Gulf Shore Care Center

In the surveyor’s words

From the most serious findings on record at Gulf Shore Care Center, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF812Nov 9, 2023

  Based 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. Findings included: On 11/06/2023 at 9:07 a.m., a general tour of the kitchen was conducted. While conducting the tour, the Dietary Manager was observed operating the dish machine. The dish machine log was reviewed for the week of (10/30-11/05) and revealed daily water temperatures as well as sanitizer concentration logged three times a day except for 11/05 at 1:00 p.m. and 7:00 p.m. […]

• No harm, potential for more than minimal, patternF645Mar 25, 2026

  Based 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 harm, potential for more than minimal, patternF684Mar 25, 2026

  Based 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. […]

• No harm, potential for more than minimal, patternF550Sep 3, 2021

  Based 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. Findings included: During a facility tour on 09/02/21 at 09:12 a.m., an observation was made of Resident #81 being assisted with a breakfast meal. Staff W, CNA (Certified Nursing Assistant) was observed standing by the resident's left side of the bed, while assisting her with meal. On 09/02/21 at 09:19 a.m., an interview was conducted with Staff W, CNA. Staff W stated she works this hall and knows the residents well. […]

• No harm, potential for more than minimal, patternF812Sep 3, 2021

  Based 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. Findings included: On 08/31/21 at 9:35 a.m., an initial tour of the kitchen was conducted with the Kitchen Manager. During the tour, the inside of the ice machine was observed to have brown stains on both sides of the ice machine (photographic evidence obtained). The inside of the microwave was observed with a splattered brown substance (photographic evidence obtained). […]