Gulf Pointe Plaza

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. The facility failed to ensure Resident #22's oxygen was administered at the correct setting on 03/08/2026 as ordered by the physician. 5. The facility failed to ensure Resident #22's oxygen tubing was connected to humidification. These failures…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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.The facility failed to ensure no staff items were being stored in the kitchen refrigerators. These failures could have placed residents at risk of ingesting foreign objects as well as possible foodborne illnesses.The findings…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. The facility failed to obtain a signed informed consent for Resident #7's Divalproex (a medication used to treat seizures, but could also be used to treat anxiety [intense, excessive and persistent worry and fear about everyday situations], depression [a mood disorder which caused a persistent feeling of sadness and loss of interest], schizophrenia [a severe mental disorder which affects how a person thinks, feels, and behaves, often leading to hallucinations, delusions, and disorganized thinking], and bipolar disorder [a mental health condition characterized by extreme mood swings which include emotional highs and lows]). 2. The facility failed to obtain a signed informed consent for Resident…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. The findings included: Record review of Resident #57's face sheet dated [DATE] revealed she was a [AGE] year-old female admitted to the facility on [DATE]. Resident #57's diagnoses included Alzheimer's Disease (a progressive disorder which is the most common cause of dementia, characterized by memory loss, cognitive decline, and behavioral changes) and Picks Disease (a progressive and degenerative brain disease which usually affects people under…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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.The findings included:An observation on 01/20/2026 at 3:47 PM of the 100 Hall Nurse Med-Cart parked at the nurses' station revealed an unlocked medication cart. The lock on the cart was popped out, and all drawers except the narcotic drawer were able to be accessed. There was no staff observed at the cart, but there were multiple residents sitting out in the front lobby close to where the cart was parked. In an interview on 01/20/2026 at 3:48 PM LVN-A stated 100 Hall Nurse Med-Cart was hers, and she had not realized she had not locked the med-cart back after counting medications with the off-going nurse. LVN-A stated she knew she was not…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings included:Record review of Resident #1's face sheet dated 04/19/25 revealed a [AGE] year-old female with an admission date of 04/19/25. Diagnoses included Warnicke's Encephalopathy (a brain disorder caused by a severe deficiency of thiamine (vitamin B1), Alzheimer's, Chronic Respiratory Failure (advanced lung disease which makes it progressively harder to breathe over time and can lead…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. The findings included: Record Review of Resident #47's face sheet dated [DATE] revealed a [AGE] year-old male with an initial admission date of [DATE] and a current admission date of [DATE]. Pertinent diagnosis included Vascular Dementia (general term describing problems with reasoning, planning, judgment, memory and other thought processes caused by brain damage from impaired blood flow to your brain).…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings included: Record review face sheet, on 12/18/2024 at 3:17 PM, revealed Resident #7 was a [AGE] year-old-female with an original…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. The findings include: Observation of the central supply room door on 12/17/24 at 8:25 AM revealed the door was unlocked and easily opened. There was a key to the lock hanging on the wall just outside of the door. There was a sign on the door that read, Staff Only Do Not Enter. In the room were 12 closed boxes and one open box of disposable razors. There were 6 boxes of loose nail clippers, and 1 large box full of multiple individual bottles of liquid soap. The items were in cubby type shelves located from the floor to approximately waist high. Observation of the central supply room door on 12/18/24 at 9:18 AM revealed the door was unlocked and easily opened. There was one can of spray lubricant,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. Findings included: During an observation at 7:15 AM on 12/17/24, this surveyor pulled the top drawer of the overflow medication cart and it opened. The overflow medication cart was unlocked with no employee nearby. During an interview with CMA C at 7:16 AM on 12/17/24, CMA C stated she was not aware the medication cart was unlocked until she saw the drawer open. CMA C stated she arrived at the facility this morning at around 5:45 AM. CMA C stated the cart that was left unlocked was the overflow cart where they store extra medications for residents. CMA C stated she had not used the overflow cart yet since…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. The findings included: An interview on 09/27/23 at 10:28 AM with the Maintenance Director revealed he did not know what Legionnaire's was. He stated he had been working at this facility for three and a half years. The Maintenance Director stated the facility water is on city water and that he visually inspects water. The Maintenance Director stated to his knowledge, there was no system to monitor effectiveness of control measures. He stated that he had no training upon hire. He was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. Findings included: Observation on 09/25/23 at 1:45 PM revealed a medication cart was left unlocked, unattended and medication cart keys left in medication cart lock by nurse's station. There was one resident about 5 to 10 feet away from cart and one nurse located at the nurses station out of view of the unlocked medication cart. This surveyor opened the top drawer recognizing the cart being unlocked. Multiple medications in bulk bottles and blister packs were easily assessable for removable. The DON walked by approximately 5 to 10 minutes later and was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.