Gulf Coast Village
Cape Coral, Florida · CCN 105672
21 surveys since 2011. The first finding at harm level was recorded in 2016.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
- Citations on record
- 94
- Surveys
- 21
- Harm or worse
- 20
- Immediate jeopardy
- 12
Findings at the most serious level CMS records.
Older surveys no longer in CMS’s monthly file or on Care Compare. They are shown here.
The facility
- Certified beds
- 85
- Ownership
- Non profit - Corporation
- Chain
- VOLUNTEERS OF AMERICA SENIOR LIVING
- County
- Lee
- Medicare-certified since
- 1989
CMS ratings
- Overall
- —
- Health inspection
- —
- Staffing
- —
- Quality measures
- —
CMS’s own Five-Star ratings.
Compared with similar facilities
Since 2021, this facility recorded more weighted findings than most of its peer group.
Weighted by harm level, against 19 not-for-profit facilities of 66–99 beds in Florida.
Last survey on record
May 26, 2026
167 days ago.
Counts surveys with at least one finding. A clean survey leaves no record here, so the real gap may be shorter.
Staffing
| Measure | This facility | Peer median |
|---|---|---|
| Nurse hours per resident day | 4.93 | 3.98 |
| Registered-nurse hours per resident day | 1.20 | — |
| Annual nurse turnover | 53.6% | 32.1% |
As reported by the facility to CMS, beside the peer-group median.
Enforcement
- Fines
- $37,092 across 3 penalties
- Special focus
- SFF
Federal civil money penalties and remedies as CMS currently publishes them. Amounts may still be under appeal.
Severity of recent findings
| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J— | K419.0% | L— |
| Actual harm | G14.8% | H— | I— |
| No harm, potential for more than minimal | D942.9% | E523.8% | F29.5% |
| No harm, potential for minimal | A— | B— | C— |
Most frequently cited here
In CMS’s current monthly file.
- F6892×
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- F8122×
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- F5781×
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
- F5801×
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
- F5821×
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
In the surveyor’s words
From the most serious findings on record at Gulf Coast Village, in the surveyor’s own words.
- Immediate jeopardy, patternF578Apr 2, 2024
Based on record review, facility's policies and procedures review and staff interviews, the facility failed to ensure staff followed established policies and procedures to honor the advance directives for full code status for 1 (Resident #1) of 3 residents reviewed. On [DATE] at 5:19 a.m., Resident #1 was found unresponsive, without a pulse or respiration. Clinical staff failed to ensure timely confirmation of code status and immediately initiate cardiopulmonary resuscitation (CPR) for Resident #1 who had a full code status. Three Licensed Nurses on duty did not call Emergency Medical Services (EMS) or initiate CPR for 51 minutes while they attempted to locate a non-existent Do Not Resuscitate Order. Resident #1 was pronounced dead by EMS. […]
- Immediate jeopardy, patternF678Apr 2, 2024
Based on record review, facility's policies and procedure reviews and staff interviews the facility staff failed to immediately initiate cardiopulmonary resuscitation (CPR) in the absence of a Do Not Resuscitate (DNR) Order for 1 (Resident #1) of 4 residents reviewed who was found without a pulse or respirations. On [DATE] at 5:19 a.m., Resident #1 was found unresponsive, had no pulse, and no respirations. Clinical staff delayed calling Emergency Medical Services (EMS) and did not initiate CPR for 51 minutes while attempting to locate a non-existent DNR order. CPR is a crucial life-saving technique that aims to sustain blood circulation and oxygenation in individuals experiencing cardiac arrest. […]
- Immediate jeopardy, patternF726Apr 2, 2024
Based on observation, record review, facility's policies and procedures review, and staff interview, the facility failed to ensure nursing staff had the appropriate competencies to immediately initiate lifesaving measures, including cardiopulmonary resuscitation (CPR) when residents with full code status experience cardiac or respiratory arrest. On [DATE] at 5:19 a.m., clinical staff found Resident #1 in cardiac and respiratory arrest. Three nursing staff on duty (two Registered Nurses and one Licensed Practical Nurse) delayed the initiation of CPR and the calling for Emergency Medical Services (EMS) for 51 minutes while they attempted to locate a non-existent Do Not Resuscitate Order. […]
- Immediate jeopardy, patternF835Apr 2, 2024
Based on observation, record review and staff interview, the facility's Administration failed to utilize its resources effectively by failing to ensure staff was adequately trained and knowledgeable in policies and procedures to honor residents' rights to advance directives, including the right to receive cardiopulmonary resuscitation (CPR) in the event of cardiac or respiratory arrest. On [DATE] at 5:19 a.m., Resident #1 was found without pulse or respiration. The clinical staff on duty did not initiate CPR until 6:10 a.m., 51 minutes after Resident #1 was found unresponsive. Resident #1's wishes to be a full code and receive CPR was not documented in the baseline care plan, despite the Social Services Department being aware of the resident's full code status on [DATE]. […]
- Immediate jeopardy, isolatedF600Nov 17, 2022
Based on observation, record review and interview, the facility failed to provide the necessary care and services to prevent the development and promote healing of advanced stage pressure ulcers for 3 of 11 sampled residents (Resident #55, #27, and #74) identified at risk for pressure ulcer development. Resident #55 was admitted on [DATE] with a stage 3 (full thickness tissue loss) pressure ulcer to the coccyx and was dependent on staff for all activities of daily living. The facility neglected to complete a thorough skin assessment upon admission. The pressure ulcer was not identified until 11/4/22 and the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . […]
Read 38 findings in full →The most serious and the most recent: 38 of 94 on record.
Every survey on record
FindingsAt actual harm or above
- May 26, 2026Complaint1 finding
- May 7, 2026Standard2 findings
- Nov 20, 2025Standard10 findings · 1 harm
- May 1, 2025Standard and complaint4 findings · 1 harm
- Nov 7, 2024Standard9 findings
- Apr 2, 2024Complaint4 findings · 4 harm
- Apr 18, 2023Complaint2 findings · 1 harm
- Nov 17, 2022Standard12 findings · 5 harm
Show the 13 earlier surveys
- Oct 8, 2021Complaint3 findings · 1 harm
- Jun 16, 2021Complaint1 finding · 1 harm
- Apr 22, 2021Standard2 findings
- May 12, 2020Complaint3 findings
- Aug 29, 2019Standard1 finding
- Feb 15, 2019Complaint2 findings · 2 harm
- Aug 4, 2017Complaint2 findings · 2 harm
- Aug 11, 2016Standard7 findings · 2 harm
- Jul 16, 2015Standard4 findings
- Aug 14, 2014Standard3 findings
- Sep 12, 2013—7 findings
- Oct 11, 2012—5 findings
- Dec 8, 2011—10 findings
Surveys that found no deficiencies are not in CMS’s files and do not appear here.
Comparable facilities
The nearest facilities to this one in the same peer group, by weighted findings.
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