Below average — CMS composite of the measures below.
A standard survey is most likely before around September 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 Gulfport Nursing Center during CMS and state inspections, most recent first.
The facility failed to ensure that nursing staff had appropriate IV therapy competencies, resulting in non-certified LPNs administering and managing IV medications and lines for two residents receiving treatment for cellulitis, infection, and related conditions. Physician orders included midline and PICC insertion, IV antibiotics, saline flushes, and PICC/midline monitoring, all of which were documented as performed by LPNs without verified IV certification. Leadership and medical staff interviews revealed conflicting understandings of LPN IV scope, with the NHA stating certification was not required for most IV tasks, while the DON, ADON, Medical Director, and Attending Physician stated that LPNs must be IV certified to administer, monitor, or maintain IV/PICC lines. Orientation processes did not include collection or verification of IV certifications, and personnel files for involved LPNs lacked documentation of IV certification despite facility policy and job descriptions referencing the need for advanced IV training and compliance with state IV therapy requirements.
A resident with multiple complex medical conditions and cognitive impairment did not have a discharge plan documented in her comprehensive care plan. Staff interviews and record reviews confirmed that, despite facility policy requiring discharge planning within 7 days of assessment, the care plan lacked this component.
Two residents dependent on mechanical lifts for transfers were subjected to neglect when staff failed to follow proper assessment, documentation, and transfer protocols. One resident suffered a severe femur fracture after being transferred by two CNAs who lacked formal training, while another was transferred by a single CNA, causing distress. Facility policies requiring two-person transfers and staff competency were not followed, and staff had not received adequate training or clear guidance on mechanical lift use.
The facility failed to ensure that nurses and nurse aides were properly trained and competent in the use of mechanical lifts for dependent residents, resulting in unsafe transfer practices. Staff relied on general observation to select sling sizes, lacked specific training, and care plans and Kardexes were not updated to reflect accurate transfer needs. This led to incidents where a resident was transferred alone and another suffered a serious hip fracture after a transfer, with confusion among staff about the cause and proper procedures.
The facility did not provide written notification to the local LTC Ombudsman when several residents were transferred to the hospital, as required by policy and regulation. Review of transfer and discharge notices, as well as interviews with staff, confirmed that the Ombudsman was not notified and that there was no documentation of such notifications.
The facility did not ensure an RN was on duty for eight consecutive hours each day, as required, with multiple days lacking RN coverage due to staffing shortages, scheduling conflicts, and disruptions from hurricanes. Inaccurate PBJ reporting also occurred because agency nurse hours were not submitted, resulting in noncompliance with federal staffing requirements.
The facility did not ensure that laundry chemical dispensers were regularly checked or calibrated, as neither the EVS Director nor the NHA could provide documentation or evidence of routine maintenance. The vendor's manual highlighted the need for regular monitoring, and a service form noted issues with chemical dispensing. No policy for equipment maintenance was available when requested.
The facility did not complete or update PASARRs for two residents with mental health diagnoses. In one case, only a substance abuse diagnosis was recorded, omitting other qualifying mental health conditions and failing to submit a Level II PASARR. In another case, the PASARR form was left blank for mental illness, and this was confirmed by the Social Services Director. Facility policy requires proper PASARR completion for all admissions.
A resident with morbid obesity and a fractured leg, requiring a mechanical lift and two-person assist for transfers, was not consistently assisted by staff to get out of bed despite expressing a desire to attend group activities. Observations and interviews confirmed the resident remained in bed for extended periods, and there was no documentation supporting staff claims of refusal. Facility policy and care plans required such assistance, but it was not provided as needed.
A resident with a left hand contracture did not receive her prescribed hand splint/hand carrot as ordered, due to staff failing to apply it when the Restorative Aide was off duty. Observations confirmed the splint was not in use, despite documentation indicating otherwise, and there was no record of refusal or alternative intervention. The care plan and physician's orders for contracture management were not consistently followed or documented.
An LPN did not prepare IV antibiotics immediately before administration and failed to properly prime IV tubing for a resident, instead combining medication and fluid at the start of her shift and struggling to remove air from the tubing. These actions did not follow professional standards or facility policy, as confirmed by the DON.
A resident admitted after a traumatic accident with multiple injuries and a family loss was prescribed medications for PTSD and other behavioral health conditions, but the facility failed to develop a care plan addressing PTSD or mood/behavior issues. Staff interviews revealed missed communication and lack of care plan updates, and the facility's PASARR policy did not address updating for new mental illness diagnoses.
Non-certified LPNs Administering and Managing IV Therapy for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure that nurses and nurse aides had appropriate competencies for providing IV therapy, resulting in non-certified LPNs administering and managing IV medications and lines for two residents. One resident was admitted with cellulitis of the left lower limb, peripheral vascular disease, and polyneuropathy, and had multiple physician orders for IV therapy, including insertion of a midline and PICC, IV vancomycin and cefepime, routine saline flushes, and PICC/midline measurements and dressing changes. Medication administration records showed that LPNs, including Staff C and Staff D, documented administration of these IV medications. In an interview, Staff C stated she did not have IV certification but had administered IV medications to this resident on several occasions and did not recall the facility asking about IV certification. Another resident was admitted with cellulitis and an elevated white blood cell count and had physician orders for a midline insertion, IV ceftriaxone, saline flushes, and PICC or midline monitoring, including arm circumference and catheter length measurements. Medication administration records showed that an LPN, Staff A, documented administration of the IV medications and assessment of the IV access. Staff A reported she did not know where her IV certification was and that the facility had not requested a copy of it. Review of personnel files revealed that Staff A, Staff C, and Staff D did not have IV certifications on file. Interviews with facility leadership and medical staff revealed inconsistent understanding and enforcement of IV competency requirements. The Nursing Home Administrator stated that LPNs could give medications, monitor, and change dressings for IV or PICC lines without certification, except for inserting or removing PICC lines. In contrast, the DON, ADON in training, Medical Director, and Attending Physician all stated that LPNs must be IV certified to administer medications, monitor, or maintain IV or PICC lines, and that PICC line removal must be done by an RN. The ADON in training also stated that the nursing department did not collect or verify IV certifications during orientation, and the Business Office Manager confirmed that IV certifications were not requested at orientation and were not present in the personnel files. Facility policy on IV therapy and the LPN job description referenced the need for advanced training and/or certification and compliance with state IV therapy competency requirements, which were not followed in practice.
Failure to Include Discharge Plan in Comprehensive Care Plan
Penalty
Summary
The facility failed to develop a comprehensive, person-centered care plan that included a discharge plan for one resident. The resident in question was admitted with multiple complex diagnoses, including sepsis, stage 4 pressure ulcer, chronic kidney disease, muscle wasting, and bilateral lower extremity DVTs. Upon review, the resident's care plan did not contain any documentation of a discharge plan, despite facility policy requiring such plans to be developed within 7 days of the comprehensive assessment. Interviews with facility staff, including the Rehabilitation Director, MDS Coordinator, DON, and Social Services Director, confirmed that the resident was considered a short-term admission and that a decision regarding her inability to return home was made recently. However, no discharge plan was documented in her care plan. Observations of the resident showed she required significant assistance with activities of daily living and 24-hour care. Staff interviews revealed that the resident had memory concerns and lacked capacity to make informed decisions, as documented by the physician. Despite these needs and the facility's own policy, the care plan did not address discharge planning, and staff confirmed the omission upon review of the electronic clinical record. The facility's policy specifically requires that the care plan include the resident's goals for admission, desired outcomes, preferences for future discharge, and discharge plans as appropriate, which was not followed in this case.
Neglect in Mechanical Lift Transfers Resulting in Resident Injury
Penalty
Summary
The facility failed to protect residents from neglect related to the improper use of mechanical lifts during transfers, affecting two residents who were dependent on such equipment. One resident, with severe cognitive impairment and total dependence for transfers, was not properly assessed for mechanical lift use, and staff were not adequately educated on correct transfer methods. On the day of the incident, two CNAs transferred the resident using a mechanical lift, after which significant pain and a displaced right hip were observed. The resident was sent to the hospital, where a displaced spiral subtrochanteric fracture of the right femur was diagnosed, requiring surgical intervention. Interviews revealed that staff had not received formal training or competency demonstrations on mechanical lift use, and there was confusion regarding responsibility for assessing residents and selecting appropriate sling sizes. Another resident, who was cognitively intact and also dependent on mechanical lift transfers, was observed being transferred by a CNA using the mechanical lift alone, contrary to facility policy requiring two staff members for such transfers. The resident expressed feeling nervous about being transferred with only one staff member present. Review of the resident's care documentation showed that the number of staff required for transfers was not specified, and staff interviews confirmed a lack of clarity and adherence to the two-person transfer policy. Facility policies required at least two staff for mechanical lift transfers and mandated staff training and competency in the use of such equipment. However, interviews with staff and review of training records indicated that training was informal, often provided by other aides rather than through structured demonstration or competency assessment. The lack of proper assessment, documentation, and staff education directly contributed to the neglect and subsequent injury, as well as the unsafe transfer practices observed.
Failure to Ensure Staff Competency in Mechanical Lift Transfers
Penalty
Summary
The facility failed to ensure that licensed nursing staff and nurse aides were knowledgeable and competent in providing care and services related to safe mechanical lift transfers for dependent residents. Staff interviews revealed that CNAs and LPNs determined the need for mechanical lift transfers by referencing the care planning section of the Kardex, but there were no specific instructions regarding the type or size of sling to use for each resident. Staff selected slings based on general observation and self-assessment, and confirmed they had not received specific education or training on mechanical lift use at the facility. Observations showed that a CNA transferred a resident alone using a mechanical lift, contrary to the requirement for two staff members, and the Kardex did not specify the number of staff required for transfers. For one resident, who was cognitively intact and dependent on staff for transfers, interviews and record reviews indicated that she was routinely transferred by only one CNA, making her feel nervous. The Kardex and care plan for this resident did not accurately reflect her transfer needs. For another resident with severe cognitive impairment and multiple diagnoses, including dementia and osteoarthritis, records showed she was dependent on staff for transfers and required a mechanical lift with two-person assistance. This resident experienced a displaced spiral subtrochanteric fracture of the right femur after being transferred, which was discovered when staff noticed her leg was out of place following a transfer. There was confusion among staff and the primary care provider regarding the cause of the injury, with discrepancies in documentation and reporting. Interviews with facility leadership, including the DON, ADON, and Director of Rehabilitation, confirmed that there was no formal training or competency assessment for mechanical lift use, and that care plans and Kardexes were not updated to reflect residents' current transfer needs. The Director of Rehabilitation stated that therapy did not provide formal training or assessments for mechanical lift use, and the DON acknowledged that training was typically provided informally by other aides. The facility assessment and job descriptions reviewed did not ensure that staff had the necessary competencies to provide safe care for residents requiring mechanical lift transfers.
Failure to Notify Ombudsman of Resident Transfers and Discharges
Penalty
Summary
The facility failed to provide written notification to the local Long-Term Care Ombudsman regarding the transfer and discharge of five residents who were sent to the hospital. Record reviews for these residents showed that their Nursing Home Transfer and Discharge Notices did not indicate that the Ombudsman had been notified as required. The facility's Admission/Discharge report confirmed that nine residents had been transferred to an acute care hospital within the review period, but there was no documentation of Ombudsman notification for these cases. Interviews with the Social Services Director and the Nursing Home Administrator revealed that the facility had not notified the Ombudsman of the residents' transfers and did not have documentation to support that such notifications had occurred. An email from the local Long-Term Care Ombudsman Program District Manager further indicated that the Ombudsman had not received the required discharge notifications from the facility. The facility's own policy requires notification of the Ombudsman and staff training on these procedures, but compliance was not demonstrated.
Failure to Provide Required RN Coverage and Accurate PBJ Reporting
Penalty
Summary
The facility failed to ensure that a registered nurse (RN) was on duty for eight consecutive hours each day, seven days a week, as required. Review of Payroll Based Journal (PBJ) data and daily timecard reports for multiple dates in October, November, and December 2024 revealed that there were no RN hours recorded on several days. Interviews with the staffing coordinator and human resources staff confirmed that there were ongoing challenges with RN staffing, including difficulties retaining nurses, reliance on agency nurses, and scheduling issues such as a nurse not working on Saturdays for religious reasons and another only working weekdays. Additionally, the facility experienced disruptions during hurricanes, with staff working in different buildings and possible power outages affecting the time clock system, which may have contributed to incomplete or missing RN hour records. The nursing home administrator, who started after the period in question, acknowledged that agency nursing hours had not been submitted to the payroll company, resulting in inaccurate PBJ data. The facility's staffing policy requires sufficient licensed nurses and certified nursing assistants to provide care 24 hours a day and mandates that all direct care staffing information, including agency and contract staff, be submitted to the CMS PBJ system. However, the failure to record and report RN hours on the specified dates led to noncompliance with federal staffing requirements.
Failure to Maintain and Monitor Laundry Chemical Dispensers
Penalty
Summary
The facility failed to ensure that both washing machines' chemical dispensers were properly checked and calibrated according to regulations and industry standards. During an observation and interview in the laundry room, the EVS Director was unable to state when the chemical dispensers were last checked or calibrated and was not aware of any scheduled maintenance by the vendor. The NHA was also unable to provide documentation, such as invoices, to show that the chemical dispensers had been checked or calibrated on a routine basis and confirmed that there was no regular schedule for vendor calibration prior to the survey date. A review of the vendor's service form indicated that there was a concern about chemicals not being correctly dispensed from the buckets to the machines. The vendor's chemical dispenser manual emphasized the importance of regular monitoring and maintenance, including checking chemical levels and cleaning the dispenser. Additionally, the facility was unable to provide a policy related to maintaining facility equipment when requested during the survey.
Failure to Complete/Update PASARRs for Residents with Mental Disorders
Penalty
Summary
The facility failed to complete or update the Pre-admission Screening and Resident Reviews (PASARRs) for two residents with mental disorders or intellectual disabilities. For one resident admitted and readmitted with diagnoses including anxiety disorder and bipolar II disorder, the Level I PASARR only noted a substance abuse diagnosis and did not include the qualifying mental health diagnoses, nor was a Level II PASARR submitted. For another resident admitted with major depressive disorder and generalized anxiety disorder, the PASARR form had the section for mental illness left blank and did not reflect any diagnosis. The Social Services Director confirmed the omission during an interview. The facility's policy requires that all admissions have the appropriate PASARR completed, but this was not followed in these cases.
Failure to Provide Required ADL Transfer Assistance
Penalty
Summary
A deficiency occurred when staff failed to provide necessary assistance with activities of daily living (ADLs), specifically transfers from bed to wheelchair, for a resident who was unable to perform these tasks independently. The resident, who was morbidly obese, had a fractured right lower leg in a cast, and required a mechanical lift with two-person assistance for transfers, reported that in the initial days after admission, staff assisted him in getting out of bed to attend activities. However, in the following weeks, the resident stated that staff frequently did not assist him out of bed despite his requests, resulting in him remaining in bed and missing several group activities he wished to attend. Multiple observations over several days confirmed that the resident remained in bed with the call light within reach and was not assisted out of bed for scheduled activities, even when he expressed a desire to participate. Interviews with Certified Nursing Assistants (CNAs) revealed that they believed the resident always refused to get up, but there was no documentation in the medical record or CNA ADL task sheets to support consistent refusals. The Activities Director and the Director of Nursing (DON) both acknowledged that the resident required significant assistance for transfers and that he had previously participated in activities when assisted, but had not been seen out of bed for activities in recent weeks. Review of the resident's medical record confirmed he was alert, oriented, and able to make his own decisions. Care plans and assessments indicated he was totally dependent on staff for transfers and required a mechanical lift with two-person assistance. Facility policy required that residents unable to perform ADLs independently receive necessary services to maintain their abilities, and that care be provided in accordance with the plan of care. Despite this, there was no evidence that staff consistently offered or provided the required assistance for transfers, nor was there documentation of refusals, leading to the resident's inability to participate in desired activities.
Failure to Provide Contracture Management and Accurate Documentation
Penalty
Summary
A deficiency occurred when a resident with a left hand contracture was not provided with her prescribed hand splint/hand carrot as ordered by the physician and outlined in her care plan. Multiple observations on 6/9/2025 revealed the resident was not wearing the splint, and there was no splint present in her room. The resident was unable to apply the splint herself and was dependent on staff for this intervention. Interviews with staff confirmed that the Restorative Aide, who is responsible for applying the splint, was not present that day, and other staff did not ensure the splint was applied. There was also confusion among staff regarding who was responsible for applying the splint in the absence of the Restorative Aide. Documentation in the Medication Administration Record (MAR) and Treatment Administration Record (TAR) indicated that the splint was applied as ordered, but direct observation and staff interviews confirmed this was not the case. There was no documentation of the resident refusing the splint, and staff were unaware of the need to document refusals or the absence of the splint. The care plan and physician's orders specified the use of the splint daily, with skin checks before and after application, but these interventions were not consistently implemented or documented. The resident's medical record indicated a history of contractures, muscle weakness, and dependence on staff for activities of daily living. Despite clear orders and care plan interventions for contracture management, the facility failed to ensure continuity of care when the designated Restorative Aide was off duty. This resulted in the resident not receiving the prescribed intervention to maintain or improve range of motion, and the lack of accurate documentation further contributed to the deficiency.
Failure to Follow IV Medication Preparation and Administration Standards
Penalty
Summary
Staff L, an LPN, failed to follow professional standards and facility policy during the preparation and administration of IV antibiotics for a resident. The LPN initially used a reconstituted vial of Cefepime that had been combined with IV fluid at the beginning of her shift, rather than immediately before administration as required. During the preparation process, she was unable to remove all the medication from the vial and disposed of it, then repeated the preparation with a new vial and IV bag. The LPN attempted to prime the IV tubing over a trash can but was unable to clear all the air from the tubing at that time, only completing the air removal after hanging the bag on the IV pole. The facility's policy requires that medications be prepared immediately before administration and that IV tubing be properly primed to remove air before connecting to the resident. The Director of Nursing confirmed that staff are expected to follow these procedures. The observed actions did not align with these requirements, resulting in a failure to provide care and services according to professional standards and facility policy for the safe and appropriate administration of IV fluids.
Failure to Develop PTSD Care Plan for Resident with Behavioral Health Diagnoses
Penalty
Summary
The facility failed to develop a care plan addressing Post-Traumatic Stress Disorder (PTSD) for a resident who was admitted following a serious motor vehicle accident resulting in multiple fractures and the death of a family member. Although the resident was prescribed medications such as Prazosin for PTSD-related nightmares and Temazepam for insomnia, and behavioral health notes documented diagnoses including adjustment disorder with anxiety, major depressive disorder, generalized anxiety disorder, and insomnia, there was no corresponding care plan for PTSD or mood/behavior issues. The resident's Minimum Data Set (MDS) and Preadmission Screening and Resident Review (PASARR) did not reflect a mental illness diagnosis, and a follow-up PASARR was not completed despite new diagnoses being documented in behavioral health notes. Interviews with facility staff revealed gaps in communication and responsibility regarding care plan updates and PASARR processes. The Social Service Director was unaware of the PTSD diagnosis and acknowledged that a care plan should have been created, while the MDS coordinator admitted to missing the Prazosin order and not routinely reviewing behavioral health provider notes. The facility's PASARR policy did not include procedures for updating the PASARR when new mental illness diagnoses were identified, contributing to the oversight in care planning for the resident's PTSD and related behavioral health needs.
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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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Nursing homes near Pasadena
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Aviata At The Sea - Pasadena | 0.2 mi | ★★★★★ | 0 | 0 |
| Springs At Boca Ciega Bay | 1.1 mi | ★★★★★ | 5 | 4 |
| Egret Cove Center | 1.4 mi | ★★★★★ | 0 | 0 |
| Boca Ciega Center | 1.5 mi | ★★★★★ | 1 | 0 |
| Marion And Bernard L Samson Nursing Center | 2 mi | ★★★★★ | 0 | 0 |
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