Vicksburg Nursing Facility Cited for Personal Hygiene Failures and Inadequate Resident Care
VICKSBURG, MS - A January 2025 inspection at The Bluffs Rehabilitation and Healthcare Center revealed systematic failures in basic resident care, with multiple residents found with overgrown nails, unkempt facial hair, and inadequate bathing assistance despite facility policies requiring daily personal hygiene services.
Systematic Personal Hygiene Deficiencies Documented
Federal inspectors documented widespread personal care violations affecting multiple residents at the 255-bed facility. The most concerning findings involved residents who had not received basic grooming services for extended periods, despite care plans explicitly requiring staff assistance with these daily activities.
One resident with diabetes was found with fingernails measuring approximately one inch long and jagged edges, with brown substances accumulated underneath. The resident also had facial hair growth of about three-quarters of an inch on her chin. During the inspection, the resident stated, "I don't like these whiskers. They are very long, and they need to be cut," and expressed that "it's been a while since I've had my fingernails cut, and I would like them cleaned and trimmed."
The facility's Licensed Practical Nurse acknowledged during interviews that she had last trimmed this resident's fingernails about a month prior, stating, "We just do nail care when we notice that it needs to be done. I take full responsibility for not doing her nail care." The nurse confirmed there was no established schedule or reminder system in the documentation system for nail care services.
Another resident was discovered lying in bed on sheets saturated with urine that extended approximately eight inches from the resident's body, with a brown ring around the outer edges indicating the urine had been present for an extended period. This same resident had approximately three-quarters of an inch of facial hair growth. A Certified Nursing Assistant confirmed the observations, stating the urine "looked like the night shift did not change him."
Risks Associated with Inadequate Personal Care
Proper personal hygiene in nursing facilities serves multiple critical functions beyond basic comfort and dignity. For residents with diabetes, maintaining trimmed and clean fingernails is particularly important because the condition affects blood circulation and immune system function, making individuals more susceptible to infections. Long, jagged nails can cause skin tears through scratching, and any break in the skin can become a serious infection risk for diabetic patients, potentially leading to complications such as cellulitis or more severe systemic infections.
The Director of Nurses acknowledged during the inspection that with fingernails "long and jagged, she could scratch herself and cause skin concerns." This recognition demonstrates facility awareness of the risks, making the failure to provide care more concerning from a quality assurance perspective.
Prolonged contact with urine creates multiple health hazards. Urine contains urea, which bacteria convert to ammonia, creating an alkaline environment that breaks down the skin's protective barrier. This moisture-related damage, known as incontinence-associated dermatitis, causes skin breakdown that can progress to pressure injuries. The brown discoloration observed around the urine stain typically indicates prolonged exposure, suggesting the resident remained unchanged for multiple hours.
Extended periods without bathing compound these risks. The skin's natural barrier function depends on appropriate cleansing to remove bacteria, dead skin cells, and bodily secretions. When residents require assistance with bathing and don't receive it, bacterial colonization increases, raising infection risks particularly in skin folds and areas with existing wounds.
Absence of Bathing Schedules and Accountability Systems
The inspection revealed the facility operated without a formal bathing schedule, leaving decisions about when residents received showers to staff discretion. One recently admitted resident reported being at the facility for over two weeks without receiving a shower, shave, or having his hair brushed, despite requesting showers multiple times. The resident stated staff would acknowledge the request by saying "ok" but would not return to provide the service.
The shower team Certified Nursing Assistant confirmed during interviews that "the facility did not have a set shower schedule for the residents" and that showers were documented only after they occurred, with no advance planning or tracking system to ensure residents received regular bathing assistance.
The Director of Nurses acknowledged this systematic gap, stating, "The facility had one in place for a while, but no one was following up on it, so it was stopped." She confirmed awareness that "there was a problem with residents not receiving showers" but admitted "she should have put something in place before now."
This absence of systematic scheduling violates fundamental principles of care management in healthcare facilities. Without scheduled services and accountability mechanisms, care becomes dependent on individual staff memory and initiative rather than systematic processes designed to ensure consistent service delivery. This represents a failure at the administrative and quality assurance level, not merely individual staff performance issues.
Care Plan Implementation Failures
Beyond the absence of bathing schedules, inspectors identified failures to implement existing individualized care plans that specifically outlined personal hygiene needs and assistance levels required for each resident. These comprehensive care plans detailed whether residents needed "total dependence on one staff" or "substantial/maximal assistance" with bathing and personal hygiene, yet observations revealed staff were not following these documented requirements.
One resident's baseline care plan, developed within 48 hours of admission as required by regulations, indicated the resident preferred showers and required partial to moderate assistance with bathing and setup assistance with personal hygiene. Despite these documented preferences and needs, the resident reported not receiving a shower during the initial weeks of residence.
The MDS Coordinator confirmed during interviews that "if staff did not shower the resident, they did not implement his care plan for his preferences" and "if staff did not assist the resident with bathing and personal hygiene needs, staff did not implement his care plan related to self-care performance." She emphasized that "the purpose of any type of care plan is to direct resident specific care required to meet their needs."
This disconnect between documented care requirements and actual service delivery indicates systematic failures in care plan implementation monitoring and staff accountability for following individualized resident care instructions.
Infection Control Protocol Violations
Inspectors also documented infection control violations during wound care procedures. A Registered Nurse was observed providing treatment for a Stage 4 sacral pressure ulcer without changing gloves or washing hands between cleaning the wound (a contaminated procedure) and applying clean ointment and dressing (a sterile procedure).
Proper infection control during wound care requires distinct separation between contaminated and clean procedures. When staff handle soiled dressings or clean wound beds of drainage and debris, gloves become contaminated with bacteria. Applying clean medications or dressings with those same contaminated gloves can introduce bacteria directly into the wound bed, potentially causing wound infections that delay healing, cause pain, and in severe cases can lead to systemic infections requiring hospitalization.
The nurse acknowledged not performing proper hand hygiene between these steps, and the Director of Nurses confirmed "proper hand hygiene was not performed" and that "not doing so is an infection control issue and could delay healing."
Staffing and Administrative Compliance Issues
The inspection identified additional systematic compliance concerns beyond direct care delivery. The facility failed to maintain required Registered Nurse coverage for eight consecutive hours on December 25, 2024. The Director of Nurses acknowledged the scheduled RN had previously requested the day off, but she failed to arrange coverage, stating she was "not coming in to cover someone else's responsibility and miss my family."
Federal regulations require RN coverage specifically to provide supervision for complex situations, handle emergencies, and manage intravenous medication administration. While no incidents occurred on the day in question, the absence of required supervisory nursing staff represents a compliance violation and potential safety risk.
The facility also failed to provide required written notifications to residents or their representatives when transferring residents to hospitals for three residents reviewed. These notifications inform residents or families about transfer reasons and bed-hold policies, allowing them to make informed decisions about maintaining their facility placement. The Social Services Director stated she "did not realize that she needed to provide the residents or resident representative this notification" for hospital transfers.
Additional Issues Identified
Inspectors documented broken or missing window blind slats in multiple resident rooms (Rooms 203, 505, 601, and 607), compromising resident privacy as rooms were visible from outside. The Administrator acknowledged awareness of the issue through daily rounds but admitted replacement blinds had been received but not installed, with no documentation of maintenance requests or completion timelines.
The facility also submitted inaccurate staffing data to the federal Payroll-Based Journal system for the fourth quarter of 2024, with weekend staffing figures flagged as "excessively low." Administrators attributed this to employees failing to clock out and in for weekend meal periods, but this affected the accuracy of publicly reported staffing levels used by families and regulators to assess facility resources.
Finally, inspectors found inaccurate MDS assessment coding for one resident regarding anticoagulant medication administration, with the assessment indicating seven days of anticoagulant therapy during a period when medication records showed the resident received no such medications.
The systematic nature of these violations—affecting personal care, infection control, administrative compliance, and data accuracy—indicates quality assurance failures requiring comprehensive corrective action across multiple operational areas at The Bluffs Rehabilitation and Healthcare Center.
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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