Dolphin Pointe Health Care Center

In the surveyor’s words

From the most serious findings on record at Dolphin Pointe Health Care Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Mar 17, 2021

  Based on record reviews and interviews, the facility failed to ensure residents received adequate supervision and assistance to prevent accidents for one (Resident #1) of one resident reviewed for accidents and supervision. On 8/22/2020, Resident #1's Activities of Daily Living (ADL) care was provided by one Certified Nursing Assistant (CNA) rather than by two CNAs as indicated in the nursing and therapy assessments. The resident fell out of bed during ADL care and sustained pelvic and sacral fractures. On 3/16/2021, the facility's census was 49. Any residents who required staff assistance with ADL care were at risk. There were 44 residents who required assistance with ADL care at that time. […]

• Immediate jeopardy, isolatedF726Mar 17, 2021

  Based on observations, interviews, and record reviews, the facility failed to ensure Nurses and Certified Nursing Assistants (CNAs) had the appropriate competencies and skills sets to provide resident-specific care ensuring resident safety as determined by resident assessments. This involved two (Employees B and C) of four CNAs and one (Employee D) of two nurses interviewed at the time of the survey. On 8/22/2020, Resident #1's Activities of Daily Living (ADL) care was provided by one CNA rather than by two CNAs as indicated in the nursing and therapy assessments. The resident fell out of bed during ADL care and sustained pelvic and sacral fractures. Employees B and C were interviewed and were unable to access resident care needs in the electronic Kardexes. […]

• Immediate jeopardy, isolatedF867Mar 17, 2021

  Based on record reviews, staff interviews and a review of the facility's policy and procedure for Quality Assurance Performance Improvement (QAPI), the facility failed to develop and implement appropriate plans of action to correct identified quality deficiencies, particularly those that cause adverse outcomes. This resulted in a lack of improvement of their systems and processes, which placed 44 residents who required assistance with Activities of Daily Living (ADLs), at risk for serious adverse outcomes similar to that of Resident #1. The facility's actions contributed to Resident #1's serious injuries. […]

• No harm, potential for more than minimal, widespreadF812Jan 30, 2026

  Based on observations of kitchen food preparation and storage areas and interviews with staff, the facility failed to adhere to acceptable food storage practices to prevent food contamination or foodborne illness by failing to ensure opened foods were sealed, labeled and dated, and food preparation and storage equipment was clean and sanitary. Food storage and kitchen sanitation is important in health care settings serving nursing home residents. Unsafe food handling practices present a potential source of pathogen exposure and has the potential to affect all residents who consumed foods from the facility, An initial tour of the kitchen was conducted with the Certified Dietary Manager (CDM) on 1/26/26 at 2:15 PM. […]

• No harm, potential for more than minimal, widespreadF812Feb 15, 2024

  Based on the kitchen food service observations, staff interviews, facility record review, and facility policy and procedure review, the facility failed to document temperatures and sanitation, and clean and maintain kitchen foodservice equipment to prevent the outbreak of foodborne illness, with the potential to affect all residents who consumed foods from the facility. The facility failed to maintain temperature logs for the 3-compartment sink and maintain the kitchen oven in a clean and sanitized condition. Food safety and sanitation is important in health care settings serving nursing home residents. Kitchen equipment shall be maintained and kept free of food residue and other debris to avoid a potential source of pathogen exposure. […]