Gulf Pointe Plaza

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents who needed respiratory care were provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 3 of 10 residents (Resident #18, Resident #57, and Resident #22) reviewed for respiratory care. 1. The facility failed to ensure Resident #18's oxygen was administered at the correct setting on 03/08/2026 as ordered by the physician. 2. The facility failed to ensure Resident #57's oxygen was administered at the correct setting on 03/08/2026 as ordered by the physician. 3. The facility failed to post an oxygen sign outside of the room indicating Resident #57 received oxygen on 03/08/2026 4. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for sanitation. The facility failed to properly label and date open, shelf stable food. The facility failed to dispose of expired shelf stable and refrigerated food. The facility failed to ensure containers and bags of food were sealed appropriately. The facility failed to ensure behind the ice machine and under the sink were clean. The facility failed to ensure all dry and/or shelf stable foods were labeled with received by, opened, and use by dates. The facility failed to ensure pans were free from dents and dings, as well as from having the Teflon scraped off. The facility failed to ensure there were no chemicals stored in the kitchen or serving area. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure residents had the right to be fully informed in advance about the risks or benefits of any proposed treatment that may affect the resident's well-being for 2 of 6 (Resident #7 and Resident #10) residents reviewed for psychotropic medication consents. 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents had the right to request, refuse, and or discontinue treatment and to formulate an advance directive for 1 (Resident #57) of 5 residents reviewed for Advance Directives. The facility failed to ensure Resident #57's OOH-DNR was completed. The OOH-DNR form did not have the resident or RP signature. This failure could affect residents who have implemented Advance Directives and established their choice to not be resuscitated to a risk of receiving CPR and being resuscitated against their wishes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all drugs and biologicals were stored appropriately for 1 of 4 medication carts (100 Hall Nurse Med-Cart) reviewed for storage. The facility failed to ensure the 100 Hall Nurse Med-Cart was locked and secured. This failure could have placed residents at risk of gaining access to unlocked medications which were not prescribed to them and could have caused them harm.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident for 1 of 5 residents (Resident #1) reviewed for pharmacy services. The facility failed to ensure LVN A's medication cart on hall 400 and MAR contained an accurate count and record for Resident #1's liquid Morphine (a narcotic used to treat pain). This failure could place residents at risk for drug diversion and/or a delay in medication administration, as well as risk of not having allegations investigated or timely.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents had the right to formulate an advance directive for 1 of 8 residents (Resident #47) reviewed for advanced directives. The facility failed to revise orders for Resident #47's code status from full code to DNR after his return from the hospital to correctly reflect the resident's wishes. The resident had a signed DNR form from 2019, but also had an active order for full code. This deficient practice could affect residents who require care and monitoring and place them at risk of not receiving the care and services to meet their needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop a comprehensive care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs, as well as describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 5 residents (Resident #7) reviewed for care plans in that: The Facility failed to ensure that Resident #7's care plan was revised, updated and individualized with interventions and goals to address Resident #7's urinary incontinence. This deficient practice could place residents in the facility at risk of not being provided with the necessary care or services and not having personalized or individualized plans developed to address specific needs or concerns.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the resident environment remained free of accident hazards as is possible for 1 of 1 central supply room reviewed for the environment. The facility failed to maintain and assure the central supply room was locked at all times. This failure could place residents at risk of living in an unsafe environment.

Inspectors wroteBased on observation and interview, the facility failed to ensure all drugs and biologicals were stored in locked compartments and labeled in accordance with currently accepted professional principles reviewed for medications stored in 1 of 7 medication carts (Overflow cart) reviewed for storage. The facility failed to keep the overflow cart locked when not in use. This failure could place residents in the facility at risk of drug diversion or misuse of medications leading to harm.

Inspectors wroteBased on interview, and record review, the facility failed to maintain an infection and prevention control program that included, at a minimum, a system for preventing and controlling Legionella through a program that identifies areas in the water system where Legionella can grow and spread for the facility reviewed for infection control. The facility failed to have a system in place for preventing and controlling Legionella through a program that identifies areas in the water system where Legionella can grow and spread. This deficient practice place the facility residents at risk for airborne infections.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store all drugs and biologicals in locked compartments on 1 of 5 medication carts reviewed for storage of drugs. Nurses' Medication Cart was left unattended, unlocked and medication cart keys left in medication cart lock by nurse's station area. This deficient practice could affect residents who have medications on the Nurses' Medication Cart and could result in lost medications, drug diversion, or harm due to accidental ingestion of unprescribed medications.