Gulfport Care Center

Inspectors wroteBased on record review, staff interviews, and facility policy review, the facility failed to develop and implement a comprehensive, person-centered care plan that included individualized interventions to ensure physician-ordered dialysis treatments were received when routine transportation was unavailable, for one (1) of three (3) residents reviewed for care planning (Resident #1).

Inspectors wroteBased on record review, interviews, and facility policy review, the facility failed to ensure a resident received physician-ordered dialysis treatment by failing to arrange alternate transportation after becoming aware the scheduled transportation provider was unavailable due to a holiday, for one (1) of three (3) residents reviewed for dialysis services (Resident #1).

Inspectors wroteBased on interview, facility policy review, and record review, the facility failed to timely report an instance of elopement involving a resident with a history of hallucinations for one (1) of four (4) residents reviewed for accidents and hazards (Resident #55). Resident #55 was observed inside the facility at approximately 4:00 AM on 5/31/25 and was found unsupervised in the facility parking lot by dietary staff at approximately 4:30 AM. Facility staff were unaware the resident had left the facility through an alarmed door, which staff failed to investigate despite hearing the audible alarm. This event was not reported to the State Agency until 6/2/25. The delay in reporting placed this resident and other residents at continued risk for exiting the facility unsupervised which increased the likelihood of serious injury, serious harm, serious impairment, or death. [...]

Inspectors wroteBased on interview, facility policy review, and record review, the facility failed to initiate an investigation timely when Resident #55, who had a history of hallucinations, exited the facility for one (1) of four (4) residents reviewed for accidents and hazards (Resident #55). Resident #55 was observed inside the facility at approximately 4:00 AM on 5/31/25 and was found unsupervised in the facility parking lot by dietary staff at approximately 4:30 AM. Facility staff were unaware the resident had left the facility through an alarmed door, which staff failed to investigate despite hearing the audible alarm. This event was not investigated by the facility until 6/2/25 in which the Administrator stated she was unaware of the elopement and believed the resident had been returned by staff immediately, indicating that no internal investigation was initiated as required. [...]

Inspectors wroteBased on observation, interview, record review, and facility policy review the facility failed to ensure supervision and implement adequate safety interventions to prevent accidents for two (2) of four (4) residents reviewed for accidents and hazards (Resident #55 and Resident #47) as evidenced by: 1) failing to monitor door alarms and failing to immediately investigate an active exit alarm to prevent Resident #55 exiting the facility unsupervised and 2) failing to ensure safe transfer techniques when staff manually lifted Resident #47 without the use of the required stand lift, resulting in the resident's foot becoming caught under the wheelchair and causing a right ankle injury. On 5/31/25, at approximately 4:00 AM, Resident #55 exited the facility through the 400 hall exit door, which caused the door to alarm. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff followed the comprehensive care plan for three (3) of twenty (20) sampled residents reviewed for care plan implementation, Resident #164, Resident #47, and Resident #7. Specifically, the facility failed to: 1) provide Percutaneous Endoscopic Gastrostomy (PEG) tube site care for Resident #164, resulting in a purulent wound, 2) failed to ensure a call light was within reach for Resident #7, and 3) failed to use a mechanical lift as directed in the care plan for Resident #47, resulting in a right ankle sprain.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure proper care and monitoring of enteral feeding and gastrostomy sites as evidenced by not providing timely physician orders, monitoring, and dressing changes for a Percutaneous Endoscopic Gastrostomy (PEG) site which resulted in an infected site with foul-smelling, purulent drainage (Resident #164) and enteral feeding equipment not labeled (Resident #6) for two (2) of two (2) residents reviewed for tube feeding and site care.

Inspectors wroteBased on observation, interview, facility policy review, and record review the facility failed to ensure a call light was within reach for one (1) of 20 sampled residents, Resident #7.

Inspectors wroteBased on observation, interview, facility policy review, and record review, the facility failed to ensure residents' rights to privacy and confidentiality were maintained, when personal care signage was posted on the resident's door for one (1) of 20 sampled residents, Resident #14.

Inspectors wroteBased on interview and record review, the facility failed to complete a Minimum Data Set (MDS) significant change in status assessment for a resident admitted to hospice services (Resident #7) for one (1) of 20 sampled residents' MDS assessments reviewed.

Inspectors wroteBased on interview, facility policy review, and record review, the facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for two (2) of 20 sampled residents reviewed for assessment accuracy (Resident #7 and Resident #5).

Inspectors wroteBased on observation, staff interview, record review, and facility policy review, the facility failed to store food in a sanitary manner to prevent the potential for foodborne illness during one (1) of three (3) kitchen observations. Specifically, expired milk and key lime juice were observed in use and/or not stored in accordance with manufacturer guidelines.

Inspectors wroteBased on interviews, record review, facility investigation, and policy review, the facility failed to treat a resident with respect and dignity during care for one (1) of four (4) residents sampled.

Inspectors wroteBased on observation, interviews, record review, and facility policy review, the facility failed to provide sufficient nursing staff resulting in residents not receiving showers and call lights not answered timely for five (5) of 18 sampled residents (Resident #25, #35, #60, #4, #65) and had the potential to affect all 72 residents residing in the facility.

Inspectors wroteBased on observation, staff interviews, and facility policy review, the facility failed to store food in accordance with professional standards for food service safety related to food items not dated with a use-by-date, food items without an identifying label, and food items opened and exposed for one (1) of three (3) kitchen observations. Findings Include: A review of the facility's policy Food Storage Labeling, revised 5/18, revealed POLICY: The facility will ensure the safety and quality of food by following good storage and labeling procedures. Procedure: 1. Labeling a. All foods in the facility will be labeled. Information included on the label: Name of the Food . Date of storage . 3. Rotations .b. Foods stored in storage units will be surveyed routinely to identify and discard foods that have passed its manufactured use-by date or expiration date . 4. [...]

Inspectors wroteBased on staff interview and Certification and Survey Provider Enhanced Reports (Casper) reporting data review, the provider failed to ensure their Payroll Based Journal (PBJ), (information of the staffing hours for the appropriate care of the residents) was accurately submitted to the Centers for Medicare and Medicaid Services (CMS) for one (1) of four (4) quarters reviewed. (4th Quarter)

Inspectors wroteBased on interviews, record reviews, and facility policy review, the facility failed to ensure residents had access to their personal fund accounts on weekends for nine (9) of 18 sampled residents with the potential of affecting 40 residents with personal funds. (Residents #2, 4, 19, 35, 37, 42, 46, 48, and 55)

Inspectors wroteBased on interviews, record review, and facility policy review, the facility failed to provide resolution to grievances related to call lights not being answered and Certified Nursing Assistants (CNAs) turning off the call light and not returning for three (3) of six (6) months of Resident Council grievance logs reviewed. Findings Include: A review of the facility's Grievances-Residents, revised 10/23, revealed, .The facility shall make prompt efforts to resolve the grievances .The Administrator and his/her designee will conduct an impartial investigation of the allegations and will discuss the findings and recommendations within five (5) work days of receiving the complaint, with the complainant . In all grievance cases, the resident and/or legal representative will be informed of the result of the investigation . [...]

Inspectors wroteBased on interviews, record review and facility policy review, the facility failed to ensure the resident rights were honored by not consistently providing residents with their choice of receiving showers for three (3) of (18) residents reviewed for choices. Resident #25, Resident #35, and Resident #60.

Inspectors wroteBased on staff interview, record review, and facility policy review, the facility failed to include the reason for resident transfers in a manner they could understand in the written notification of transfer provided to the resident and the Resident Representative (RR) for two (2) of two (2) sampled residents reviewed for hospitalization. (Resident #16 and Resident #77)

Inspectors wroteBased on staff interview, record review, and facility policy review, the facility failed to provide a resident and the Resident Representative (RR) written information at the time of a resident transfer to the hospital regarding bed hold policies for one (1) of two (2) sampled residents reviewed for hospitalization. (Resident #16) Findings Include: Review of the facility's, Bed Hold Policy revised 11/23, revealed, .2. When a resident is transferred to the hospital .a copy of the completed form (notice) is provided to the resident, specifying the duration of the bed- hold according to the state plan, and the facilities policy regarding bed-hold periods. In case of emergency transfer, notice at the time of transfer means that the family or resident representatives are provided with written notification within 24 hours of the transfer. [...]

Inspectors wroteBased on staff interview, record review, and facility policy review, the facility failed to ensure an as needed (PRN) psychotropic medication was limited to a 14-day duration without clinical rationale documentation for one (1) of five (5) residents reviewed for unnecessary medications.

Inspectors wroteBased on observation, interviews, record review, and facility policy review, the facility failed to discard insulin vials after the discard date for one (1) of three (3) medication carts reviewed.

Inspectors wroteBased on observation, staff interviews, record review, and facility policy review, the facility failed to ensure call lights were functioning for two (2) of 14 resident rooms on the 300 Hall. room [ROOM NUMBER] and room [ROOM NUMBER] Findings Include: A record review of the facility's policy Call Light/Bell, revised 01/24, revealed Purpose: To provide the resident a means of communication with staff members .To provide staff members a means of summoning assistance when they are with the resident . Procedure . 8. If the call light is defective, immediately report this information to the unit supervisor. Discuss with the charge nurse a rounding schedule to ensure that the resident's needs are met until the call light is in working order again . [...]