Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Gulf Coast Village during CMS and state inspections, most recent first.
Failure to Investigate and Document a Resident Fall: A resident with ataxia, vascular parkinsonism, dementia, and severe cognitive impairment was observed with both knees on the floor mat beside the bed and later had bruising to the eye and a leg abrasion. OT staff and an RN described the resident slipping off the bed, but no incident report was completed at the time and the fall care plan was not updated. A later fall incident report documented the resident found on the floor, and the DON stated the event should have been treated as a fall.
Arbitration agreement language required use of a named lawyers association and allowed the facility to select an alternate arbitration service if that group could not serve, while venue was also selected by the facility. Three residents who signed the agreement said they did not remember it being explained, did not know what arbitration was, or did not know if they had signed a contract. The ADON/Admissions staff and Administrator stated they were unsure what would happen if a resident declined the listed arbitrator or found the venue inconvenient.
Care plan failed to include anticoagulant therapy for a resident with intact cognition and multiple diagnoses, including post-joint replacement care, weakness, unsteadiness, and adjustment disorder. The MDS noted anticoagulant use, the MAR showed an order for Eliquis, and both an RN and the DON confirmed the care plan did not reflect the anticoagulant.
Improper mechanical lift use led to a resident bruise during transfer. A resident with ataxic gait, repeated falls, and intact cognition required a lift and 2-person assist, but staff reportedly left her hanging in the sling when a battery issue occurred and later placed the sling directly under the axilla without properly securing the waist belt. The resident reported pain and discomfort, and the ADON observed the sling and positioning were not done correctly during a sit-to-stand transfer.
Food Storage and Sanitation Deficiencies: Dietary staff were observed preparing meals without hair restraints, and staff from the Independent Living side crossed into the nursing home kitchen during meal prep without hair restraint. Surveyors also found undated opened food items in the reach-in refrigerator, a dusty eye wash sink with dead bugs, a dirty walk-in freezer with uncovered fish stored on the floor, non-food items stored in the Bistro pantry, a heavily soiled cabinet under the coffee maker, flying insects in two dining areas, and a rusty, dusty ice machine spout with white residue.
Failure to Notify Ombudsman of Resident Discharges: The facility did not follow its policy requiring Social Service or designee to notify the LTC Ombudsman of facility-initiated discharges and hospital transfers. Review of the discharge log showed numerous resident discharges, including transfers to acute care, ALF, SNF, and home, but the DON could not locate documentation of any Ombudsman notifications. The State LTC Ombudsman office confirmed it had not received discharge or transfer notifications from the facility since the stated date.
Incomplete documentation affected three residents. One resident had an emesis episode, was evaluated by an APRN, and had labs ordered, but the chart lacked nursing notes for the change in condition and follow-up; the resident later died. A second resident who was dependent for all ADLs had missing bath/shower documentation across multiple scheduled days. A third resident with a pubis fracture and bathing assistance needs had CNA entries showing refusals and not-applicable codes, but the nursing record did not document the refusals or reasons.
QAPI failed to show effective systemic review of repeated kitchen sanitation problems and an increase in falls. Surveyors observed flying insects during meals, dietary staff without hair restraints, unlabeled and undated food, uncovered fish on a soiled freezer floor, and a dirty, rusted ice machine. The Administrator had no documentation of sustained interventions or audits. The facility also had rising fall counts, inconsistent QAPI reporting, and no documented root-cause analysis or targeted prevention strategies.
Pest Control Program Not Effective: Multiple small flying insects were observed in the memory care dining area and the Bistro during lunch, with family members swatting at them. The pest control vendor’s reports repeatedly noted a dry drain trap allowing pest entry, instructions to keep garbage cans clean, and a recommendation for a fly light. Flying insects were later seen on an uncovered tray of Danishes, and the DON stated she was new to the facility and had not previously heard about the fruit flies, despite family members raising the issue at a meeting the night before.
A resident with dementia and mood disorders had vomiting after a recent procedure, and an APRN ordered CBC, CMP, and Zofran for nausea. The record did not show that the resident's RP/POA was notified of the change in condition, the lab orders, or the new medication, and the RP later said the facility never informed her of the decline or treatment changes. The DON stated there was no documentation from nursing about what happened and that a change in condition note and family notification should have occurred.
Incomplete ABNs for two residents receiving skilled services. One resident’s NOMNC and SNF ABN contained conflicting coverage information, no estimated cost, and no choice selected, while another resident’s SNF ABN listed room, board, and therapy costs but left the decision section blank. The Administrator acknowledged the forms were not filled out correctly.
A resident with legal blindness, schizoaffective disorder, and major depressive disorder was not provided activities that matched her stated interests and needs. Although her care plan and recreation records reflected a preference for music, socialization, and nail care, she was repeatedly observed in bed with no music or TV on, and she said she missed a live music program because no one assisted her. Activity staff and the AD said they spent time with her and offered sensory and nail care, but the record did not document the participation they described.
Unsecured medications and a controlled substance were found in several areas of the facility. A resident who was not approved for bedside meds had two medication cups with pills left on the tray table, treatment carts were observed unlocked, medicated creams and a loose pill were left on top of a cart, and creams were found on another resident’s nightstand. Staff also found a broken seal on lorazepam with the tablet accessible behind the foil, and the DON said it should not have been stored that way.
Surveyors identified deficiencies in food service sanitation, including a visibly soiled ice machine with black biofilm, improper storage of the ice scooper, and kitchen staff working without hair restraints. Cleaning logs for the ice machine were outdated and lacked recent documentation, and staff could not verify that required cleaning had occurred.
A resident with moderate cognitive impairment and incontinence was subjected to verbal and mental abuse by a CNA from a staffing agency, who became upset and yelled at the resident after episodes of diarrhea, causing the resident to feel humiliated and cry. Staff observations and interviews confirmed the resident's emotional distress, and the CNA's behavior was inconsistent with facility policy on abuse.
A resident with severe cognitive impairment and dependence on staff for ADLs was found with excessively long, untrimmed fingernails containing debris. Despite facility policy and care plans requiring nail care on shower days, there was no documentation or evidence that this grooming task was performed over a 30-day period. Staff interviews confirmed a lack of clarity and follow-through regarding responsibility for nail care.
A resident's family member reported symptoms and requested lab work due to a history of hypokalemia. An APRN received a text from staff and issued a stat order for CBC and CMP, but the order was not documented or carried out, and no lab work was performed. The resident later experienced an acute change in condition and was transferred to the hospital after cardiac arrest. The DON confirmed the order was missed and there was no policy for handling texted orders.
The facility failed to ensure dietary staff were trained to test the sanitizing solution in the low-temperature dishwasher, risking foodborne illnesses. The high-temp dishwasher was converted to low-temp, but staff were unaware of testing requirements, and test strips were expired. Additionally, food storage was unsanitary, with insects and improper storage observed. The contracted company serviced the dishwasher, but it had not been tested since April due to lack of staff knowledge.
The facility failed to address grievances from resident council meetings, with no documentation or follow-up on complaints about staffing and call light response times. Residents and families reported long wait times for assistance, particularly on weekends and night shifts, with one resident left in soiled conditions due to staffing shortages. The facility's grievance resolution process was not followed, as confirmed by staff interviews.
The facility failed to provide ongoing resident-centered activities in the TCU, as required by its policy. Two residents reported a lack of suitable activities and engagement, with one expressing a desire for group activities and another noting the absence of an activity director. Observations confirmed the absence of organized activities and staff, and interviews with staff and family members supported these findings.
A facility failed to update the Level I PASRR for a resident with severe mental health issues, using an outdated PASRR from 2018 that did not reflect the resident's current diagnoses of Psychotic Disorder with delusions and Schizoaffective Disorder. The resident required regular clinical evaluations due to multiple psychiatric conditions, but the PASRR was not updated to ensure appropriate specialized treatments.
A resident identified as a high fall risk was administered multiple psychotropic medications, leading to seven falls within a short period. Despite a care plan intervention for a drug regimen review, no documentation of such a review was found. Staff interviews confirmed the lack of documentation and the resident's multiple falls.
A facility failed to justify the continued use of an indwelling urinary catheter for a resident admitted from a hospital. Despite the facility's policy requiring assessment for catheter removal, there was no documentation of such an assessment or a urology referral. The resident, with a diagnosis of neurogenic bladder, reported never needing a catheter before. Staff interviews revealed no voiding trial or consultation was conducted, although the catheter was eventually removed successfully.
A facility failed to obtain physician's orders for the care and management of a PICC line for a resident receiving IV antibiotics. The resident's PICC dressing was heavily soiled and had not been changed since the date marked on it. Staff confirmed the absence of physician's orders, and the DON acknowledged the issue was identified during admission but not addressed.
The facility failed to secure medications as required, with five pills and a Lidoderm patch left unattended on a resident's bedside table, and four large pharmacy medication bags left unattended at the nurses' desk, accessible to staff, residents, and visitors.
The facility did not submit required staffing data to the CMS PBJ system for the third quarter of 2024, resulting in deficiencies such as a one-star rating, low weekend staffing, no RN hours, and lack of 24-hour licensed nursing staff coverage. Despite having supportive documentation, the data upload was unsuccessful, and the Administrator could not explain the issue.
A resident with a full code status was found unresponsive without a pulse or respiration. Despite the resident's clear wishes for life-saving measures, CPR was not initiated promptly. Three LPNs on duty delayed calling EMS and starting CPR for 51 minutes while searching for a non-existent DNR order. This delay in confirming code status and initiating CPR led to a critical lapse in providing timely medical intervention, resulting in the resident being pronounced dead by EMS. The incident highlighted a breakdown in communication and process among the staff, leading to a failure to follow established policies and procedures regarding advance directives.
Facility staff delayed CPR for an unresponsive resident without a pulse or respirations for 51 minutes while searching for a non-existent DNR order. Despite the facility's policy requiring immediate CPR in the absence of a DNR order, staff, including RNs and LPNs, experienced confusion and communication breakdowns. Surveillance footage revealed delays and uncertainty in determining the resident's code status. The incident highlighted deficiencies in staff training, communication, and adherence to emergency protocols.
Nursing staff faced challenges in initiating CPR for a resident in cardiac and respiratory arrest due to confusion over the resident's code status. Three staff members, including two RNs and one LPN, delayed CPR and EMS notification for 51 minutes while searching for a non-existent Do Not Resuscitate (DNR) order. The delay occurred as RN Staff A, who found the resident unresponsive, struggled to locate the DNR order and drew her own conclusion. LPN Staff B identified the resident as full code and initiated CPR, while RN Staff C assisted but had not participated in code blue drills.
A facility's administration did not ensure staff were adequately trained and knowledgeable in policies regarding residents' rights to advance directives, including CPR. A resident with full code status was found unresponsive, and CPR was delayed by 51 minutes due to communication breakdown and lack of clear protocols. The resident's code status was known but not documented in the baseline care plan, leading to confusion. The RN Staff Educator and DON acknowledged gaps in staff competency verification and documentation, contributing to the delay in initiating life-saving measures.
Failure to Investigate and Document a Resident Fall
Penalty
Summary
The facility failed to investigate a fall and failed to implement individualized interventions to reduce the risk of additional falls and fall-related injuries for one resident. The facility’s Fall Management Program required fall risk assessment, individualized fall precautions, post-fall documentation, a post-fall huddle, root cause analysis, and interdisciplinary review of accident/incidents. The resident had diagnoses including ataxia, vascular parkinsonism, dysphagia, pneumonia, moderate protein-calorie malnutrition, unspecified dementia, adjustment disorder with mixed anxiety and depressed mood, and thyroid disorder. The MDS showed the resident required supervision or touching assistance with bed mobility, transfers, and toileting-related care, and had severely impaired cognition. On the morning of the event, OT staff observed the resident with both legs outside the bed and both knees resting on the floor mat next to the bed. The resident was assisted back to bed, and bruising was later noted around the right eye along with a minor abrasion to the right lower leg. RN staff stated the resident was slipping off the bed and that the legs were off the bed, but no incident report was completed at that time. The fall care plan was not updated after this event, and the DON stated that no new fall interventions were put into place because the fall was not known to management at the time. A later fall incident report documented that the resident was found on the floor on the floor mats and was confused and unable to explain how it occurred. The fall care plan was not updated until several days later, when a perimeter defining mattress was added. During interviews, the DON stated that a fall includes a change in plane and that two knees on the floor next to the bed constituted a fall. The DON also stated that the nurse should have completed an incident report and verified that no new interventions were implemented after the initial event.
Arbitration Agreement Lacked Neutral Arbitrator Choice and Convenient Venue
Penalty
Summary
The facility failed to ensure that the arbitration agreement signed by 3 of 3 residents reviewed provided for the selection of a neutral arbitrator agreed upon by both parties and a venue convenient to both parties when a dispute arose. Review of the facility’s arbitration agreement showed that disputes would be administered by a named lawyers association under its rules, and if that association was unable or unwilling to serve, the facility would select an alternative neutral arbitration service within 30 days. The agreement also stated that arbitration would be conducted at a site selected by the facility, either at the facility or somewhere within a reasonable distance of the facility that was convenient for both the facility and the resident. Resident #111 had an admission date of 4/29/26 and signed the arbitration agreement on 5/1/26; during an interview on 5/5/26, she verified her signature but said she did not remember signing the contract or anyone discussing the arbitration agreement with her, and she asked whether it was for discharge from the facility. Resident #115, admitted on 4/30/26, also signed the agreement on 5/1/26 and stated on 5/5/26 that he did not remember anyone discussing arbitration with him, did not know what it was, and did not remember signing the contract. Resident #107, admitted on 4/29/26, signed the agreement on 5/1/26 and stated on 5/6/26 that she did not know if she signed a contract, did not know what an arbitration agreement was, and said no one had explained it to her. The Admissions Director stated that she and her assistant handled contract signing and explained that the arbitration agreement was optional, but she did not know what would happen if a resident declined the listed arbitration company or if the proposed location was not convenient. The Administrator stated the agreement was specific to using the listed lawyers association as the arbitrator, that she was not sure what would happen if the resident did not agree to that choice, and that the agreement offered the resident no choice.
Care Plan Did Not Address Anticoagulant Therapy
Penalty
Summary
The facility failed to develop and implement an individualized care plan for Resident #104 to address anticoagulant use. The resident was admitted on 4/16/2026 with diagnoses including primary osteoarthritis of the left knee, aftercare following joint replacement surgery, unspecified psychophysiologic insomnia, unsteadiness on feet, generalized muscle weakness, anemia in other chronic diseases, and adjustment disorder with mixed anxiety and depressed mood. The 5-Day MDS showed a BIMS score of 15 out of 15, indicating intact cognition, and also noted that the resident was prescribed an anticoagulant. Review of the medication record showed a physician's order dated 4/17/2026 for Eliquis 2.5 mg by mouth twice daily for 30 days as an anticoagulant. The resident's care plan, initiated on 4/18/26, did not reflect the use of the anticoagulant. During interview on 5/6/2026, RN Staff A confirmed that anticoagulant use was not included in the care plan and stated it should be listed when a resident is on anticoagulants. On 5/7/2026, the DON also stated that anticoagulation therapy should be reflected on the care plan.
Improper Mechanical Lift Transfer Resulted in Resident Bruising
Penalty
Summary
The facility failed to ensure a safe mechanical lift transfer for a resident with ataxic gait, repeated falls, and intact cognition who required two-person assistance and a lift for toilet or bath transfers. The resident’s care plan directed staff to use a lift and, when needed, padding between the resident and the sling to prevent friction to the skin and underarms. Facility policies stated residents must be free from accident hazards and that staff receive training on mechanical lift safety, sling selection, inspection, and maintenance. Record review and interviews showed the resident sustained a bruise to the left upper extremity after a lift transfer. The resident reported that a CNA used a mechanical lift, the battery went out, and she was left hanging in the sling for 5 to 10 minutes while the CNA left to get a new battery. The resident said she was uncomfortable, in pain, and developed a bruise on her left arm from the sling. Observation during the interview showed a black and yellow discoloration on the upper left outer arm, and the incident review documented a bruise above the left antecubital area. The facility’s investigation and staff interviews also described improper lift use during transfers. An ADON observed CNAs conduct a sit-to-stand transfer in which the resident was abruptly moved, her feet were not properly positioned until prompted, the sling was placed directly under the axilla area, the shirt was wrinkled and bunched up, and the waist stabilizing belt was not connected around the resident. The resident and the Director of Rehab reported that staff sometimes did not use the sit-to-stand lift correctly and that it pinched the resident’s skin. Staff accounts conflicted about which CNA was involved and whether a battery issue occurred, and the Administrator stated there was no documentation that the resident refused the safety belt before the incident.
Food Storage and Sanitation Deficiencies
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Review of the facility policy stated that food must be stored in clean, dry areas free from contaminants, at appropriate temperatures, and in a manner that prevents contamination or cross contamination, with refrigerated foods covered, labeled, and dated and frozen foods kept clean and off the floor. During the initial kitchen tour with the CDM, dietary staff were observed preparing meals without hair restraints, and the CDM stated the kitchen was shared with the Independent Living Facility and that Independent Living dietary staff were crossing over to the nursing home side during meal preparation without hair restraint. Additional observations showed an opened container of three bean salad and an opened container of pudding stored undated in the reach-in refrigerator. The yellow emergency eye wash sink was dusty and contained several small deceased bugs. The walk-in freezer floor was dirty with a large accumulation of black and brown dirt, a large amount of frozen white chunky substance was on the floor under a shelf, and a clear plastic bin of fish was stored uncovered on the floor. In the Bistro pantry, boxes of children's shoes containing child's pajamas were stored with food items, and the cabinet under the coffee maker in the Bistro dining area was heavily soiled with brown and black dirt. Multiple small flying insects were observed in the memory care dining area and the Bistro dining area during lunch service, and the TCU ice machine spout, inner dispensing spout, ice tray, and surrounding area were rusty and dusty with white residue.
Failure to Notify Ombudsman of Resident Discharges
Penalty
Summary
The facility failed to implement its policy and procedure requiring notification to the office of the Long-Term Care Ombudsman for residents’ discharges. The facility’s policy, Admission, Transfer, Discharge, created in 12/2019, stated that Social Service or designee should provide the ombudsman with information on all involuntary discharges, facility-initiated discharges, including hospital transfers, according to the format and frequency requested by the specific ombudsman office. Review of the Admission/Discharge log from 7/8/25 through 11/20/25 showed 244 discharges, including 65 transfers to an acute care hospital, 20 discharges to an Assisted Living Facility, 120 discharges home, and 5 transfers to a skilled nursing facility. A sample review included Resident #112, who was admitted and later discharged home, and Resident #24, who was admitted and later discharged to an Assisted Living Facility on 11/17/25. On 11/20/25, the DON stated she could not locate documentation that the Ombudsman office had been notified of the discharges. Later that day, a representative from the State Long Term Care Ombudsman office reported by email that the facility had not notified the office of any discharges or transfers to the hospital since 7/7/25, and the DON confirmed the Administrator had verified that no resident discharge or transfer notifications had been sent since that date.
Incomplete Documentation of Change in Condition and ADLs
Penalty
Summary
The facility failed to ensure clinical records were completely and accurately documented for 3 residents reviewed. For one resident with diverticulosis, prior GI hemorrhage, a sacral pressure ulcer, dementia, and bipolar disorder, an APRN evaluated the resident after one episode of emesis and ordered Zofran and lab work. The record did not contain nursing documentation of the change in condition or follow-up assessments. The resident was later found deceased, and an alert note documented DNR status, but no vital signs were recorded. The DON verified there was no nursing documentation about what happened to the resident and stated a Change in Condition form should have been completed and the family should have been notified. For a second resident with cerebral palsy, congenital hydrocephalus, and osteoporosis, the resident was dependent on staff for all ADLs and had a care plan calling for bathing or showering 2-3 times per week in the morning. CNA documentation for October and November showed bathing was scheduled for specific nights, but there was no documentation that the resident received a bath or shower on multiple scheduled dates in October, and there was no bathing or shower documentation for November. The DON verified the missing bathing documentation and stated there was no CNA documentation for November because of a system glitch being investigated. For a third resident admitted with a pubis fracture and requiring substantial to maximal assistance with bathing, the care plan called for physical help into the bath or shower and one-person assist for bathing. CNA documentation for November showed scheduled bathing days, but also showed refusals on several dates and code 97 entries marked not applicable on other dates. There was no nursing documentation showing the resident refused a bath or shower on two of those dates. The DON stated that if a resident refuses bathing, the CNA should notify the nurse and the nurse should document the reason for refusal, and she verified the missing documentation and could not explain why bathing was marked not applicable.
QAPI Failed to Address Repeated Kitchen Sanitation Deficiencies and Increasing Falls
Penalty
Summary
The facility failed to develop and implement systemic corrective actions related to repeated quality of care deficiencies involving falls and failed to identify and address an unresolved quality deficiency related to food safety and sanitation in the kitchen. The facility’s QAPI policy stated that the program was intended to ensure care delivery systems function consistently, prevent deviation from care processes, identify issues and opportunities for improvement, and develop and implement plans to correct identified areas. Survey history showed repeated kitchen sanitation deficiencies during prior recertification surveys, including improper food storage, bio growth on refrigeration equipment, a visibly soiled ice machine, improper ice scoop storage, inadequate sanitizer levels, and dietary staff not wearing proper hair restraints. During the most recent survey, flying insects were observed during meals in 2 of 3 dining areas, dietary staff were again observed without hair restraints during meal preparation, and unlabeled and undated food was stored in the refrigerator. Uncovered fish was observed on the heavily soiled floor of the walk-in freezer, and the ice machine in the Transitional Care Unit had a white residue on the outer spout, rust on the inner spout, and a soiled and rusty ice tray. The Administrator stated the facility was working on the fruit flies but had no documentation of interventions or progress toward resolution. She also said the CDM was doing weekly audits, but the last audit provided was dated 11/7/25 and only showed check marks for hairnet, ice machine, and ice scoop checks. The Administrator had no documentation of her own audits and offered no explanation for the unsanitary conditions. The facility also had an ongoing increase in falls that was discussed in QAPI, but the documentation did not show accurate trending or systemic analysis. Fall incidents increased across the months reviewed, and the number of falls reported in QAPI minutes did not match the facility incident lists for August and September 2025. QAPI minutes noted a performance improvement plan for falls and later stated that QAPI would review fall locations and develop targeted prevention strategies, but the Administrator said there was nothing documented in clinical leadership showing what was being done to address the increase in falls. She also stated there was no documentation of targeted prevention strategies and no documentation that the facility trended the falls to determine root cause and implement systemic interventions.
Pest Control Program Not Effective
Penalty
Summary
The facility failed to maintain an effective pest control program to keep the environment free from pests and rodents. Review of the facility policy stated that the facility maintains an effective pest control program and takes ongoing measures to prevent, contain, and eradicate common household pests. During observation of the lunch meal in the memory care unit, multiple small flying insects were seen in the dining area, and family members were observed swatting at them. During observation of the lunch meal in the Bistro dining area, multiple small flying insects were also seen. The pest control company’s service summaries for the memory care unit documented repeated concerns, including instructions to keep the garbage can clean, noting that a drain trap was dry and allowing pest entry, advising that water be added to block pest entry, and recommending a fly light. Later, flying insects were observed on an uncovered tray of Danishes placed on a conference room table, and the DON observed the insects and told staff not to eat them. The DON stated she was new to the facility and had not previously heard about the fruit flies, and she also reported that five family members had mentioned the flying insects in the memory care unit at a meeting the previous evening.
Failure to Notify Representative of Change in Condition and New Medication Order
Penalty
Summary
The facility failed to notify the resident's representative of a change in condition requiring treatment with a new medication for one resident. The resident was admitted with diagnoses including dementia, bipolar disorder, and recurrent major depressive disorder, and was assessed as having moderately impaired cognition. The resident's emergency contact was the responsible party and power of attorney for care. After the resident had an episode of vomiting, the APRN evaluated the resident and documented that the resident appeared stable, had recently undergone a suprapubic procedure, had experienced hypoxemia during that procedure, and had been transferred back to the facility on amoxicillin, which was considered a possible cause of the nausea. The APRN ordered a CBC, CMP, and Zofran 4 mg every 8 hours and 4 mg by mouth every 4 hours as needed for breakthrough nausea. The clinical record, including nursing progress notes and assessments, did not show that the resident's emergency contact was notified of the vomiting, the laboratory orders, or the new medication. An alert note later documented the resident as DNR and indicated a message was left for the family to call the facility to notify them of the resident's passing. The responsible party stated in interview that the facility never notified her of the resident's declining condition, the vomiting, the need to start a new medication, or the laboratory test ordered. The DON stated there was no documentation from any nurse about what happened to the resident and that a change in condition note should have been completed and the family should have been notified.
Incomplete ABNs for Skilled Services
Penalty
Summary
The facility failed to ensure that the Advanced Beneficiary Notice of Non-Coverage forms were completed accurately for two residents receiving skilled services. For Resident #66, the Medicare Part A skilled services episode began on 5/2/25, and the Notice of Medicare Non-Coverage form stated that coverage for the current skilled services would end on 6/7/25. Resident #66 signed the notice on 6/5/25, but the Skilled Nursing Facility ABN listed that Medicare may not pay for physical therapy, occupational therapy, and daily skilled nursing care beginning on 5/2/25, did not include an estimated cost per day or per service, and did not have any of the choice boxes checked to show whether the resident wanted to continue care, have Medicare billed, or assume financial responsibility. As of 11/20/25, Resident #66 remained in the facility as a private payor. For Resident #92, the Skilled Nursing Facility ABN signed on 9/22/25 stated that beginning on 9/25/25 the resident may have to pay $470.00 per day for room and board and $75.00 per unit/per discipline for therapy, and identified physical therapy, occupational therapy, and daily skilled nursing care as the services involved. However, the section for the resident to indicate whether to discontinue care, continue care with Medicare billed, or continue care and pay privately was left blank. As of 11/20/25, Resident #92 remained in the facility with a private payor source. During interview on 11/20/25, the Administrator stated the ABNs for Residents #66 and #92 were not filled out correctly and that they should have checked a box indicating whether they wished to continue care and whether Medicare should be billed if they chose to receive care after coverage ends.
Failure to Provide Activities Aligned With Resident Preferences
Penalty
Summary
The facility failed to provide activities that met the interests and accommodated the needs of one resident who had legal blindness, schizoaffective disorder with delusions, major depressive disorder, and moderately impaired cognition. The resident lived on the secured memory care unit, had severe vision impairment, and her activity preferences identified music, group activities, and favorite activities as important to her. Her care plan called for three one-to-one room visits and/or group activities per week for socialization and stimulation, with staff to offer reminders and transport her to activities. The resident’s recreation records showed repeated entries of unable or blank for several scheduled activities, including hymn sing, sing-a-longs, hand massage, and nail care, and did not document participation in the music activity, hand and nail care, sensory care, or the amount of time the Activity Director said she spent with the resident. During observations, the resident was repeatedly found in bed in her room with the television off and no music playing. On one observation, live music entertainment was occurring in the dining area of the secured unit, but the resident remained in her room. During interview, the resident said she enjoyed all kinds of music and would have loved to attend the live music entertainment, but she was blind and no one assisted her to the activity. She also stated that no one came to pick her up for the music program. Activity staff said they did room visits and tried to get her up, but could not explain why she was not at the music activity. The Activity Director stated the resident loved music and that she provided sensory and nail care, but the record did not document those services as described.
Unsecured Medications and Controlled Substance Storage
Penalty
Summary
Drugs and biologicals were not stored in accordance with accepted professional principles because medications were found unattended and unsecured in multiple locations. The facility policy stated medications and treatment items should be securely stored in a locked cabinet, cart, or medication room inaccessible to residents and visitors, and that controlled substances must be stored to maintain integrity and security. Despite this, two medication cups containing pills were observed on Resident #66’s tray table, and Resident #66 stated the nurse left them there that morning. Resident #66’s self-administration form indicated the resident did not wish to self-administer medications or keep them at bedside. Additional observations showed a B-Wing treatment cart unlocked, a Cove Unit treatment cart with four tubes of medicated cream and a loose pill on top, and medicated creams on Resident #94’s nightstand. The Cove Unit medication cart was later observed unattended and unlocked, and RN staff acknowledged it should have been locked. During a cart check, a broken seal was found on Lorazepam 0.5 mg tablet, pill #27, with the tablet accessible behind the broken foil. RN staff said she had questioned it during the narcotic count that morning, and the DON stated the lorazepam should not have been stored that way and should have been wasted.
Sanitation Deficiencies in Food Service Operations
Penalty
Summary
Surveyors observed multiple lapses in food service sanitation, including a visibly soiled ice machine with black biofilm and crust-like debris on both the interior and exterior surfaces. The ice scooper was repeatedly found lying unholstered, first on the ice machine and later on the edge of a table next to the machine. Photographic evidence was obtained for these observations. The Certified Dietary Manager (CDM) confirmed that facility policy required monthly cleaning and sanitizing of the ice machine, but cleaning logs provided only covered earlier months and lacked documentation for recent cleaning. The Lead Chef acknowledged that the logs were outdated and attributed missing signatures to new staff, but could not provide evidence that cleaning had occurred as required. Additionally, during tray line preparation, three kitchen staff members were observed without proper hair restraints, with one being redirected to put on a hairnet only after being noticed. These observations were verified by the CDM. The facility's failure to maintain sanitary conditions in food service areas, as evidenced by the state of the ice machine, improper storage of the ice scooper, and lack of hair restraints, constituted a deficiency in compliance with professional standards for food safety.
Failure to Protect Resident from Verbal and Mental Abuse
Penalty
Summary
A resident with moderate cognitive impairment, frequent incontinence, and a need for assistance with personal care experienced verbal and mental abuse from a Certified Nursing Assistant (CNA) assigned through a staffing agency. The resident reported that the CNA became upset and yelled at her after she had episodes of diarrhea, and also gave her dirty looks while providing care. The resident expressed feelings of humiliation and mortification as a result of the CNA's behavior, and was observed crying by staff. The incident was documented in the resident's progress notes, and the resident stated she could not stop crying after the event. Interviews with staff confirmed the resident's emotional distress, with one LPN noting that the resident's reaction was different from her usual tearfulness. The CNA involved denied yelling but acknowledged telling the resident to wait while she attended to another patient. The facility's policy defines mental abuse as including humiliation and demeaning statements, which aligns with the resident's account of the incident. The events leading to the deficiency were directly related to the CNA's inappropriate response and attitude toward the resident during a vulnerable moment.
Failure to Provide Required Nail Care for Dependent Resident
Penalty
Summary
The facility failed to provide necessary grooming care for a resident who was dependent on staff for activities of daily living (ADLs). The resident, who had a diagnosis of unspecified dementia and was assessed as having severely impaired cognition, required partial to moderate assistance with personal hygiene. Observations revealed that the resident's fingernails were excessively long, curled inward, and had a brown substance underneath. Despite the facility's policy requiring staff to clean and trim nails on shower days, there was no documentation that this task had been completed for the resident over a 30-day period. The CNA Kardex specified that nail care should occur on designated shower days, but CNA documentation did not show that the task was performed. Interviews with staff confirmed the lack of clarity regarding responsibility for nail care and the absence of documentation. The resident expressed that no one had come to cut her nails and was unable to recall the last time they were trimmed. Staff members, including a CNA, RN, and the Activities Director, acknowledged that the resident's nails were too long and that nail trimming was not being performed as required. The Administrator also confirmed that, according to the Kardex, the task should have been completed by nursing assistants.
Failure to Document and Implement Stat Physician Order Received via Text
Penalty
Summary
A deficiency occurred when a physician's order for stat laboratory work, given in response to a family member's concern about a resident's symptoms and medical history of hypokalemia, was not documented, signed, dated, or implemented. The resident's son reported his father was cold, shaky, and not feeling well, and requested lab work to check potassium levels. Although a nurse texted the Advanced Practice Registered Nurse (APRN) with this information and received an order for a stat CBC with differential and a CMP, there was no documentation in the resident's chart of the physician notification, the order, or any lab work being performed on that day. The APRN later confirmed the order was given via text, but could not identify which nurse sent the message, and the order was never carried out. Subsequent review of the resident's medical record revealed no progress notes or documentation of the change in condition or the physician's order on the date in question. The resident later experienced an acute change in condition, including altered mental status and diarrhea, and was emergently transferred to the hospital after a cardiac arrest. The Director of Nursing (DON) confirmed the absence of documentation and implementation of the stat order, noting that the nurse involved was an agency nurse who no longer worked at the facility. The facility did not have a policy or procedure in place for handling medication orders received via text.
Deficiency in Dishwasher Sanitization and Food Storage Practices
Penalty
Summary
The facility failed to ensure that dietary staff operating the low-temperature dishwasher were adequately trained and competent in testing the sanitizing solution, which is crucial for preventing foodborne illnesses among residents consuming an oral diet. The high-temperature dishwasher had been converted to a low-temperature one due to malfunction, requiring the use of a sanitizer. However, dietary staff, including Dietary Aide Staff C, were not aware of the need to test the sanitizer, nor did they know where the test strips were kept. The Certified Dietary Manager (CDM) and the Executive Chef were unaware of the requirement for daily monitoring/testing of the sanitizer, and the test strips available were expired. Additionally, the facility failed to store food in a sanitary manner. During an inspection, a small flying insect was observed on a bucket of chicken bouillon, and food items were stored on the floor, contrary to the facility's food storage policy. The walk-in refrigerator and freezer were found to have black bio growth around the bottom of the freezer entry door and the refrigerator ceiling. These observations were verified by the CDM, who acknowledged the presence of the insect and the improper storage of food items. The facility's contracted company had been servicing the dishwasher, which was in chemical sanitation mode due to a back-ordered booster heater. The chemical line was found severed, causing sanitizer to be pumped onto the floor, but it was repaired during a service call. The contracted company representative stated that the dishwasher should be tested monthly, but it had not been tested since the booster went out in April, as no one at the facility knew it was required. The facility had not documented any monitoring of the sanitizer level, and the Executive Chef admitted to not having started training the kitchen staff on testing the sanitizer level.
Failure to Address Resident Grievances
Penalty
Summary
The facility failed to promptly address grievances expressed during resident council meetings, as evidenced by a lack of documentation and follow-up on complaints regarding staffing and call light response times. The facility's policy requires grievances to be filed verbally or in writing and resolved promptly, with non-emergency concerns addressed within seven days. However, grievances voiced during resident council meetings in July, August, September, and October 2024 were not documented in the Grievance Log, and there was no evidence of resolutions to these complaints. The grievances included insufficient staff to assist residents after meals and delayed response to call lights, particularly on weekends and night shifts. Interviews with residents and their families corroborated these issues, with reports of long wait times for call light responses and inadequate staffing on weekends. One resident reported waiting up to two hours for assistance at night, despite having a history of falls with fractures. Another resident's son reported that his mother, who is incontinent and has dementia, was left in soiled conditions for over an hour due to staffing shortages. The Social Worker and Administrator confirmed that grievances from resident council meetings were not being logged or tracked, indicating a breakdown in the facility's grievance resolution process.
Lack of Resident-Centered Activities in TCU
Penalty
Summary
The facility failed to implement an ongoing resident-centered activities program to meet the needs of residents in the Transitional Care Unit (TCU). The facility's policy, revised in October 2022, stated that it would provide a program to support residents' choice of activities, including daily activities and events, and encourage participation from residents and families. However, observations and interviews revealed that the facility did not adhere to this policy, as there were no organized activities or activity staff present in the TCU during the survey period. Resident #250, who had intact cognition and expressed a strong interest in group activities, reading, and religious activities, reported that there were no activities available in the TCU. The resident participated in therapy sessions in the morning but stated that there was nothing to do for the rest of the day. The resident was unaware of the available games and puzzles and felt discouraged from accessing them due to staff behavior. Similarly, Resident #251 expressed dissatisfaction with the lack of activities, stating that there were no activities that suited her interests and that she was unaware of any activity director or outdoor activities. Interviews with staff and family members corroborated the residents' experiences. A family member noted the absence of activities and the unavailability of BINGO in the TCU, despite requests to the Unit Manager. The Life Enrichment Volunteer Coordinator mentioned that the TCU had its own activity calendar, but residents were not informed or engaged in these activities. The Activity Assistant stated that the TCU was rehabilitation-focused, implying that therapy was considered the primary activity for residents, which did not align with the residents' needs and preferences.
Failure to Update PASRR for Resident with Severe Mental Health Issues
Penalty
Summary
The facility failed to complete an accurate Level I Preadmission Screening and Resident Review (PASRR) for a resident with a diagnosis of severe mental health issues requiring treatment. The resident was transferred from another skilled nursing facility with a PASRR dated from 2018, which did not reflect the resident's current diagnoses of Psychotic Disorder with delusions and Schizoaffective Disorder. These diagnoses were made in 2018 and 2020, respectively, but were not updated in the PASRR documentation. The resident's clinical record indicated that they were admitted with significant psychiatric conditions, including a recent diagnosis of Major Depressive Disorder. The psychiatric progress note highlighted the need for regular clinical evaluations due to the resident's multiple psychiatric conditions. During an interview, the Minimum Data Set (MDS) Coordinator confirmed that the PASRR from the previous facility was outdated and did not accurately represent the resident's current mental health status, which could potentially prevent the resident from receiving appropriate specialized treatments.
Failure to Conduct Drug Regimen Review Leads to Multiple Falls
Penalty
Summary
The facility failed to conduct a drug regimen review for a resident receiving psychotropic medications who sustained multiple falls. The resident, admitted with diagnoses including pleural effusion, generalized muscle weakness, and a left rib fracture, was identified as a high fall risk. Despite this, the resident was administered multiple medications, including Xanax, Alprazolam, Zolpidem Tartrate, Lorazepam, and Oxycodone, which have potential side effects of increased falls, dizziness, and weakness. A drug interaction warning was triggered for the combination of these medications, indicating the risk of additive central nervous system depression. The resident experienced seven falls within a short period, with incidents occurring during attempts to transfer unassisted or while changing positions. Despite the addition of a medication regimen review to the care plan, there was no documentation that this review was conducted. Interviews with staff confirmed the lack of documentation and the multiple falls sustained by the resident. The facility's failure to implement the care plan intervention for a drug regimen review contributed to the resident's repeated falls.
Failure to Justify Continued Use of Indwelling Urinary Catheter
Penalty
Summary
The facility failed to provide justification for the continued use of an indwelling urinary catheter for a resident who was admitted with the catheter from an acute care hospital. The facility's policy requires an assessment for the removal of the catheter unless clinically necessary, but there was no documentation of such an assessment or a urology referral in the resident's clinical record. The resident, who had a diagnosis of neurogenic bladder and intact cognition, reported that she had never needed a catheter before her recent hospital admission and that it was removed once at the hospital due to a urinary tract infection. Interviews with facility staff revealed that the resident had failed a voiding trial at the hospital, but no subsequent voiding trial or urology consultation was conducted at the facility. The catheter was eventually removed, and the resident was able to void successfully. The Director of Nursing did not provide additional information regarding the use of the catheter for this resident, indicating a lack of proper documentation and assessment for the necessity of the catheter's continued use.
Failure to Obtain Physician's Orders for PICC Line Care
Penalty
Summary
The facility failed to obtain physician's orders upon admission for the care and management of a peripherally inserted central catheter (PICC) for a resident receiving intravenous antibiotics. The facility's policy required sterile dressing changes for central vascular access devices upon admission unless the dressing was clean, dry, and intact. However, the clinical record for the resident showed no documentation of a physician's order for the care, including dressing changes of the PICC. During an observation, the resident was found with a heavily soiled PICC dressing that had not been changed since the date marked on it. Interviews with the resident and staff confirmed the lack of physician's orders for the PICC line care. The Director of Nursing verified the issue and acknowledged it was identified during the admission assessment, but no corrective action was taken at that time.
Unsecured Medications Found in Facility
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored securely in locked compartments, as required by their policy. During an observation, five unidentified pills and a sealed Lidoderm patch were found unsecured and unattended on a resident's bedside table while the resident was not present in the room. A registered nurse confirmed that these medications were left unattended, acknowledging that they should not have been left on the bedside table. Additionally, four large plastic pharmacy medication bags were observed left unattended at the B wing nurses' desk. These bags, which contained medications delivered by the pharmacy, were easily accessible to staff, residents, and visitors passing by. The Regional Nurse Consultant verified the unattended status of these bags and confirmed their contents.
Failure to Submit Staffing Data to CMS PBJ System
Penalty
Summary
The facility failed to submit the required staffing data to the Center for Medicare/Medicaid (CMS) Payroll-Based Journal (PBJ) system for the Fiscal Year Quarter three of 2024, covering the period from April 1 to June 30. A review of the facility's Staffing Data Report for this period revealed deficiencies in several areas, including a one-star rating, excessively low weekend staffing, no Registered Nurse (RN) hours, and a failure to maintain licensed nursing staff coverage 24 hours a day. Although the facility provided supportive documentation verifying the required staffing and nursing hours for the third quarter, the data was not successfully uploaded to the PBJ system. During an interview, the Administrator explained that the Corporate Office had sent a digital file containing the staffing information for the third quarter, which staff at the facility attempted to upload. However, the upload was unsuccessful, and the Administrator could not explain the reason for the failure. The staff is currently working on preparing the staffing file for the fourth quarter.
Failure to Honor Advance Directives for Full Code Status
Penalty
Summary
The facility failed to honor the advance directives for full code status for Resident #1, who was found unresponsive without a pulse or respiration on [DATE] at 5:19 a.m. Despite having a full code status, CPR was not initiated promptly. Three Licensed Nurses on duty did not call Emergency Medical Services (EMS) or initiate CPR for 51 minutes while attempting to locate a non-existent Do Not Resuscitate Order. The delay in initiating CPR for Resident #1, who had expressed the wish to receive life-saving measures in the event of cardiac or respiratory arrest, resulted in the resident being pronounced dead by EMS. The clinical staff's failure to promptly confirm code status and initiate CPR for Resident #1, as per the facility's policy and procedure on Advance Directives and CPR, led to a delay in providing life-saving measures. Despite the resident's clear full code status, there was confusion among the staff in locating a DNR form, which was not present. This confusion and delay in decision-making regarding CPR led to a critical lapse in honoring the resident's advance directives and right to receive appropriate medical intervention in a timely manner. The investigation into the incident revealed that there was a breakdown in communication and process among the staff involved in responding to Resident #1's medical emergency. The failure to promptly initiate CPR, despite the resident's full code status and expressed wishes for life-saving measures, highlights a significant deficiency in ensuring that staff follow established policies and procedures to honor advance directives. This deficiency placed Resident #1 at risk and resulted in a violation of the resident's right to receive timely and appropriate medical treatment as per their expressed wishes.
Delayed CPR Initiation Due to Miscommunication and Policy Misunderstanding
Penalty
Summary
The facility staff failed to immediately initiate cardiopulmonary resuscitation (CPR) for Resident #1, who was found unresponsive, without a pulse or respirations. Despite the absence of a Do Not Resuscitate (DNR) Order, CPR was delayed for 51 minutes while staff attempted to locate a non-existent DNR order. Resident #1, who had Chronic Obstructive Pulmonary Disease with acute exacerbation and generalized muscle weakness, was pronounced dead by Emergency Medical Services (EMS). The facility's policy clearly outlined the importance of prompt initiation of CPR for residents requiring emergency care, especially in the absence of a DNR order. The investigation revealed that the facility staff, including Registered Nurses (RN) and Licensed Practical Nurses (LPN), were involved in the delay of initiating CPR for Resident #1. Despite efforts to locate a DNR order, including checking the Electronic Medical Record (EMR) and hard chart, no such order was found. The staff's actions, as captured in the surveillance video, showed a series of delays and confusion in determining the resident's code status and initiating CPR promptly. The failure to follow established protocols for residents without a DNR order led to a critical delay in providing life-saving measures for Resident #1. During interviews and incident investigations, it was evident that there was a breakdown in communication and understanding among the staff regarding the process for initiating CPR in the absence of a DNR order. Despite the facility's clear policy on CPR initiation and code status determination, there were discrepancies in staff responses and actions when faced with an unresponsive resident. The delay in administering CPR to Resident #1 highlighted a critical deficiency in staff training, communication, and adherence to established protocols for emergency situations.
Delayed CPR Initiation Due to Miscommunication on Code Status
Penalty
Summary
The facility failed to ensure nursing staff had the appropriate competencies to immediately initiate lifesaving measures, including CPR, when residents with full code status experienced cardiac or respiratory arrest. In a specific incident on [DATE] at 5:19 a.m., Resident #1 was found in cardiac and respiratory arrest, but three nursing staff members (two Registered Nurses and one Licensed Practical Nurse) delayed the initiation of CPR and calling for Emergency Medical Services (EMS) for 51 minutes while attempting to locate a non-existent Do Not Resuscitate Order. This delay in providing immediate lifesaving measures resulted in Resident #1 being pronounced deceased by EMS. The investigation revealed that the nursing staff involved, including RN Staff A, LPN Staff B, and RN Staff C, faced challenges in determining the appropriate course of action when Resident #1 was found unresponsive. RN Staff A, who found Resident #1 unresponsive, struggled to locate a DNR order and ultimately drew her own conclusion, leading to a delay in initiating CPR. LPN Staff B, who responded to the call for help, also faced difficulties in locating the DNR order but correctly identified Resident #1 as a full code and initiated CPR. RN Staff C, who was busy with another resident, assisted with CPR but did not recall participating in any code blue drills.
Deficiency in Staff Training and Documentation of Advance Directives
Penalty
Summary
The facility's Administration failed to ensure staff were adequately trained and knowledgeable in policies and procedures regarding residents' rights to advance directives, including the right to receive CPR in the event of cardiac or respiratory arrest. This deficiency was highlighted when Resident #1, who was a full code, was found unresponsive without pulse or respiration. Despite the resident's full code status being known to the Social Services Department, it was not documented in the baseline care plan. The clinical staff on duty did not initiate CPR until 51 minutes after Resident #1 was found unresponsive, ultimately resulting in the resident's death. The investigation revealed that the delay in initiating CPR was due to a breakdown in communication and a lack of clear protocols for staff to follow in such situations. The RN Staff Educator mentioned a process breakdown where staff were unsure of what to do in the absence of a yellow DNR form. The Director of Nursing acknowledged that while nurses were CPR certified, there was a lack of documentation and verification of their competency in responding appropriately to residents found unresponsive. The Social Worker confirmed that Resident #1's advance directives and code status were not documented in the baseline care plan, leading to confusion among staff during the critical event. The deficiency in ensuring staff were trained and knowledgeable in honoring residents' advance directives, specifically regarding CPR procedures, created a situation where Resident #1's expressed wishes as a full code were not promptly honored. The failure to have clear documentation and protocols in place for such scenarios led to a delay in initiating life-saving measures, ultimately resulting in the resident's death. The lack of a systematic approach to ensuring staff competency and adherence to advance directives put residents at risk of not receiving appropriate and timely care in emergency situations.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 60 citations issued within 25 miles in the last 12 months — including the 7 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Cape Coral
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Aviata At Santa Barbara | 1.6 mi | ★★★★★ | 10 | 4 |
| Rehab & Healthcare Center Of Cape Coral | 2.6 mi | ★★★★★ | 0 | 0 |
| Aviata At North Fort Myers | 4.3 mi | ★★★★★ | 6 | 0 |
| Cedarbrook Health And Rehabilitation Center | 6.3 mi | ★★★★★ | 0 | 0 |
| Lee Memorial Hospital Skilled Nursing Unit | 6.3 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 October 2026) and official state health department websites.