the incident and a plan of correction.
- In-servicing began on Wandering/Missing Resident, Prevention of Abuse and Neglect, and door alarms policies.
- The system will be checked daily by maintenance staff and the devices will be checked for placement each shift and checked for functionality daily by nursing staff.
- The daily checks of the door systems and placement of the patient devices, as well as the q shift checks of functionality of the patient devices, will be monitored by DON for completion.
- Monitoring has been put in place and the findings will be evaluated by the Quality Assurance and Improvement Committee.
- All corrective actions were completed and the Immediate Jeopardy was removed.
Resident Elopement Due to Inoperable Wander Alarm Device
Penalty
Summary
The facility failed to provide adequate supervision and assessment of a wandering alarm device, which resulted in a resident, identified as an elopement and wandering risk, exiting the facility unnoticed and unsupervised. The resident was wearing a wander alarm device that was found to be inoperable. This incident occurred when the resident exited the facility and walked approximately 0.7 miles, crossing a four-lane highway, before being located by facility staff and returned to the facility. The facility's policy on elopement and wandering risk required the placement and functionality of wander monitoring system devices to be checked every shift and daily, respectively. However, the staff did not adhere to this policy, as evidenced by the failure to test the resident's wander guard transmitter on the day of the incident. The maintenance department confirmed that the wander guard system was not functioning correctly, as the transmitters worn by residents at risk for elopement were not preventing the door from opening or sounding an alarm when a transmitter was within eight feet of the front door. The resident involved in the incident had a history of cognitive impairment, as indicated by a Brief Interview for Mental Status (BIMS) score of 99, which required a staff assessment for mental status. The resident had long and short-term memory problems and severely impaired cognitive skills for daily decision-making. Despite these known risks, the facility failed to ensure the proper functioning of the wander guard system, leading to the resident's unsupervised exit from the facility.
Removal Plan
- Resident #1 was assessed upon return to the facility and had no injuries, the wander guard device was found to be inoperable, and Resident was placed on one-on-one supervision.
- The facility reviewed the wandering/missing resident policy, educated staff on the wandering/missing resident policy and held a quality assurance meeting.
- Staff checked all exit doors out of the facility and all wander guards currently being utilized in the building, placing any not working on 1:1 supervision.
- A complete headcount was performed, and the door codes were changed.
- LPN #1 was notified that Resident #1 could not be accounted for, and the appropriate personnel were notified.
- CNA #1 showed a video of a man she saw walking next to Hwy 90, leading to the retrieval of Resident #1.
- Resident #1 was returned to the facility, and a head-to-toe body audit was completed with no injuries noted.
- The Assistant Maintenance Director performed checks on all exterior doors and windows, along with the wander guard system.
- The resident was placed on 1:1 supervision, and a 24-hour door monitor was put in place at the front.
- The door monitor continued until the wander guard system was verified to function properly.
- The door keypad codes were changed.
- RN #2/Unit Manager began educating staff on elopement wandering risk policy, missing resident policy, following care plans, abuse and neglect, and resident's rights.
- The Director of Social Services reassessed Resident #1's Brief Interview for Mental Status (BIMS).
- Wandering risk evaluation completed on all residents with no newly identified wandering risk.
- Elopement binders were updated and located at both nurses' stations and up front.
- An Ad hoc QAPI meeting was held to discuss the incident and a plan of correction.
- Interviews were conducted to learn of Resident #1's path, and it was discovered that Resident #1 most likely exited the front door when a visitor entered the facility.
- The incident was taken to a quality assurance performance improvement (QAPI) meeting, and no further action was needed.
- In-servicing began on Wandering/Missing Resident, Prevention of Abuse and Neglect, and door alarms policies.
- No staff was allowed to work before receiving education.
- The system will be checked daily by maintenance staff, and the devices will be checked for placement each shift and checked for functionality daily by nursing staff.
- Monitoring has been put in place and findings will be evaluated by the Quality Assurance and Improvement Committee.
- All corrective actions were completed and the Immediate Jeopardy was removed.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide timely incontinence care for six residents, leading to skin excoriations and other issues. Resident #57 was observed in a saturated and soiled brief, resulting in redness and excoriations on the perineal area and lower buttocks. Despite being cognitively intact and requiring substantial assistance, the resident was left in this condition for extended periods, as staff preferred to use two briefs to avoid frequent changes. The Medical Director and Director of Nursing were unaware of the severity of the excoriations until later observations and interviews confirmed the issue. Resident #55 was found wearing two incontinence briefs, which is against facility policy unless specifically care planned. The resident reported that CNAs sometimes applied multiple briefs to avoid changing him during the night. This practice was confirmed by an LPN and a CNA, who admitted to not checking on the resident as required. The resident had a current diagnosis of a urinary tract infection and required total dependence for toileting hygiene. Other residents, including Resident #1, Resident #8, Resident #14, and Resident #38, also experienced delays in incontinence care. Resident #1's call light was ignored, and he was not changed despite multiple requests. Resident #8 and Resident #14 were found in double briefs or soiled conditions, with staff failing to perform regular checks. Resident #38 was left in a soiled brief for over an hour, with staff citing meal tray distribution as a reason for the delay. These incidents highlight a systemic issue with timely incontinence care and adherence to facility policies.
Inaccurate Submission of PBJ Staffing Data
Penalty
Summary
The facility failed to accurately submit direct care staffing information based on payroll data to the Centers for Medicare and Medicaid Services (CMS) for Quarter 1 of Fiscal Year 2023. The facility's policy on staffing requirements, effective since 2014, was not adhered to, resulting in the Metric of Excessively Low Weekend Staffing being triggered. The Payroll Based Journal (PBJ) data entry report for October, November, and December 2023 revealed that adjustments for salaried employees, specifically the Minimum Data Set (MDS) Staff RN, did not occur on weekends, leading to inaccurate reporting of weekend staffing levels. Interviews with the Human Resource Coordinator, an LPN, and the Administrator confirmed that the corporate office was responsible for submitting PBJ staffing data for all facilities in the corporation. The Human Resource Coordinator and the Administrator were unaware of the inaccuracies until the audit spreadsheet was reviewed. The LPN, responsible for making staffing schedules, confirmed that salaried staff had helped cover the schedule during the months in question. The Administrator acknowledged the importance of accurate PBJ reporting to CMS and recognized that it was ultimately the facility's responsibility to ensure the accuracy of the submitted data.
Failure to Transfer Low Air Loss Mattress After Room Change
Penalty
Summary
The facility failed to ensure that a pressure ulcer intervention, specifically a low air loss mattress, was continued after a room change for a resident. The resident, who had a Braden Scale score indicating a risk for pressure ulcers, had a physician's order for a low air loss mattress. However, when the resident was moved from the skilled unit to the long-term care unit, the mattress was not transferred to the new bed. This oversight was confirmed by the resident's family member, the Medical Doctor, and the Director of Nursing during interviews. The resident was admitted to the facility with a diagnosis of cervical spinal cord injury and was cognitively intact as indicated by a BIMS score of 15. The failure to transfer the low air loss mattress was acknowledged by the Medical Doctor during a care plan meeting, where he apologized to the resident's family member. The resident was later sent to the hospital due to abnormal laboratory findings and subsequently admitted to another facility after the hospital stay.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to ensure a resident's right to a dignified dining experience when staff did not provide incontinence care for a resident, resulting in odors in the resident's room and causing the meal to be unappetizing. On the specified date, a CNA entered the resident's room, acknowledged the resident's request for assistance, but did not provide the necessary care, stating she was passing out meal trays. However, no meal trays were being served at that time. The resident had to eat lunch while wearing a soiled brief, which made her uncomfortable due to the odor in the room. Further investigation revealed that the resident had been sitting in a soiled brief for over an hour and had to eat lunch in that condition. The resident reported this to two other CNAs who were unaware of her need for assistance before lunch. The resident's brief was heavily soiled, and the incontinence pad had a dark brown ring. The CNA who initially responded admitted she forgot to inform anyone about the resident's request. Interviews with the DON and the Administrator confirmed that it was unacceptable for a resident to remain in a soiled brief and that staff are expected to provide timely assistance and care.
Failure to Address Substance Use Disorder in Resident
Penalty
Summary
The facility failed to ensure the safety of a resident with a known substance use disorder (SUD) by not assessing the risk of substance use and not developing appropriate interventions. Resident #57, who is cognitively intact and uses an electric wheelchair, frequently left the facility to visit a friend and consumed alcohol during these visits. Despite the resident's history of alcohol abuse and the fact that he returned to the facility impaired, no care plan or interventions were developed to address his SUD. Interviews with the resident, his family member, and facility staff, including the Director of Nursing (DON) and the Medical Director (MD), confirmed the lack of assessment and intervention for the resident's alcohol abuse problem. The resident's family member and the MD both indicated that the resident needed help with his alcohol abuse, but the facility had not recommended any programs or behavioral health services related to SUD. The resident was admitted to the facility with diagnoses including quadriplegia and an unspecified injury at the C1 level of the cervical spinal cord. His Annual Minimum Data Set (MDS) indicated that he was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15. Despite this, the facility did not take appropriate measures to address his substance use disorder, leading to a deficiency in ensuring the resident's safety and well-being. The DON confirmed that the resident brought alcohol and tobacco products back into the facility and distributed tobacco to other residents, further highlighting the lack of appropriate interventions and supervision.
QAPI Committee Failures During Leadership Transition
Penalty
Summary
The facility's Quality Assurance and Performance Improvement (QAPI) Committee failed to sustain its program during transitions in leadership and did not maintain implemented procedures or monitor interventions put in place in April 2022. This failure was evident in two recited deficiencies related to residents' rights and wound care. Specifically, the facility did not ensure a dignified dining experience for a resident by failing to provide incontinence care, resulting in odors that made the meal unappetizing. Additionally, the facility failed to continue a Pressure Ulcer (PU) intervention involving an air mattress after a room change for another resident. A review of the facility's policy and previous survey findings revealed that these issues were previously cited in April 2022. The deficiencies included not covering a resident during incontinence/catheter care and failing to provide wound care within professional standards. The current Administrator, who was not employed at the time of the previous survey, confirmed awareness of these citations. The continued failure during two surveys indicates a pattern of the facility's inability to sustain an effective QAPI Committee.
Infection Control Deficiencies in Medication Handling and Incontinence Care
Penalty
Summary
The facility failed to prevent the possible spread of infection as evidenced by improper medication handling and incontinence care practices. During a medication administration observation, a registered nurse placed a resident's pill into her ungloved hand before transferring it to a medication cup, which was confirmed by the nurse as a break in infection control. The facility's policy explicitly states that medications should not be touched with bare hands, and this was acknowledged by both the nurse involved and the Infection Preventionist during interviews. In another instance, certified nursing assistants were observed discarding soiled linens and briefs directly onto the floor during incontinence care for two residents. The facility's policy requires soiled items to be placed in a bag immediately to maintain proper infection control. Both the CNAs involved and a licensed practical nurse confirmed that the practice of placing soiled items on the floor was against the facility's infection control procedures. The Director of Nursing was informed of the incident and confirmed that the CNA had been trained and had competency skills check-off related to incontinence care and infection control.
Failure to Develop and Implement Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement care plan interventions for three residents, leading to deficiencies in their care. Resident #55, who was admitted with diagnoses including Hemiplegia and Hemiparesis following a cerebrovascular disease, had a UTI but did not have a care plan developed for this condition despite being on antibiotics. Both the Director of Nursing (DON) and an LPN confirmed the absence of a care plan for the UTI, acknowledging that care plans should be updated with new physician orders to ensure proper care. Similarly, Resident #57, who had a history of alcohol abuse and was diagnosed with Quadriplegia, did not have a care plan addressing his Substance Use Disorder (SUD). The resident's family member and an LPN confirmed the lack of interventions or programs to assist with the SUD, despite the resident's increased alcohol consumption and need for help with substance abuse. Both residents were cognitively intact, with BIMS scores of 15, indicating they were aware of their conditions and the lack of appropriate care plans. Additionally, the facility failed to implement a care plan intervention for Resident #261, who required a low air loss mattress due to a cervical spinal cord injury. The resident was moved from the skilled unit to the long-term care (LTC) unit, but the therapeutic mattress was not transferred to the new bed. This oversight was confirmed by the DON and a family member, who attended a care plan meeting where the Medical Doctor (MD) apologized for the error. The comprehensive care plan for Resident #261 included the need for a therapeutic mattress, but this intervention was not executed, compromising the resident's care.
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 51 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 Ocean Springs
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Sunplex Sub-acute Center | 1.5 mi | ★★★★★ | 15 | 6 |
| River Chase Village | 4.5 mi | ★★★★★ | 0 | 0 |
| Greenbriar Nursing Center | 11.3 mi | ★★★★★ | 4 | 0 |
| Diversicare Of Moss Point | 11.7 mi | ★★★★★ | 12 | 0 |
| Plaza Community Living Center | 12 mi | ★★★★★ | 1 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.