Gulfport Care Center

In the surveyor’s words

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

• Immediate jeopardy, isolatedF609Jun 5, 2025

  Based on interview, facility policy review, and record review, the facility failed to timely report an instance of elopement involving a resident with a history of hallucinations for one (1) of four (4) residents reviewed for accidents and hazards (Resident #55). Resident #55 was observed inside the facility at approximately 4:00 AM on 5/31/25 and was found unsupervised in the facility parking lot by dietary staff at approximately 4:30 AM. Facility staff were unaware the resident had left the facility through an alarmed door, which staff failed to investigate despite hearing the audible alarm. […]

• Immediate jeopardy, isolatedF610Jun 5, 2025

  Based on interview, facility policy review, and record review, the facility failed to initiate an investigation timely when Resident #55, who had a history of hallucinations, exited the facility for one (1) of four (4) residents reviewed for accidents and hazards (Resident #55). Resident #55 was observed inside the facility at approximately 4:00 AM on 5/31/25 and was found unsupervised in the facility parking lot by dietary staff at approximately 4:30 AM. Facility staff were unaware the resident had left the facility through an alarmed door, which staff failed to investigate despite hearing the audible alarm. […]

• Immediate jeopardy, isolatedF689Jun 5, 2025

  Based on observation, interview, record review, and facility policy review the facility failed to ensure supervision and implement adequate safety interventions to prevent accidents for two (2) of four (4) residents reviewed for accidents and hazards (Resident #55 and Resident #47) as evidenced by: 1) failing to monitor door alarms and failing to immediately investigate an active exit alarm to prevent Resident #55 exiting the facility unsupervised and 2) failing to ensure safe transfer techniques when staff manually lifted Resident #47 without the use of the required stand lift, resulting in the resident's foot becoming caught under the wheelchair and causing a right ankle injury. […]

• Actual harm, isolatedF656Jun 5, 2025

  Based on observation, interview, and record review, the facility failed to ensure staff followed the comprehensive care plan for three (3) of twenty (20) sampled residents reviewed for care plan implementation, Resident #164, Resident #47, and Resident #7. Specifically, the facility failed to: 1) provide Percutaneous Endoscopic Gastrostomy (PEG) tube site care for Resident #164, resulting in a purulent wound, 2) failed to ensure a call light was within reach for Resident #7, and 3) failed to use a mechanical lift as directed in the care plan for Resident #47, resulting in a right ankle sprain. Findings include: A review of the facility's policy titled Care Plan Process, with the latest review date of 12/24, revealed, . […]

• Actual harm, isolatedF693Jun 5, 2025

  Based on observation, interview, record review, and facility policy review, the facility failed to ensure proper care and monitoring of enteral feeding and gastrostomy sites as evidenced by not providing timely physician orders, monitoring, and dressing changes for a Percutaneous Endoscopic Gastrostomy (PEG) site which resulted in an infected site with foul-smelling, purulent drainage (Resident #164) and enteral feeding equipment not labeled (Resident #6) for two (2) of two (2) residents reviewed for tube feeding and site care. Findings included: A review of the facility's policy titled Tube Feedings with the latest revision date of 12/15 revealed, . 1. All tube feedings will be administered in accordance with . […]