Gulfside Health and Rehabilitation Center

Inspectors wroteBased on observation, staff interviews, and record review, the facility failed to ensure the kitchen's low temperature dishwashing machine operated per manufacturer specifications. The machine did not reach the required wash and rinse temperatures of at least 120 F (Fahrenheit) in one of one dish machines in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure concerns voiced during resident council meetings were documented and processed as grievances in accordance with facility policy in four of five resident council meetings reviewed (12/5/25, 1/19/26, 3/24/26, and 4/20/26).

Inspectors wroteBased on observations, interviews, and record review the facility failed to maintain a clean, safe, and homelike environment and did not ensure equipment was properly maintained and functional in multiple areas of the building. Deficient environmental conditions were identified on the smoking patio, in the north unit shower room, and in ten of the seventeen resident rooms on the north unit (Rooms 120, 121, 122, 124, 126, 129, 130, 131, 134, and 135).

Inspectors wroteBased on observations, interviews, and record review, the facility did not ensure infection control standards were followed related to a urinary catheter drainage bag for one resident (#71) out of two residents with an indwelling urinary catheter.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to maintain an environment free of pests in one unit (South) of two units observed. Findings Included: On 06/09/2026 at 11:43 a.m., a medium sized brown roach was observed crawling on the floor in room [ROOM NUMBER]. On 06/09/2026 at 9:44 a.m., multiple flies were observed in room [ROOM NUMBER], including a fly landing on a resident's face. Staff were observed fanning at the insect; no additional interventions were implemented at the time. On 06/11/2026 at 2:04 p.m., Staff T, Licensed Practical Nurse (LPN) stated she had seen roaches in the facility, especially palmetto bugs. On 06/11/2026 at 2:07 p.m., Staff U (Housekeeper) reported seeing roaches sporadically in the facility. On 06/11/2026 at 2:08 p.m., Resident #10 stated, I saw a fly this morning. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure activities of daily living (ADL) care was provided in a manner that maintained dignity and privacy for one resident (#2) out of 20 reviewed.

Inspectors wroteBased on observations and interviews, the facility failed to provide prior notification to residents before temporarily displacing them from their rooms for deep cleaning, affecting two residents (#27 and #39) out of eight reviewed.

Inspectors wroteBased on record review and interviews, the facility failed to follow its grievance process related to missing personal belongings for one resident (#27) of three residents sampled.

Inspectors wroteBased on record review and interviews the facility failed to provide the resident/resident representative with proper notice regarding Nursing Home Transfer and Discharge, Bed Hold Policy, and Ombudsmen Notification for two residents (#68 and #74) out of five sampled. Findings Included: 1) Review of Resident #68's admission record revealed an initial admission date of 4/13/26 and a readmission date of 5/16/26 with diagnoses to include: hepatic failure, bipolar disorder, chronic obstructive pulmonary disease (COPD), portal hypertension, viral hepatitis, hepatic fibrosis, and hepatomegaly with splenomegaly. Review of Resident #68's order summary report, including active orders as of 5/13/26, revealed no physician order for hospital transfer dated 5/13/26. Review of Resident #68's general note, dated 5/14/26 at 4:46 a.m. revealed hospitalized / admitted . [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure residents were provided services in the most appropriate setting to meet their needs by following Level II Preadmission Screening and Resident Review (PASRR) recommendations for two residents (#4 and # 37) out of five residents reviewed for PASRRs.

Inspectors wroteBased on record review and interviews the facility failed to ensure PASRR Level I was accurate for one Resident (#9) out of eight residents sampled

Inspectors wroteBased on observation, record review, and interviews, the facility failed to ensure a care plan was revised for one resident (#53) out of twenty residents reviewed.

Inspectors wroteBased on observations, interviews, and medical record review, the facility failedto provide one resident (#39) with meals free from ingredients the resident wasallergic to during one of six meals observed.

Inspectors wroteBased on observations, record reviews and interviews, the facility failed to ensure one resident (#12) received dialysis services consistent with professional standards of practice out of three residents sampled.

Inspectors wroteBased on observations, interviews and record review, the facility failed to providetrauma informed care to eliminate or mitigate triggers that may cause re-traumatizationfor one resident (#39) diagnosed with Post Traumatic Stress Disorder (PTSD)out of four residents sampled.

Inspectors wroteBased on record review and interviews, the facility failed to ensure side effect monitoring was implemented based on pharmacy recommendations for psychotropic medications for one resident (#2) out of five residents sampled.

Inspectors wroteBased on observations, record reviews, and interviews the facility failed to ensure a medication error rate of less than 5.00%. Forty-seven medication administration opportunities were observed, and three errors were identified for two residents (#23 and #47 ) out of four residents observed. These errors constituted a 6.38% medication error rate.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure medications were properly labeled, dated, and stored according to manufacturer guidelines and professional standards of practice in one medication cart (2 North) of three medication carts observed. Findings Included:During an interview and observation of the 2 North medication cart on 6/8/26 at 9:45 a.m. with Staff A, Licensed Practical Nurse (LPN) the following improperly labeled and undated medications were stored:Resident #17: Albuterol AER HFA inhaler found undated, with no open date or expiration date visible. Resident #7: Fluticasone/Salmeterol inhaler open and undated, with no open date or expiration date recorded. Resident #34: Novolog FlexPen found open but not dated, leaving the beyond-use date unable to be determined. [...]

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to coordinate and ensure follow up dental services for one resident (#27) out of eight residents sampled.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a scheduled meal was provided for one resident (#39) out of forty-one observed, during one of four days observed.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure: a) residents were provided a nourishing nighttime snack by failing to follow the standardized recipe and b) cartons of milk were held under 41 degrees Fahrenheit during one (on 6/10/26) of six meal services observed.

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide adequate supervision for four (#5, #6, #3, and #7) of four residents in a manner that protected them from falls resulting in injuries.

Inspectors wroteBased on record reviews and interviews the facility failed to report an injury of unknown origin following an unwitnessed fall for one (#5) out of two residents sampled.

Inspectors wroteBased on interviews, record reviews, and review of facility policy, the facility failed to provided physician ordered medications to one (Resident #2) of three residents sampled for pharmacy services.

Inspectors wroteBased on interview, record review and review of the facility's policy, the facility failed to complete the Preadmission Screening and Resident Review (PASARR) Level II upon a new qualifying mental health diagnosis and / or ensure the accuracy of a PASARR Level I for 4 (#13, #17, #46, #42) of 7 sampled residents with mental health diagnoses

Inspectors wroteBased on observation, interviews and review of the facility's policy titled Use and Storage of Food brought in by Family of Visitors, the facility failed to ensure food items were stored in accordance with professional standards for food service safety for one refrigerator (dining area) out of three refrigerators reviewed in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure one (Residents #29) of three residents sampled for Beneficiary Notice, received Beneficiary Notice when discharged from a Medicare covered Part A stay and remained in the facility. Findings Included: Review of documentation provided by the facility's Director of Social Services related to Beneficiary notification for Resident #29 revealed a last covered Medicare Part A Day was 10/27/2023 and he remained in the facility. Documentation on the SNF Beneficiary Protection Notification Review form revealed a SNF ABN Form CMS -10055 (Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNFABN)) form was not provided to the resident. Continued review of the form revealed a handwritten note under Other Explain which indicated Resident payor source changed on 10/28/2023 and remained in the facility. [...]

Inspectors wroteBased on interviews and record review, the facility failed to provide discharge documentation for two residents (#265, # 61) out of eight residents sampled. Findings Included 1. Review of the admission Record revealed Resident #265 was admitted [DATE] with a primary diagnosis of Type 2 Diabetes Mellitus without Complications, Difficulty in Walking, not elsewhere classified, major depressive disorder, recurrent, moderate, other specified persistent mood disorders, depression, unspecified. Review of Nursing progress note dated 12/22/2023 showed Resident #265 wanted to discharge Against Medical Advice (AMA) and had been informed of the risk. It was noted that he signed all the paperwork and was escorted to the front door with all his belongings. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure the comprehensive Minimum Data Set (MDS) assessment was accurately coded for one (Resident #8) of fifteen sampled residents.

Inspectors wroteBased on record review, interviews, and review of the facility's policy titled Resident Assessment-Coordination with PASARR Program, the facility failed to ensure the Level I Preadmission Screening and Resident Review (PASRR) was accurate upon admission for two (Resident #38 and #47) of fifteen residents sampled for PASRR review.

Inspectors wroteBased on record review and interview, the facility failed to provide care and services related to 2 of 2 sampled residents (#13 and #49). Resident #13 lacked documentation related to a new diagnoses of melanoma, biopsy, care, and documentation of the characteristics of the wound. Resident #49 lacked follow up regarding need for antibiotics with the physician and Hospice.

Inspectors wroteBased on interview and record review, the facility failed to provide adequate care related to pressure ulcer care for 1 of 3 sampled residents (#17). The facility failed to document the characteristics of the pressure ulcer in the medical record.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure one resident (# 4) was assessed to conduct self- catheterization out of four residents sampled.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the medication error rate was below 5% for three (#10, #31, #35) of 6 sampled residents who were administered medications. This resulted in 3 errors of 30 medication administration opportunities for a medication error rate of 10%.

Inspectors wroteBased on observation, interviews and review of the facility's policy titled Food: Quality and Palatability the facility failed to serve food at an appetizing temperature for one Resident (#48) out of 15 sampled residents reviewed for food services.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff followed acceptable standards of practice related to infection control including hand hygiene, disinfecting of the glucose monitoring machines, and water testing.

Inspectors wroteBased on interview and record review, the facility failed to review and revise the Person-Centered Comprehensive Care Plan for 1 (#13) of 28 sampled residents related to a new diagnoses of Melanoma requiring a biopsy and wound care.

Inspectors wroteBased on medical record review, staff and resident/resident representative interviews, the facility failed to provide requested medical record access, and copies of medical records for one (#2) of two sampled residents.

Inspectors wroteBased on staff and resident representative interviews, and medical record review, the facility failed to provide one (#2) of two sampled residents with a Bed Hold Notice, prior to and/or after the resident was transferred to a higher level of care facility.

Inspectors wroteBased on observations, staff and resident interview and record review, the facility failed to ensure two residents (#21 and #16) of twenty-four sampled residents were invited and accommodated with activities that met their interest, and to group activities scheduled during three of three days observed (12/27/2021, 12/28/2021 and 12/29/2021).

Inspectors wroteBased on observations, staff interview and facility record review, the facility failed to ensure the daily nurse staffing numbers were posted to reflect the current date for one day (12/27/2021) of three days observed.