Gulf Shore Care Center

Inspectors wroteBased on observation, interviews and record reviews the facility failed to ensure Pre admission Screening and Resident Review (PASARRs) were accurate for five residents (#78, #5, #77, #2, #8) out of six residents sampled. Findings Included: 1. Review of Resident #78's admission record revealed an admission date of 02/20/2026. Resident #78 was admitted to the facility with diagnosis to include post-traumatic stress disorder, unspecified, major, depressive disorder, recurrent, moderate, alcohol abuse, and generalized anxiety disorder. Review of Resident #78's PASARR dated 02/20/2026 revealed section A. MI (Mental illness) was blank. Section II. Questions 1-7 were marked no. Section III revealed it was marked: no to provisional admission. IV. No diagnosis or suspicion or Serious MI or ID indicated. Level II PASARR eval not required was marked. 2. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents received care and treatment in accordance with professional standards of practice, the comprehensive care plan, and resident choice related to: 1) positioning of one (Resident #18), 2) communication with hospice for one (Resident #14), and 3) documentation of physician orders related to behavior monitoring, medications administration, wound care and tube feeding for three (Resident #5, Resident #11 and Resident #1) of six residents sampled. Findings Included: During an observation on 3/22/2026 at 12: 30 p.m., Resident #18 was observed in the dining room sitting in her wheelchair. Resident #18's torso was shifted off center towards the left of the wheelchair. During an observation on 03/23/2026 at 1:22 p.m., Resident #18 was observed sitting in a wheelchair near the nurse's station. [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure the resident's right to be treated with dignity was honored, related to untimely incontinence care, resulting in anxiety for one resident (#13) out of one resident sampled.

Inspectors wroteBased on observations, interviews and record reviews the facility failed to ensure a call light was within reach for one (Resident #127) out of one residents sampled. Findings Included: During an observation on 3/23/2026 at 2:36 PM Resident #127 was observed seated in a wheelchair on the right side of the bed, facing east, a table in front of him with an open styrofoam container with spaghetti and meatballs. Resident #127 raised his left wrist and pointed saying pain. Resident #127 pointed to his neck with his right hand and said pain. I have told many people, and they have not done anything. I cannot walk or move and my pants are dirty. Resident #127's call light was observed to be hanging on the left side of his bed, out of his reach. During an observation on 3/24/2026 at 8:49 AM Resident #127 was observed wearing a hospital gown, sitting on the right side of the bed facing the door. [...]

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure the comprehensive Minimum Data Set (MDS) was accurately coded for two (2) out of six sampled residents (Resident #6 # 77).

Inspectors wroteBased on observations, record reviews and interviews, the facility failed to ensure appropriate supervision during smoking time for one (Resident #77) out of four residents sampled.

Inspectors wroteBased on observations, record reviews and interviews, the facility failed to ensure a medication was obtained one (Resident #27) of seven residents sampled.

Inspectors wroteBased on observations, interviews, and record review the facility did not ensure narcotics were double locked and stored safely, medications were labeled with an opened date and an expiration date, and thickened liquids requiring refrigeration were removed from one of two medication storage rooms and one of four medication carts.

Inspectors wroteBased on observation, record review, and staff interview, the facility failed to ensure the sanitizer solution reached the low temperature dish machine by way of pump and tubing, failed to maintain the chlorine concentration between 50-100 ppm (parts per million) per manufacturer recommendations, and failed to maintain the ice machine in one of two nourishment rooms in a clean and sanitary manner.

Inspectors wroteBased on observations, interviews, and review of facility policy, the facility failed to ensure appropriate care and services for urinary catheters were provided to prevent infection for one (Resident #455) of one resident sampled for urinary catheters.

Inspectors wroteBased on observation, interview, and review of facility procedures, the facility failed to ensure proper storage of respiratory equipment in accordance with professional standards of practice for two (Resident #92 and Resident #32) of two residents sampled for respiratory care.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure the medication error rate was less than 5.00%. Twenty-five medication administration opportunities were observed and eleven errors were identified for one (Resident #355) of three residents. These errors constituted a 44% medication error rate. Findings Include: On 11/08/23 at 10:55 a.m., an observation of medication administration with Staff C, Registered Nurse (RN) was conducted for Resident #355. Staff C dispensed the following medications: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure drugs and biologicals were labeled and stored in accordance with professional standards by 1.) failing to ensure medications were securely stored and dispensed for two (Resident #83 and Resident #355) of thirty five sampled residents, 2.) failing to ensure one of six medication carts in the facility were kept locked when unattended by staff, 3.) failing to ensure medications were properly dated when opened in three of three medication carts, and 4.) failing to ensure medication carts were free of expired medications in one of three medication carts.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure meals were served in a dignified manner related to: 1) Staff standing when assisting residents with a meal for four (#81, #16, #15, and #19) of four residents observed; and 2) waiting for greater than 30 minutes for meal assistance for one resident (#19) of four residents observed.

Inspectors wroteBased on observations, record review, and staff interviews, the facility failed to ensure the kitchen was maintained in a sanitary manner, and food was stored appropriately related to maintenance of the ice machine, maintenance of the microwave, maintenance of the dish machine, and dating opened foods in the walk-in cooler.

Inspectors wroteBased on record reviews, interviews, and a review of the policy and procedure Resident Mistreatment, Neglect and Abuse Prohibition Guidelines, the facility failed to ensure an alleged allegation related to abuse for one resident (Resident #32) out of the sampled twenty-nine residents was reported immediately to the governing agency in accordance with the State law.

Inspectors wroteBased on record reviews and interviews, the facility failed to take the appropriate actions in response to an alleged violation related to abuse inflicted by direct care staff such as thoroughly investigate the alleged violations to prevent further abuse, neglect, and mistreatment from occurring for one resident (Resident #32) out of the sampled twenty-nine residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the medication error rate was below 5.00%. A total of twenty-five medications were observed administered and two errors were identified for two (Resident #81 and #258) of five residents observed. These errors constituted a medication error rate of 8.00 percent.

Inspectors wroteBased on observation, interviews and record review the facility failed to ensure medications were secured appropriately, as evidenced by: 1) an unsecured and unattended box of medications on top of one (300 hall) of three medication carts observed; 2) loose and unidentified medications in two (100 hall and 300 hall) of three medication carts observed; and 3) staff personal items stored in one (100 hall) of three medication carts observed.

Inspectors wroteOn 09/01/21 at 09:22 a.m., a tour of hall 100 was conducted. An observation was made of Staff Z, CNA going room to room picking up breakfast trays from 09:22 a.m. to 09:32 a.m. Staff Z, was observed without wearing a gown in rooms noted with droplet precautions posted on the doors. Staff Z, went to room [ROOM NUMBER] walked out without tray, went to room [ROOM NUMBER] and grabbed a tray, then room [ROOM NUMBER], 105 and 107, grabbing trays. Staff Z then went back to room [ROOM NUMBER] and was there for 5 minutes and walked out with a tray. Staff Z was observed without a gown during the entire process and did not change gloves or use ABHR between room to room encounters. An interview was conducted with Staff Z on 09/01/21 at 09:32 a.m. Staff Z stated that she was going in to pick up trays and assist the residents who are finishing up with breakfast. [...]