VICKSBURG, MS - Federal inspectors cited The Bluffs Rehabilitation and Healthcare Center for multiple violations following a complaint investigation that revealed disturbing incidents of verbal threats against residents and widespread hygiene care failures.
Staff Member Threatened Wheelchair-Bound Resident with Vehicle
The most serious violation occurred on September 8, 2024, when a certified nursing assistant threatened to run over a resident with her truck following a verbal disagreement outside the facility. The resident, who has a spinal cord injury at the thoracic level affecting T2-T6 vertebrae, was in his motorized wheelchair when the incident occurred.
According to the investigation report, CNA #5 asked the resident to dispose of trash while he was outside the facility. When he refused, telling her he "did not have to do anything for her," the aide responded by threatening to run him over with her truck. Witnesses reported that she then entered her vehicle, put it in reverse, and began backing up while the resident was positioned behind and slightly to the left of her truck.
"I ought to run down your [expletive]," CNA #3 reported hearing the aide say before witnessing her back up toward the resident, screech her tires, and leave the facility parking lot.
The resident, who is cognitively intact according to his mental status assessment, described feeling that the aide intended to hit him, though no physical contact occurred. He reported the incident the following morning to facility administration.
The facility's investigation substantiated that verbal abuse had occurred. CNA #5 was immediately suspended pending the investigation and the facility confirmed the verbal abuse finding. Federal regulations require nursing homes to protect residents from all forms of abuse, including verbal threats and intimidation.
Verbal threats in healthcare settings create serious psychological trauma, particularly for residents with disabilities who may feel especially vulnerable. When caregivers, who are in positions of trust and authority, make threatening statements, it violates the fundamental principle that residents should feel safe and secure in their living environment.
Widespread Personal Hygiene Care Failures
Inspectors documented systematic failures in basic hygiene care affecting multiple residents throughout the facility. Four residents were found with significant grooming and cleanliness issues that had persisted for extended periods.
One resident was discovered lying on urine-saturated bedding with a dried brown ring around the stained area, indicating the person had been left unchanged for an extended period. The same resident had approximately three-quarters inch of facial hair growth and appeared unkempt.
"You can tell he has not been changed in a while because of that brown ring around the outer edge," confirmed the CNA assigned to the resident's care.
Another resident was observed with fingernails measuring approximately one inch long, jagged and containing brown substance underneath. The same person had facial hair growth of about three-quarters inch and told inspectors, "I don't like these whiskers. They are very long, and they need to be cut."
A newly admitted resident reported going over two weeks without receiving a shower, shave, or having his hair brushed since admission. His fingernails were approximately half an inch long with thick brown substance under the nail beds. He told inspectors he had repeatedly requested shower care but staff would agree and then never return to provide the service.
Medical Risks of Inadequate Hygiene Care
Poor hygiene maintenance in nursing home settings creates multiple health risks for residents. Long, jagged fingernails can cause skin tears and scratches that may lead to infections, particularly dangerous for diabetic residents whose wounds heal more slowly and are prone to complications.
Prolonged contact with urine can cause skin breakdown, leading to pressure sores and urinary tract infections. The moisture creates an ideal environment for bacterial growth, while the ammonia in urine can cause chemical burns to sensitive skin.
Inadequate bathing and grooming also impacts residents' psychological well-being and dignity. Regular cleanliness is a basic human need, and failure to maintain it can lead to depression, social isolation, and diminished quality of life.
For diabetic residents, proper nail care is particularly critical. The facility's own policy requires nurses to trim diabetic residents' fingernails due to their increased risk of infection and poor healing. Long, dirty nails create entry points for bacteria that can lead to serious complications.
Facility Environment and Maintenance Issues
Beyond care failures, inspectors found environmental problems affecting residents' privacy and comfort. Multiple rooms had broken or missing window blind slats, leaving residents visible from outside the building and compromising their privacy.
The facility administrator acknowledged awareness of the broken blinds during daily rounds but admitted that while replacement blinds had been received, they had not yet been installed. The maintenance director confirmed knowledge of the issues across multiple rooms but provided no documentation of when repairs were ordered or scheduled.
These environmental deficiencies violate federal requirements that nursing homes provide a clean, comfortable, and homelike environment for residents.
Care Plan Implementation Failures
The inspection revealed that comprehensive care plans existed for residents' hygiene needs but were not being followed by staff. Care plans specifically addressed personal hygiene requirements, bathing assistance levels, and grooming needs, yet multiple residents were found in conditions that directly contradicted their documented care requirements.
For diabetic residents, care plans specifically required nail trimming and cleaning on bath days and as necessary, with nurses responsible for this care due to diabetes-related complications. Despite these written requirements, multiple diabetic residents had long, dirty fingernails that posed health risks.
The facility's MDS coordinator confirmed that when staff fail to provide care specified in comprehensive care plans, they are not implementing the resident-centered care required by federal regulations.
Systemic Issues with Shower Scheduling
The investigation revealed the facility had discontinued its shower schedule system, leaving no systematic approach to ensure residents receive regular bathing. The Director of Nurses confirmed they previously had a schedule but stopped using it because "no one was following up on it."
This lack of systematic shower scheduling contributed to residents going extended periods without bathing, including the newly admitted resident who went over two weeks without a shower despite his care plan indicating he required substantial assistance with bathing.
The absence of proper scheduling systems represents a failure of facility administration to ensure basic care standards are met consistently across all residents.
Regulatory Response and Implications
The violations identified during this complaint investigation represent failures in fundamental aspects of nursing home care - resident safety, dignity, and basic hygiene maintenance. While classified as causing "minimal harm or potential for actual harm," these violations indicate systematic problems in care delivery and staff supervision.
The verbal threat violation is particularly concerning as it involves a direct threat against a vulnerable resident by someone in a position of care and trust. Such incidents can create lasting psychological trauma and erode residents' sense of safety in their living environment.
The widespread hygiene failures suggest inadequate staffing, poor supervision, or both. When multiple residents across a facility experience similar care deficits, it indicates systemic problems rather than isolated incidents.
Federal regulations require nursing homes to maintain detailed correction plans addressing how they will resolve cited violations and prevent recurrence. The facility must demonstrate ongoing compliance through monitoring and documentation systems.
For families considering nursing home placement, these violations highlight the importance of regularly visiting residents, observing their appearance and demeanor, and advocating for proper care when deficiencies are noted.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for The Bluffs Rehabilitation and Healthcare Center from 2025-01-09 including all violations, facility responses, and corrective action plans.
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