Gulfport Nursing Center

Inspectors wroteBased on interviews and record reviews the facility failed to have sufficient nursing staff with the appropriate skills and competencies to provide intravenous services to two (Residents #2 and #4) of two residents sampled.

Inspectors wroteBased on record review, observation, and interview, the facility failed to ensure a comprehensive person-centered care plan was developed to include a discharge plan for one (#5) of five sampled residents. Resident #5 had no discharge plan documented in her care plan.

Inspectors wroteBased on record review and interviews, the facility failed to notify the Long-Term Care Ombudsman in writing of transfers and discharges for five residents (#48, #34, #304, #302, and #17) out of eight residents reviewed.

Inspectors wroteBased on record review and interviews, the facility failed to have eight consecutive Registered Nurse (RN) hours 7 days a week. Findings Included: Review of Payroll Based Journal (PBJ) Data for Fiscal Year (FY) Quarter 1 2025 (October 1-December 31) revealed no RN Hours were Triggered on 10/05/2024; 10/12/2024; 10/13/2024; 10/19/2024; 10/26/2024; 10/27/2024; 11/09/2024; 11/10/2024; 11/16/2024; 11/23/2024; 11/24/2024; 11/30/2024 and 12/15/2024. Review of Daily timecard reports dated 10/05/2024, 10/12/2024, 10/13/2024, 10/19/2024, 10/27/2024, 11/09/2024, 11/10/2024, 11/16/2024, 11/23/2024, 11/24/2024, 11/30/2024 and 12/15/2024 revealed no RN Hours. During an interview on 06/12/2025 at 11:58 a.m., Staff R, Staffing Coordinator, stated she is responsible for making the schedules for the RN's and Certified Nursing Assistants (CNA). She siad, It's been a while since I have had any training. [...]

Inspectors wroteBased on observations, interviews and manufacture recommendations, the facility failed to ensure two of the two washing machines' chemical levels adhered to regulations and industry standards.

Inspectors wroteBased on record review and staff interview, the facility failed to complete/update the Pre-admission Screening and Resident Reviews (PASARRs) for residents with a mental disorder and individuals with intellectual disability following qualifying mental health diagnoses for two (#39, #40) of six residents reviewed for PASARRs.

Inspectors wroteBased on observations, record review and interviews, the facility failed to provide Activities of Daily Living (ADL) transfers for one resident (#101) of fourty sampled residents related to choosing to get out from bed and to the wheelchair.

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure a contracture management program was provided for one resident (#20) of four sampled residents related to donning a hand splint/carrot splint to prevent further range of motion decline.

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to provide care and services according to professional standards of practice and facility policy, failed to prepare IV (intravenous) medications immediately before administering and failed to prime IV tubing for one resident (#301) of one resident observation of parenteral fluids administration.

Inspectors wroteBased on observations, interviews and record reviews the facility failed to develop a Post-Traumatic Stress Disorder (PTSD) care plan for one resident (#44) of two reviewed for mood and behavior.

Inspectors wroteBased on interviews and record review, the facility failed to protect the resident's right to be free from neglect related to proper use of mechanical lifts during transfers for two residents (#14 and #4) out of 21 residents dependent on mechanical lifts for transfers. The facility neglected to properly assess Resident #14 for the use of a mechanical lift and failed to educate staff to implement proper transfer methods, resulting in a major injury that occurred on 05/12/2025 resulting in Resident #14 being transferred to a higher level of care and required surgical repair of a spiral comminuted fracture of the right femur. The facility's neglect resulted in physical pain and psychosocial suffering for Resident #14. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure licensed nursing staff were knowledgeable and competent to provide care and services to include safe mechanical lift transfers for two residents (#4 and #14) out of twenty-one dependent residents sampled. This failure created a situation that resulted in a worsened condition and the likelihood for serious injury and or death to Resident #14, with potential to affect all residents who are dependent on mechanical lifts for transfers. This failure resulted in the determination of Immediate Jeopardy on 06/13/2025. The findings of Immediate Jeopardy were determined to be removed on 6/13/2025 and the severity and scope was reduced to a D after verification of removal of immediacy of harm. Findings Included: 1. On 6/10/2025 at 3:20 p.m. [...]

Inspectors wroteBased on observation, interview, and review of facility policy, the facility failed to implement an effective Quality Assurance and Performance Improvement (QAPI) program to correct previously cited deficiencies related to 1.) failing to ensure Level II Preadmission Screening and Resident Review (PASRR) was completed for three (Resident #4, Resident #5, and Resident #6) of thirteen sampled residents (F644), 2.) failing to ensure a medication error rate of less than five percent for two (Resident #7 and Resident #8) of thirteen sampled residents (F759), 3.) failing to prevent neglect related to adequate supervision to ensure safety for one (Resident #2) out of twelve identified as a high elopement risk (F600), 4.) failing to report an elopement incident for one (Resident #2) of one resident reviewed (F609), 5.) failing to thoroughly investigate an elopement incident for one (Resident #2) [...]

Inspectors wroteBased on observations, interviews and facility record review, the facility failed to maintain a clean, sanitary and homelike environment related to 1. unclean surfaces and resident equipment in two community shower rooms (first floor and second floor) of two community shower rooms, 2. a stained privacy curtain, an unclean floor and air conditioning vent as well as missing caulking in one resident room and bathroom (room [ROOM NUMBER]), and 3. broken and missing floor and wall tiles in one out of one laundry room for four days (3/27/2023, 3/28/2023, 3/29/2023, and 3/30/2023) of four days observed.

Inspectors wroteBased on observations, interviews and facility record review, the facility failed to ensure the food preparation and cooking areas were clean and sanitary related to rusted food preparation tables, walls and pipes caked with grease and food debris, a ceiling vent with chipped paint directly above the food service station and an unclean ice machine in one of one kitchen for three days (3/27/2023, 3/29/2023 and 3/30/2023) of four days observed.

Inspectors wroteBased on observations, interviews and facility record review the facility failed to ensure one of one dish washing machines was operating effectively for one day (3/27/2023) of four days observed.

Inspectors wroteBased on observation and interview the facility failed to provide a safe environment for two (First Floor Hallway and Second Floor) of two units regarding unlocked storage rooms containing potentially hazardous supplies and chemicals.

Inspectors wroteBased on record review, staff interviews, and review of the facility's policy, the facility failed to complete the Preadmission Screening and Resident Review (PASARR) Level II upon a new qualifying mental health diagnosis for one resident (#39) of three residents sampled for PASARR Level II.

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure one resident (#47) with an indwelling catheter received treatment and care in accordance with professional standards of practice related to not administering an antibiotic for five days after receiving a positive lab result for a Urinary Tract Infections (UTI) of seven residents with indwelling catheters.

Inspectors wroteBased on observation, interview and record review the facility failed to provide medications as ordered for one resident (#39) out of five residents reviewed for unnecessary medications.

Inspectors wroteBased on observation, interview and record review, the facility did not ensure that the medication error rate was below 5.00%. A total of twenty-five medications were observed, and two errors were identified for two (2) (Residents #9, 18) of five (5) residents observed. These errors constituted a medication error rate of 12 percent.

Inspectors wroteBased on observation, interview, and policy review, the facility failed to post Nursing Staffing information that included all the required elements on three of three days observed.

Inspectors wroteBased on observations, staff interviews, facility policy and record review, the facility failed to maintain the kitchen in a safe and sanitary manner as evidence by 1. Failure to ensure that staff personal items were stored away from the food preparation area, 2. Failed to ensure one of one reach-in refrigerator and one of one reach-in freezer had an inside temperature gauge to monitor for accurate temperatures, 3. Failure to ensure water was not pooling on dishware prior to lunch service, 4. Failure to ensure one of one dish machine was operating in accordance with manufacturer standards for washing and rinsing temperatures, and 5. Failure to ensure dietary staff wore gloves while handling food in the tray line.

Inspectors wroteBased on observation, interview, and record review the facility failed to develop and implement a care plan related to nutritional supplements for one resident (#63) out of 18 sampled residents.

Inspectors wroteBased on record review, interview, and policy review, the facility failed to ensure that PRN (as needed) psychotropic medications were limited to 14 days of use unless otherwise directed by the prescribing physician for one (Resident #63) of five residents sampled for unnecessary medications.