Gulf Shores Rehabilitation and Healthcare Center

In the surveyor’s words

From the most serious findings on record at Gulf Shores Rehabilitation and Healthcare Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Aug 7, 2026

  Based on interview and record review, the facility failed to ensure each resident receives adequate supervision and assistance devices to prevent accidents for 1 (Residents #1) of 5 residents reviewed for accidents and supervision. The facility did not provide Resident #1 with adequate supervision while wandering. Resident #1 entered another resident's room and obtained a regular textured food item leading to Resident #1 choking and dying on 08/03/2026. The non-compliance was identified as past non-compliance. The Immediate Jeopardy began on 08/03/26 and ended on 08/04/26. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk of sustaining serious injury, harm, and death. […]

• No harm, potential for more than minimal, widespreadF880Sep 14, 2023

  Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention program to provide a safe and sanitary environment for 1 of 1 laundry room, and 1 of 1 facility reviewed for infection control, in that: 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 by not testing for Legionella and not implementing a system for doing so. […]

• No harm, potential for more than minimal, patternF689Apr 27, 2026

  Based on observation and interview the facility must ensure that the resident environment remains as free of accident hazards as is possible 1.The facility failed to ensure the shower door in the 500 hall was closed shut and locked after use. 2.The facility failed to ensure the chemical storage closet in the 400 hall was closed shut was locked after use. 3.The facility failed to ensure the supply closet door in the 200 hall was locked which contained an unlocked electrical fuse box. These failures have the potential to result in serious injury. The findings included: In the initial facility observation on 04/27/26 at 9:53 AM the chemical room door of the 400 wing was left wide open containing cleaning agents for the kitchen and cleaning supplies with no staff in the hallway to monitor. […]

• No harm, potential for more than minimal, patternF656Dec 4, 2024

  49157 Based on observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 3 (Resident #14, Resident #24, and Resident #37) of 8 residents reviewed for care plans. 1. The facility failed to ensure that Resident #14's care plan reflected the need for Enhanced Barrier Precautions regarding Resident #14's right chest wall dialysis catheter. 2. […]

• No harm, potential for more than minimal, patternF558Sep 14, 2023

  Based on observation, interview ad record review the facility failed to ensure residents received services in the facility with reasonable accommodations of each resident's needs for 4 of 8 residents (Resident #20, Resident #35, Resident #59, and Resident #68) reviewed for call lights in that: The facility failed to ensure Resident # 18's call light was within reach, had a clip on it, was positioned where she could use it, and was appropriate for her needs The facility failed to ensure Resident # 28's call light was within reach, had a clip on it, and was positioned where she could use it The facility failed to ensure Resident # 40's call light was within reach, had a clip on it, and was positioned where she could use it The facility failed to ensure Resident # 43's call light was within… […]