Average — CMS composite of the measures below.
The next survey window likely opens 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 Dolphin Pointe Health Care Center during CMS and state inspections, most recent first.
Food storage and kitchen sanitation practices were deficient after surveyors observed buildup and contamination concerns in the kitchen. The ice machine chute had dark matter that wiped off, the plate warmer base had a white tacky residue, the fryer basket still held leftover fries and debris, and freezer items were left unsealed and undated. In the walk-in refrigerator, pooled water, condensation dripping onto boxed muffins, and dust buildup on fan parts were also observed; on reinspection, a larger area of dark buildup remained in the ice chute and wiped off with a rag and fingernail.
Failure to Provide Fingernail and Toenail Care: Multiple residents with ADL deficits were observed with elongated fingernails or toenails, and some had debris or abnormal nail conditions. A resident with impaired cognition and another with severe cognitive impairment had unclean, elongated fingernails, while a resident with diabetes had thick, yellow, elongated toenails and stated they had not been trimmed. Staff gave inconsistent answers about who was responsible for nail care, and the DON stated the facility had no policy for ADL nail care or diabetic podiatry frequency.
Self-Administration of Medications Not Properly Assessed or Secured: Surveyors found that residents’ rights to self-administer meds were not consistently assessed or safely implemented. One resident kept Flonase and Artificial Tears at bedside despite no secure storage available, another kept OTC eye drops on her table without a self-medication assessment or care plan focus, and a third resident’s Breo inhaler was treated as self-administered even though the required assessment did not include that medication. Staff and the DON confirmed the gaps in assessment and storage expectations.
Failure to Report and Investigate Alleged Abuse: A resident with severe cognitive impairment stated that someone had tried to hurt her, but the allegation was not documented in the chart and was not immediately reported or investigated as required. Interviews showed the LPN, ADON, and DON had inconsistent awareness of the event, and the written statements lacked key dates. The facility also did not show timely annual abuse/neglect training for all reviewed staff, including an ADON and a dietary aide.
Inaccurate documentation of ordered compression stockings led to a deficiency when a resident was repeatedly observed without the hose despite a physician’s order for daily use. The resident, who had COPD, cancer, schizophrenia, and a BIMS score indicating cognitive intactness, denied awareness of the stockings and was noted with mild ankle edema during observations. The TAR was signed as if the stockings were applied and removed as ordered, but there were no nursing notes or exception notes documenting refusal or removal, and the DON acknowledged the charting did not reflect what was actually occurring.
Food Storage and Kitchen Sanitation Deficiencies
Penalty
Summary
Food storage and kitchen sanitation practices were not maintained in accordance with professional standards during observations of the kitchen food preparation and storage areas. During an initial tour with the Certified Dietary Manager (CDM), the commercial ice machine’s ice chute cover had a 2-inch square area of wet, dark matter resembling biological growth, and condensation on the cover could drip into the ice below. The CDM wiped the matter with a paper towel-covered finger, and it easily wiped off. The heat-on-demand plate base near the tray line had a white powdery, tacky substance on the horizontal surfaces and on the bottom of the bases, which also wiped away when touched. The deep fryer basket still contained two fries from a prior meal, and food crumbs and debris were observed where the oil line met the fryer walls. Additional storage and sanitation concerns were observed in the freezer and walk-in refrigerator. Reach-in freezer #2 contained multiple boxes of frozen food, including one unsealed box with an open plastic bag of frozen omelets inside; the bag was not dated and the omelets were exposed to air. In the walk-in refrigerator, approximately 1/4 inch of pooled water was present on one side of the floor, and a pipe from the fan housing was covered in condensation and dripping onto two boxes of chocolate muffins. When the CDM removed the boxes, water poured off them and the muffins were sitting in water. The fan blades and both protective fan grilles also had a buildup of dark feathery matter resembling dust. On a later visit, the CDM requested a second inspection of the ice machine after removing and cleaning the chute cover, but a larger amount of dark buildup was observed on the vertical sides and corner of the ice chute, covering approximately 8 to 10 square inches. The CDM stated the area was stained, but the substance wiped off with a rag and scraped off with a fingernail, and photographic evidence was obtained.
Failure to Provide Fingernail and Toenail Care
Penalty
Summary
The facility failed to ensure residents who were dependent on staff for grooming and personal care received assistance with ADLs related to fingernail and toenail trimming and cleaning. Four residents reviewed had elongated nails and, in several cases, visible debris or abnormal nail conditions, despite care plans identifying ADL self-care deficits and, for some residents, diabetes or other conditions affecting care needs. Resident #76 was observed on multiple occasions with elongated fingernails on both hands and brown debris under the nails. The resident stated she liked her fingernails long and painted, but they were not observed to be painted or polished, and she stated staff had not cleaned under her nails. Her left hand was contracted, with fingers to the palm and later a hand splint in place, and the fingernails on that hand were also elongated with dark brown debris. Her care plan identified an ADL self-care performance deficit related to impaired mobility and impaired cognition, with an intervention to provide the amount of assistance or supervision needed. Resident #116 was observed with elongated fingernails on both hands, some filed and jagged. She stated she did not want them long and that no one at the facility had ever trimmed them, except once by her daughter. Her care plan identified an ADL self-care performance deficit related to left-sided hemiparesis due to CVA, with an intervention to provide the amount of assistance or supervision needed, but there were no goals or interventions related to fingernail care under the diabetes focus. Resident #67 was observed awake, dressed, and lying in bed, non-verbal and unable to answer questions, with elongated fingernails on both hands and brown debris under each nail on repeated observations. Her care plan identified an ADL self-care performance deficit related to muscle weakness and disease process, and noted that she required one staff member for personal hygiene. Resident #45 was observed with elongated toenails on both feet, including thick, yellow first toenails and other toenails longer than the toes. The resident stated the toenails really needed to be trimmed and that no one had been in to trim them. Her record showed diabetes, severe cognitive impairment, and a podiatry visit documenting nail dystrophy, tinea unguium, absent posterior tibial pulses, thickened nails, absent pedal hair growth, edema, and neuropathy, with a plan for trimming dystrophic nails and debridement of fungal nails. Interviews with CNA and nursing staff showed inconsistent understanding of who was responsible for fingernail care, with some stating CNAs could clean and trim nails unless the resident was diabetic, others stating only nurses could clip nails, and another stating CNAs should clean under nails during morning ADL care and on Sundays. The DON confirmed the facility did not have a policy regarding ADLs, including fingernail or toenail care, and was unsure how often diabetic residents should be seen by a podiatrist for toenail care.
Self-Administration of Medications Not Properly Assessed or Secured
Penalty
Summary
The facility failed to ensure residents’ rights to self-administer medications were consistently assessed and safely implemented. Surveyors found that required self-medication assessments were not completed for some medications and that medications approved for self-administration were not securely stored for three residents reviewed: one resident with a BIMS score of 15 who was cognitively intact, another resident with a BIMS score of 15 who was also cognitively intact, and a third resident with a BIMS score of 15 who was cognitively intact. One resident stated that her Flonase nasal spray and Artificial Tears had been left at her bedside for her to use herself and that staff later removed them, then returned them to her. The resident showed surveyors the medications in a cloth pouch on her bedside table and stated she had no place to lock them up. Her record showed a Self-Administration of Medication Evaluation dated 1/20/26 for Fluticasone Propionate nasal spray and Artificial Tears, and the evaluation indicated she could appropriately demonstrate secure storage of medications kept in the room. Her care plan also stated she had a physician’s order for unsupervised self-administration of those medications and that she may keep medication at bedside as ordered. A second resident had a bottle of Refresh eye drops on her bedside table and stated she used them for dry eyes, but no staff had evaluated her use of the eye drops to ensure she could instill them properly. She kept the bottle on her table. An LPN told surveyors that if a resident requests to self-medicate, staff should assess safe administration and safe storage and notify the doctor, and that safe storage meant the medications should be locked in the bedside table drawer. However, the resident’s record did not show a Self-Administration of Medication Evaluation, and her care plan did not include a focus related to self-administration of medications. A third resident had an order for unsupervised self-administration of Breo Ellipta inhaler, and staff stated she self-administered it and stored it in a locked bedside drawer. The resident said she kept the inhaler in her locked bedside table drawer because she wanted it in her room. However, her Self-Administration of Medication Evaluation dated 1/27/26 did not assess Breo Ellipta, and her care plan did not reference self-administration of that inhaler. The DON confirmed the resident had not been assessed for self-administration of Breo Ellipta and stated the facility expected self-administered medications to be stored in a locked drawer.
Failure to Report and Investigate Alleged Abuse
Penalty
Summary
The facility failed to follow its policy and procedure for reporting and investigating allegations of abuse for a resident who was observed standing in the doorway of her room and stating that someone had tried to hurt her and had come into her room. The resident had documented cognitive impairment, including a BIMS score of 2 out of 15, and records showed care plans for self-care deficits related to senile degeneration, weakness, impaired cognition, anxiety, depression, insomnia, wandering, and forgetting meals and walker use. Despite the resident’s statement, the record did not contain nursing documentation of the incident on either of the two days reviewed. During interviews, the LPN assigned to the resident stated she had not been informed of the resident’s report at the time it was made and said she would report it to management after being told by the surveyor. The ADON later stated she had been told about the incident by the LPN but did not follow up because she was told the resident did not remember making the statement. She acknowledged the resident’s memory problems and severe cognitive impairment and stated she should have investigated further and reported it to the DON. The DON stated she was unaware of the allegation until the survey interview and said she should have been told immediately so she could report it to the administrator and begin the investigation. When the DON reviewed the staff statements, the statements from the dietary aide, the LPN, and the ADON did not include the date of the incident or the dates staff were notified. The dietary aide stated she saw the resident but did not hear the comment and escorted her back to bed, and the LPN stated she went to the resident after being informed by the surveyor and reported to the ADON. The ADON stated the LPN told her the resident made the statement and that the resident did not recall it. The facility policy required all allegations of mistreatment, abuse, neglect, injuries of unknown origin, and misappropriation of resident property to be reported immediately and investigated by the Administrator, Risk Manager, or designee, and required annual training on abuse, neglect, and related topics. Review of staff files showed the ADON and a dietary aide had abuse and neglect training, but the dietary aide’s annual training was not completed until after the date of hire review period, and the facility did not provide additional requested training documents before survey exit.
Inaccurate Documentation of Ordered Compression Stockings
Penalty
Summary
The facility failed to ensure that Resident #155’s medical record accurately reflected her ordered use of compression stockings. The resident was observed on multiple occasions barefoot or without socks or stockings, including while in bed and while sitting on the side of her bed, and mild edema was noted to her ankles during these observations. She also stated she did not like to wear shoes and denied awareness of any compression stockings, despite having a physician’s order for knee-high compression hose to be worn in the morning and removed in the afternoon/evening for prevention. Record review showed the resident was admitted with diagnoses including COPD, cancer, schizophrenia, and medically complex conditions. Her MDS assessment reflected a BIMS score of 13, indicating she was cognitively intact. A psychiatric progress note described her as pleasant and conversant, with fair short-term memory, normal long-term memory, logical thought processes, and intact associations. The practitioner also documented that she was compliant with medical care and treatment. The physician’s order for compression stockings was documented on the TAR with separate lines for day shift and evening shift, and nursing staff signed the stockings as on and off on multiple consecutive days. However, there were no corresponding nursing notes or exception notes showing that the resident refused or removed the stockings, and no documentation that non-compliance was reported to the prescribing physician. During interview, an RN stated the resident wore the stockings but had asked to have them removed, while a CNA said he had not recently seen her wearing them. The DON acknowledged that nurses were signing the TAR as though the stockings were applied as ordered instead of documenting refusals or removal.
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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.
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How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| First Coast Health And Rehabilitation Center | 0.6 mi | ★★★★★ | 12 | 0 |
| Fountains Rehabilitation At Mill Cove | 2.3 mi | ★★★★★ | 23 | 0 |
| University Crossing | 2.8 mi | ★★★★★ | 0 | 0 |
| Vivo Healthcare University | 3.1 mi | ★★★★★ | 0 | 0 |
| Riverwood Center | 3.9 mi | ★★★★★ | 0 | 0 |
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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.