Above average — CMS composite of the measures below.
The next survey window likely opens around February 2027
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 Gulf Pointe Plaza during CMS and state inspections, most recent first.
Oxygen Therapy Not Provided at Ordered Settings: Three residents with respiratory diagnoses had oxygen flow rates set above the physician-ordered amounts, and one resident’s room lacked the required oxygen-in-use sign. One resident’s oxygen tubing was also not connected to the humidification bottle. Staff stated nurses were responsible for verifying oxygen settings each shift and that the settings should match the MD order.
Food storage and kitchen sanitation deficiencies were identified when surveyors observed dirt and grime behind the ice machine and under the sink, open or expired food items without proper dates, unsealed cheese, staff water bottles in the refrigerator, bleach stored on top of cereal dispensers, and pans with scrapes and Teflon wear. The FSD and RD stated food should be labeled with received-by, opened, and use-by dates and discarded if not properly dated or sealed, while the Adm stated staff personal items should not be kept in the kitchen refrigerator.
Missing informed consent for psychotropic medication use: Two residents had psychotropic-related medication orders without signed consent in the record. One resident with schizoaffective disorder and severe cognitive impairment had Divalproex ordered for paranoid disorder, and another resident with schizoaffective disorder, depressive type, deafness, and blindness had Depakote and Gabapentin ordered for mood-related indications. The ADON stated consent was required for new, changed, or restarted psychotropic meds, while the DON noted the facility used some anticonvulsants and anxiolytics as psychotropics.
Incomplete OOH-DNR Form: A resident with Alzheimer’s disease and Picks disease had a DNR status listed in the chart, but the OOH-DNR form was not fully completed because the resident/RP signature was missing from section F. The ADON and DON stated the form required signatures from the physician, two witnesses, and the resident or RP, and that without proper completion the form was not valid.
Surveyors found a nurse medication cart on one hall left unlocked and unattended at the nurses' station, with all drawers except the narcotic drawer accessible, while multiple residents were seated nearby in the lobby. The LVN responsible for the cart stated she had not realized she failed to lock it after completing a medication count with the off‑going nurse and acknowledged she had been previously in‑serviced on the requirement to keep the cart locked when not in use. The DON and Administrator confirmed that facility policy requires all medication compartments, including carts, to be locked when not in use so residents cannot access medications not prescribed to them.
A resident with severe cognitive impairment and chronic pain experienced discrepancies in the administration and documentation of liquid morphine, including missing doses, inaccurate narcotic counts, and improper disposal of medication bottles. Nursing staff did not consistently follow procedures for counting and documenting controlled substances, leading to unaccounted doses and compromised pain management.
A resident with vascular dementia had a signed DNR form, but upon returning from the hospital, their code status was incorrectly updated to full code. The resident expressed a desire for full resuscitation, contradicting the DNR. Staff relied on inconsistent records, risking inappropriate actions during emergencies.
A facility failed to develop a comprehensive care plan for a resident with urinary incontinence. Despite the resident's frequent complaints and observable signs of incontinence, the care plan lacked individualized interventions and goals. Staff interviews revealed a lack of awareness and action regarding the resident's needs, and the facility's policy for individualized care plans was not followed.
The central supply room in the facility was found unlocked on multiple occasions, with hazardous items such as disposable razors and spray lubricant accessible to residents. Staff interviews revealed that the locking mechanism was difficult to engage, leading to the installation of a new self-locking handle. Despite facility policies requiring proper storage of hazardous materials, the room was not consistently locked, posing a potential risk to residents.
A medication cart was found unlocked and unattended in the facility, posing a risk of unauthorized access to medications. Staff interviews revealed a lack of awareness about who left the cart unlocked, although it was acknowledged that carts should be locked when not in use. The facility's policy mandates that medication carts be secured when unattended.
Oxygen Therapy Not Provided at Ordered Settings
Penalty
Summary
The facility failed to ensure that oxygen was administered at the ordered settings for three residents who were receiving respiratory care. Resident #18, a 96-year-old female with COPD, acute and chronic respiratory failure with hypoxia, and dementia, had a physician order for oxygen via nasal cannula at 2 L/min continuously every shift for shortness of breath. During observation, she was receiving oxygen at 4.5 liters via nasal cannula while asleep in bed, and she was not in distress. Resident #57, a female with Alzheimer’s disease, Picks disease, and aphasia, had an active physician order for oxygen via nasal cannula at 2 liters per minute continuously. During observation, her oxygen concentrator was set at 2.5 liters per minute. The record also showed no specific oxygen care plan, although a respiratory infection care plan included oxygen therapy as ordered by the physician. In addition, there was no red oxygen sign posted outside her room indicating oxygen was in use. Resident #22, a female with acute respiratory failure with hypoxia, had a care plan for oxygen therapy related to ineffective gas exchange and an active physician order for oxygen via nasal cannula at 3 liters per minute continuously. During observation, her oxygen concentrator was set at 3.5 liters per minute, and the oxygen tubing was not connected to the humidification bottle on the concentrator. The humidification bottle was present with separate tubing hanging from it, but the resident’s nasal cannula tubing was connected directly to the concentrator. Staff interviews confirmed that nurses were responsible for checking and setting oxygen flow rates, that the settings should match the physician order, and that oxygen signs should be posted outside rooms where oxygen was being used.
Food Storage and Kitchen Sanitation Deficiencies
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for sanitation. During the initial kitchen tour, surveyors observed a large amount of dirt, debris, and grime behind the ice machine and under the sink in the dishwasher area. In the refrigerator, there was a small open container of milk with no opened or use-by dates, and staff water bottles were stored with food items. On the bread cart, multiple bags of bread had no received-by, opened, or use-by dates. In the walk-in cooler, tortillas, a bowl of mixed food, opened waffles, a bag of a thick white substance, opened bread, shredded lettuce, English muffins, and multiple bags of cheese were observed with missing dates, expired dates, or not sealed appropriately. Trays with cups of juice also had no use-by date or time on them, and a sticker with multiple dates was posted at the top of the juice cart instead. Surveyors also observed a bottle of bleach sitting on top of cereal dispensing containers in the kitchen serving area, and pans with scrapes, dings, scratches, and Teflon wear. The facility’s Food Receiving and Storage Policy required food storage areas to be clean, dry foods to be labeled and dated, refrigerated and frozen foods to be covered, labeled, and dated, beverages to be dated when opened and discarded after 24 hours, and toxic substances to be stored separately from food and food preparation equipment. In interviews, the FSD stated food should be labeled with received-by, opened, and use-by dates and discarded if not dated or sealed appropriately, and the RD stated the same. The FSD also stated staff personal items were allowed in the kitchen refrigerator if sealed and dated, while the Adm stated staff should not keep personal items in the kitchen refrigerator because a staff refrigerator was available in the breakroom.
Missing informed consent for psychotropic medication use
Penalty
Summary
The facility failed to ensure that residents were fully informed in advance about the risks and benefits of proposed treatment by not obtaining signed informed consent for psychotropic medication use for 2 of 6 residents reviewed. The deficiency involved Resident #7 and Resident #10, both of whom had diagnoses and care plans involving mood, psychotic, or behavioral symptoms and were receiving medications used as psychotropics without the required documented consent in the record. Resident #7 was a female with schizoaffective disorder, bipolar type, and a quarterly MDS showing severely impaired cognition with a BIMS score of 06. Her care plan identified mood stabilizing medications with potential for complications and included an intervention to obtain medication consents. Her active physician orders included Divalproex 125 mg, 4 capsules by mouth twice daily for paranoid disorder. The record contained a prior consent for Depakote (Divalproex) dated 06/27/2018 for mood disorder with psychotic features, signed by a RN and the resident, but the report did not identify a signed informed consent for the current Divalproex order. Resident #10 was admitted with diagnoses including schizoaffective disorder, depressive type, deaf non-speaking, and recurrent depressive disorders. Her quarterly MDS indicated BIMS could not be completed and her daily decision-making score was 3, meaning she rarely or never made decisions. Her record showed active orders for Depakote Sprinkles 125 mg, 2 capsules twice daily for mood disorder, and Gabapentin 100 mg in the evening for mood disorder, along with prior orders for both medications used for mood, restlessness, or chronic pain. The miscellaneous forms section contained no consent forms for Depakote or Gabapentin, and the resident could not be interviewed because of deafness and blindness. An attempt to contact the RP was unsuccessful. During interview, the ADON stated that psychotropic medications required consent and that consent was needed when a new psychotropic was started, the dose changed, or the medication was stopped and restarted. The DON stated consents should be obtained for psychotropics and/or antipsychotics, but also stated that some medications such as anxiolytics or anti-seizure medications used as psychotropics did not require consent. The facility's psychotropic medication policy stated that before initiating, increasing, or switching psychotropic medication, staff and the physician would review non-pharmacological alternatives, the indication and rationale, the potential risks and benefits, and the resident's or representative's right to accept or decline treatment.
Incomplete OOH-DNR Form
Penalty
Summary
The facility failed to ensure that Resident #57’s out-of-hospital do-not-resuscitate (OOH-DNR) order was completed with the required resident or responsible party signature. Resident #57 was a female admitted to the facility with diagnoses including Alzheimer’s disease and Picks disease. Her face sheet listed an advance directive status of DNR, and her quarterly MDS showed she was rarely or never understood, had impaired short-term and long-term memory, and had severely impaired daily decision making. Her care plan identified a code status of OOH-DNR, and her active physician order was for DNR. Record review of the OOH-DNR form showed it was signed in section C by an adult child as the qualified relative of the incompetent resident, but section F was not completed by the resident, guardian, agent, proxy, or relative signature. The ADON stated the form should have been signed in section F by the physician, two witnesses, and the resident or RP, and that without proper completion it was invalid. The DON stated the DNR or OOH-DNR form was discussed on admission and should have been signed by all required parties, and that if it was not completed properly it was not considered valid.
Unlocked Medication Cart Left Unattended Near Residents
Penalty
Summary
Surveyors identified a deficiency related to medication storage when they observed the 100 Hall nurse medication cart parked at the nurses' station with the lock popped out and all drawers, except the narcotic drawer, accessible. There were no staff members present at the cart, and multiple residents were seated in the front lobby near where the cart was parked. The facility's written policy on Storage of Medications stated that compartments containing drugs and biologicals, including carts, must be locked when not in use. During an interview, the LVN assigned to the 100 Hall cart acknowledged the cart was hers and stated she had not realized she failed to lock it after counting medications with the off‑going nurse. She confirmed she knew she was not supposed to leave the cart unlocked when she walked away and reported she had been in‑serviced on this requirement previously, though she could not recall when. In separate interviews, the DON and the Administrator both stated that medication carts should be locked when not in use so residents do not gain access to medications not prescribed to them, and that nurses had been previously educated and in‑serviced on this policy.
Failure to Accurately Account for and Administer Controlled Substances
Penalty
Summary
The facility failed to ensure the accurate acquiring, receiving, dispensing, and administering of drugs and biologicals for a resident prescribed liquid morphine for pain management. There were multiple discrepancies in the narcotic count sheets, medication administration records (MAR), and the actual physical count of the medication. Specifically, the count of liquid morphine for a resident did not match between the narcotic count sheet and the MAR, with missing doses and unexplained reductions in the amount of medication. An empty morphine bottle was found in the trash, which was against facility policy, and the bottle was not retrieved for investigation. Additionally, there were instances where medication was signed out at times when the nurse was not present in the building, and doses were documented on the narcotic sheet but not in the electronic health record. Nursing staff interviews and observations revealed that the process for counting controlled substances was not consistently followed. During shift changes, one nurse would count the medications while the other would only verify the count on the sheet, without actually observing the physical count or verifying the accuracy of the documentation. Some nurses admitted to not following the correct procedure and not reporting discrepancies or potential drug diversion. There was also confusion and errors in documenting the administration and remaining quantities of morphine, with some nurses unable to explain the discrepancies or the process errors that occurred. The resident involved had significant medical needs, including severe cognitive impairment, chronic pain, and was on hospice care for advanced cancer. The resident's pain management was compromised due to the medication discrepancies, and she reported increased pain after her liquid morphine was discontinued and replaced with other pain medications. The facility's documentation and handling of controlled substances did not comply with policy requirements, and the lack of accurate record-keeping and oversight led to unaccounted doses of narcotics and potential delays in pain management for the resident.
Discrepancy in Resident's Advance Directive Documentation
Penalty
Summary
The facility failed to ensure that a resident's advance directive was accurately reflected in their medical records, leading to a discrepancy in the resident's code status. Resident #47, who had a history of vascular dementia and a moderate cognitive impairment, had a signed Do-Not-Resuscitate (DNR) form from 2019. However, upon returning from a hospital stay, the resident's orders were incorrectly updated to indicate a full code status, despite the resident's previous DNR status. Interviews with the resident and staff revealed confusion regarding the resident's current wishes and the documentation of those wishes. The resident expressed a desire for full resuscitation efforts, contradicting the existing DNR order. Staff members, including a CNA and LVN, indicated that they relied on a binder at the nurse's station and the computer system to verify a resident's code status. However, discrepancies in the records could lead to inappropriate actions during an emergency. The Director of Nursing (DON) and other nursing staff acknowledged the potential for errors when a resident's code status is not consistently documented across all platforms. The DON noted that all orders are discontinued upon a resident's discharge to the hospital, and new orders, including code status, are entered upon their return. This process led to the incorrect full code order for Resident #47, highlighting a gap in communication and documentation that could result in staff performing CPR on a resident with a DNR or failing to perform CPR on a resident who desires it.
Failure to Individualize Care Plan for Urinary Incontinence
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident, specifically addressing her urinary incontinence. The resident, an elderly female, was on diuretic therapy for hypertension, which contributed to her frequent urination and constant wetness. Despite her complaints and the observable signs of urinary incontinence, such as a slight smell of urine and her checking her clothes for dampness, the care plan did not include individualized interventions or goals to manage her condition. The care plan lacked specific strategies like frequent brief checks, clothing changes, or a toileting program, which are essential for addressing her needs. Interviews with staff, including an LVN, ADON, and DON, revealed a lack of awareness and action regarding the resident's complaints and the need for an updated care plan. The LVN acknowledged the absence of personalized care plan elements and indicated that the MDS nurse typically updates care plans, but was unavailable. The ADON and DON also expressed uncertainty about why the care plan was not individualized, despite the resident's frequent complaints. The facility's Care Plan Policy mandates the Interdisciplinary Team to develop individualized care plans, but this was not adhered to in this case, leading to the deficiency.
Unlocked Central Supply Room Poses Hazard
Penalty
Summary
The facility failed to ensure that the central supply room was locked at all times, which could place residents at risk of living in an unsafe environment. On two separate occasions, the central supply room door was observed to be unlocked and easily opened, with a key to the lock hanging on the wall just outside the door. Inside the room, there were various items such as disposable razors, nail clippers, and liquid soap, which were accessible to residents. The presence of these items in an unlocked room posed a potential hazard to residents, as they could harm themselves or others with these items. Interviews with staff members, including a CNA, the DON, and the MS, revealed that the central supply room should be locked at all times, but the locking mechanism was difficult to engage. The CNA mentioned that she would put in a maintenance order for the lock, while the DON and MS confirmed that a new self-locking handle was installed on the door. The MS admitted to using the spray lubricant in the room and forgetting to remove it, acknowledging that it could be harmful if accessed by residents. The ADM also confirmed that the central supply room should be locked and that he was ultimately responsible for its safety. The facility's policies on the storage of supplies and hazardous materials were reviewed, indicating that all supplies and equipment must be stored according to the manufacturer's recommendations and that hazardous materials must be properly stored and labeled. Despite these policies, the central supply room was not consistently locked, and staff members were not fully aware of the potential hazards present in the room. This lack of adherence to policies and procedures contributed to the deficiency in maintaining a safe environment for residents.
Medication Cart Security Lapse
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked compartments, as observed with the overflow medication cart. During an observation, the surveyor found the top drawer of the overflow medication cart unlocked and unattended, with no employee nearby. CMA C, who was interviewed shortly after, stated she was unaware that the cart was unlocked and had not used it since arriving at the facility that morning. She acknowledged that medication carts should not be left unlocked when unattended, as this could lead to unauthorized access and potential misuse of medications. Further interviews with RN E and LVN D confirmed that medication carts should be locked when not in use. RN E, who arrived shortly after the observation, did not know who left the cart unlocked. LVN D stated that if she found an unlocked cart, she would lock it and notify the responsible party and the DON. The DON, who has been with the facility for five years, stated that she had observed unlocked medication carts about once a year and emphasized the importance of keeping them locked to prevent unauthorized access. The facility's policy requires medication carts to be locked and parked at the nurses' station or inside the medication room when not in use.
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Illustrative
What surveyors actually found near you
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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.
Illustrative
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Illustrative
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Nursing homes near Rockport
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Rockport Nursing And Rehabilitation Center | 1.8 mi | ★★★★★ | 4 | 0 |
| Avir At Portland | 19.1 mi | ★★★★★ | 12 | 0 |
| Mission Ridge Rehab & Nursing Center | 23.2 mi | ★★★★★ | 9 | 1 |
| Brookdale Trinity Towers | 27.3 mi | ★★★★★ | 11 | 0 |
| Alameda Oaks Nursing Center | 28 mi | ★★★★★ | 8 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.