Inspection Reports for
Gulf Coast Village
1333 Santa Barbara Blvd, Cape Coral, FL 33991, FL, 33991
Back to Facility ProfileDeficiencies (last 9 years)
Deficiencies (over 9 years)
4.4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
4% better than Florida average
Florida average: 4.6 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Annual Inspection
Deficiencies: 10
Date: Nov 20, 2025
Visit Reason
The inspection was conducted as an annual recertification survey to assess compliance with regulatory requirements related to resident care, safety, and facility operations.
Findings
The facility was found deficient in multiple areas including failure to notify family of resident condition changes, incomplete beneficiary notices, failure to notify the Long-Term Care Ombudsman of discharges, inadequate resident activities, unsafe mechanical lift transfers causing injury, improper medication storage, unsanitary food storage and pest control issues, incomplete clinical documentation, and ineffective quality assurance processes related to falls and food safety.
Deficiencies (10)
F 0580: The facility failed to notify Resident #115's representative of a change in condition requiring new medication and lab tests, and failed to document this notification.
F 0582: The facility failed to ensure Advance Beneficiary Notices for Residents #66 and #92 were complete and accurately reflected residents' decisions regarding skilled services and financial liability.
F 0628: The facility failed to notify the Long-Term Care Ombudsman of resident discharges and transfers as required.
F 0679: The facility failed to provide activities that met the interests and needs of Resident #7, including assistance to attend activities and documentation of participation.
F 0689: The facility failed to ensure safe mechanical lift transfers for Resident #14, resulting in a bruise due to improper sling placement and lack of safety belt use.
F 0761: The facility failed to properly store medications securely, with medications left unattended at bedside, unlocked medication carts, and improperly stored controlled substances.
F 0812: The facility failed to store, prepare, distribute, and serve food in accordance with professional standards, including unsanitary kitchen conditions, uncovered and undated food, and presence of flying insects in dining areas.
F 0842: The facility failed to ensure clinical records were complete and accurate for Residents #115, #34, and #109, including failure to document change in condition, notification, and bathing/showering refusals.
F 0867: The facility failed to develop and implement effective quality assurance actions to address falls and ongoing food safety deficiencies, with inconsistent fall data reporting and lack of documented corrective actions.
F 0925: The facility failed to maintain an effective pest control program, with observations of multiple flying insects in dining areas and documented pest control issues in the memory care unit.
Report Facts
Fall incidents: 2
Fall incidents: 7
Fall incidents: 9
Fall incidents: 14
Fall incidents: 13
Fall incidents: 16
Resident discharges: 244
Resident transfers to hospital: 65
Resident discharges to assisted living: 20
Resident discharges home: 120
Resident transfers to skilled nursing: 5
White blood cell count: 37.3
Bruise size: 11.5
Bruise size: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA Staff H | Certified Nursing Assistant | Involved in mechanical lift incident with Resident #14 |
| CNA Staff G | Certified Nursing Assistant | Named in mechanical lift incident investigation |
| Director of Nursing | Director of Nursing | Interviewed regarding documentation and facility practices |
| Administrator | Nursing Home Administrator | Interviewed regarding Advance Beneficiary Notices and quality assurance |
| Activity Assistant Staff C | Activity Assistant | Interviewed about Resident #7's activity participation |
| Director of Rehab | Director of Rehabilitation | Interviewed about Resident #14's mechanical lift use |
| RN Staff J | Registered Nurse | Verified medication cart observations |
| RN Staff E | Registered Nurse | Verified medication cart and cream observations |
| RN Staff F | Registered Nurse | Verified medication cart and controlled substance storage |
| Certified Dietary Manager | Certified Dietary Manager | Interviewed about kitchen sanitation and food safety |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jul 28, 2025
Visit Reason
State-compiled facility profile showing 22 inspections from 2017 to 2025 with deficiency history and inspection statuses.
Findings
Across multiple inspections, the facility had several inspections with deficiencies cited and corrected, but many inspections showed no deficiencies. The most recent inspections indicate no deficiencies.
Report Facts
Inspections on page: 22
Inspection Report
Complaint
Deficiencies: 0
Date: Jul 28, 2025
Visit Reason
No deficiencies noted during this complaint inspection.
Findings
No deficiencies noted during this complaint inspection.
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: May 1, 2025
Visit Reason
The inspection was conducted due to a complaint regarding failure to immediately document, sign, date, and implement physician's orders received via text for Resident #92, which potentially led to a negative outcome.
Complaint Details
The complaint involved failure to document and implement physician's orders received via text for Resident #92. The complaint was substantiated based on record review and interviews.
Findings
The facility failed to ensure that physician's orders received via text for Resident #92 were properly documented and acted upon. The resident experienced an acute change in condition and was emergently transferred to the hospital, but the stat lab orders were never documented or carried out.
Deficiencies (1)
F 0684: The facility failed to ensure physician's orders received via text for Resident #92 were immediately documented, signed, dated, and implemented, creating potential for harm. The stat lab order was never documented or carried out despite the APRN's response to the text message.
Report Facts
Residents reviewed for change in condition: 3
Date of last lab draw: Dec 14, 2024
Date of change of condition note: Dec 24, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Interim Director of Nursing | Interim Director of Nursing | Interviewed regarding text order procedures and documentation |
| Advanced Practice Registered Nurse | APRN | Reviewed medical record and responded to text order |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: May 1, 2025
Visit Reason
The inspection was conducted following a complaint alleging verbal and mental abuse of a resident and failure to provide necessary care for activities of daily living, as well as sanitary concerns in food service.
Complaint Details
The complaint involved allegations of verbal and mental abuse toward Resident #35, which was partially substantiated as the resident reported feeling humiliated by a CNA's behavior. The facility investigated, removed the staff member from the schedule, and reported the incident. The resident did not ultimately consider the behavior abusive but rude. Additional complaints included failure to provide grooming care to Resident #12 and sanitary issues in the kitchen.
Findings
The facility failed to protect a resident from verbal and mental abuse, failed to provide adequate grooming care for a resident dependent on staff, and failed to maintain sanitary conditions in the kitchen, including an unclean ice machine and staff not wearing proper hair restraints.
Deficiencies (3)
F 0600: The facility failed to protect residents from verbal and mental abuse, resulting in humiliation for Resident #35 due to a caregiver's derogatory language and dismissive behavior during incontinent care.
F 0677: The facility failed to provide necessary grooming care for Resident #12, who had long, untrimmed fingernails with brown substance under them despite documented bathing assistance.
F 0812: The facility failed to maintain sanitary conditions during food service, including a visibly soiled ice machine, inadequate sanitizer levels, and kitchen staff not wearing proper hair restraints, posing a risk of food contamination.
Report Facts
Residents Affected: 1
Residents Affected: 1
Residents Affected: Many
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff H | Certified Nursing Assistant (CNA) | Named in verbal and mental abuse finding involving Resident #35 |
| Staff G | Licensed Practical Nurse (LPN) | Documented Resident #35 crying and provided PRN medications |
| Staff F | Registered Nurse (RN) | Interviewed regarding Resident #35's care and condition |
| Staff I | Certified Nursing Assistant (CNA) | Interviewed regarding Resident #12's fingernail care |
| Staff J | Registered Nurse (RN) | Observed Resident #12's fingernails and commented on their length |
| Staff C | Lead Chef | Interviewed regarding kitchen sanitation and ice machine cleaning |
| Certified Dietary Manager (CDM) | Verified kitchen sanitation issues and ice machine cleaning logs | |
| Director of Nursing (DON) | Director of Nursing | Interviewed about abuse investigation and staff suspension |
| Administrator | Administrator | Interviewed about abuse report and responsibility for nail care documentation |
Inspection Report
Routine
Deficiencies: 9
Date: Nov 7, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident rights, care planning, medication management, activities, catheter care, IV therapy, medication storage, food safety, and staffing data submission.
Findings
The facility was found deficient in multiple areas including failure to promptly address resident grievances, incomplete PASRR screening, inadequate drug regimen review for residents on psychotropic medications, insufficient activities for transitional care residents, unjustified use of indwelling urinary catheter, lack of physician orders for PICC care, unsecured medication storage, improper dishwasher sanitizer monitoring, unsanitary food storage, and failure to submit required staffing data to CMS.
Deficiencies (9)
F 0565: The facility failed to act promptly on grievances expressed during resident council meetings, with no documentation or resolution tracking of complaints about staffing and call light response.
F 0644: The facility failed to complete an accurate Level I PASRR for Resident #38 with severe mental illness, resulting in lack of appropriate specialized treatment.
F 0656: The facility failed to conduct a drug regimen review as required for Resident #252 receiving psychotropic medications who sustained multiple falls.
F 0679: The facility failed to provide ongoing resident-centered activities meeting the needs of Transitional Care Unit residents, with no organized activities or staff engagement observed.
F 0690: The facility failed to justify continued use of an indwelling urinary catheter for Resident #252, lacking documentation of voiding trials or urology consultation.
F 0694: The facility failed to obtain physician orders for care and management of a PICC line for Resident #84, with a soiled dressing observed and no documented orders for dressing changes.
F 0761: The facility failed to ensure all drugs and biologicals were stored securely in locked compartments, with medications left unattended in a resident's room and pharmacy bags left accessible at the nurses' desk.
F 0812: The facility failed to ensure dietary staff were trained and competent to test the sanitizer in the low temperature dishwasher, failed to document sanitizer levels, and stored food unsanitarily with pests and bio growth observed.
F 0851: The facility failed to submit required direct care staffing data to CMS Payroll-Based Journal for the third quarter of 2024, resulting in a one-star rating and documented staffing deficiencies.
Report Facts
Falls: 7
Staffing Quarter: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff V | Unit Manager | Verified Resident #252 sustained multiple falls and lack of drug regimen review documentation. |
| Staff W | Licensed Practical Nurse (LPN) MDS Coordinator | Described falls review process and care plan updates. |
| Staff X | Life Enrichment Volunteer Coordinator | Reported on TCU activity calendar and staffing. |
| Staff Y | Activity Assistant | Described TCU as rehabilitation-focused with therapy as main activity. |
| Staff A | Registered Nurse (RN) | Acknowledged leaving medications unattended on resident bedside table. |
| Staff B | Registered Nurse (RN) | Verified no physician orders for PICC care for Resident #84. |
| Administrator | Discussed staffing data submission issues and grievance documentation. | |
| Director of Nursing (DON) | Verified lack of physician orders for PICC care and discussed Resident #252's falls. | |
| Executive Chef | Reported lack of training on dishwasher sanitizer testing and booster heater backorder. | |
| Certified Dietary Manager (CDM) | Reported dishwasher sanitizer not monitored and food storage issues. | |
| Regional Nurse Consultant (RNC) | Verified unattended pharmacy medication bags at nurses' desk. |
Inspection Report
Routine
Deficiencies: 0
Date: Oct 17, 2024
Visit Reason
No deficiencies noted during this standard inspection.
Findings
No deficiencies noted during this standard inspection.
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Apr 2, 2024
Visit Reason
The investigation was initiated due to a complaint regarding failure to honor a resident's advance directives and delay in initiating CPR for Resident #1 who was found unresponsive without pulse or respirations.
Complaint Details
The complaint investigation focused on the delay in initiating CPR and failure to honor Resident #1's full code advance directive. The delay was 51 minutes from when Resident #1 was found unresponsive to CPR initiation. The complaint was substantiated with Immediate Jeopardy determined and later removed after corrective actions.
Findings
The facility failed to ensure timely initiation of CPR and calling EMS for Resident #1 with full code status, resulting in a 51-minute delay. Staff were not adequately trained or competent in CPR and advance directive policies. The resident's full code status was not documented in the baseline care plan and staff did not follow established procedures. Immediate Jeopardy was determined and later removed after corrective actions including staff education, audits, and mock drills.
Deficiencies (4)
F578: The facility failed to honor the resident's right to request, refuse, or discontinue treatment and to formulate an advance directive, resulting in delayed CPR for Resident #1.
F678: The facility failed to provide basic life support, including CPR, prior to the arrival of emergency medical personnel for Resident #1 found without pulse or respirations.
F726: The facility failed to ensure nursing staff had appropriate competencies to immediately initiate lifesaving measures including CPR for residents with full code status.
F835: The facility administration failed to utilize resources effectively by not ensuring staff were adequately trained and knowledgeable in policies to honor residents' advance directives and provide CPR.
Report Facts
Delay in CPR initiation: 51
Time EMS called: 6.14
Time EMS arrived: 6.24
Number of mock code drills: 5
Number of employees in mock drills: 18
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN Staff A | Registered Nurse | Involved in delay of CPR initiation and code status confusion |
| LPN Staff B | Licensed Practical Nurse | Assisted in CPR initiation after delay, involved in code status confusion |
| RN Staff C | Registered Nurse | Assisted in CPR initiation after delay, involved in code status confusion |
| Administrator | Facility Administrator | Oversaw investigation and corrective actions |
| Director of Nursing | Director of Nursing | Responsible for staff training and compliance, interviewed regarding staff competencies |
| Staff Educator | Registered Nurse Staff Educator | Provided education and conducted code blue drills post-incident |
Inspection Report
Complaint
Deficiencies: 2
Date: Nov 30, 2023
Visit Reason
Deficiencies related to resident care and do not resuscitate orders were identified.
Findings
Deficiencies related to resident care and do not resuscitate orders were identified.
Deficiencies (2)
Tag A0031 — RESIDENT CARE - THIRD PARTY SERVICES
Tag A0076 — DO NOT RESUSCITATE ORDERS (DNROS)
Inspection Report
Annual Inspection
Deficiencies: 0
Date: May 8, 2023
Visit Reason
Annual survey inspection of Gulf Coast Village nursing home to assess compliance with health and safety regulations.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Annual Inspection
Deficiencies: 2
Date: Apr 18, 2023
Visit Reason
The inspection was conducted as a standard regulatory survey to assess compliance with nursing home regulations, including resident safety and medication management.
Findings
The facility failed to provide adequate supervision to prevent avoidable falls, resulting in a resident sustaining a major injury and subsequent death. Additionally, the facility failed to ensure medications were properly secured, posing a potential hazard to residents.
Deficiencies (2)
F 0689: The facility failed to provide necessary supervision and assistance to prevent avoidable falls for Resident #900, resulting in a fall with major injury and transfer to a higher level of care. Resident #900 was found on the floor with a large scalp laceration and later passed away at the hospital.
F 0761: The facility failed to ensure all medications were locked and secured in medication and treatment carts when unattended, creating potential hazardous health consequences for residents.
Report Facts
Residents Affected: 1
Residents Affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Licensed Practical Nurse | Confirmed treatment cart was unlocked and unattended |
| CNA Staff A | Provided interview about Resident #900 fall incident |
Inspection Report
Complaint
Deficiencies: 0
Date: Dec 7, 2022
Visit Reason
No deficiencies noted during this complaint inspection.
Findings
No deficiencies noted during this complaint inspection.
Inspection Report
Complaint
Deficiencies: 1
Date: Jun 6, 2022
Visit Reason
Deficiency related to resident care rights and facility procedures was identified.
Findings
Deficiency related to resident care rights and facility procedures was identified.
Deficiencies (1)
Tag A0030 — RESIDENT CARE - RIGHTS & FACILITY PROCEDURES
Inspection Report
Routine
Deficiencies: 6
Date: Aug 2, 2021
Visit Reason
Multiple deficiencies related to staffing standards, staff training, and background screening were identified.
Findings
Multiple deficiencies related to staffing standards, staff training, and background screening were identified.
Deficiencies (6)
Tag A0078 — STAFFING STANDARDS - STAFF
Tag A0081 — TRAINING - STAFF IN-SERVICE
Tag A0082 — TRAINING - HIV/AIDS
Tag A0086 — TRAINING - ADRD
Tag A0090 — TRAINING - DO NOT RESUSCITATE ORDERS
Tag CZ816 — BACKGROUND SCREENING-COMPLIANCE ATTESTATION
Inspection Report
Complaint
Deficiencies: 0
Date: Apr 26, 2021
Visit Reason
No deficiencies noted during this complaint inspection.
Findings
No deficiencies noted during this complaint inspection.
Inspection Report
Complaint
Deficiencies: 0
Date: Jan 12, 2021
Visit Reason
No deficiencies noted during this complaint inspection.
Findings
No deficiencies noted during this complaint inspection.
Inspection Report
Complaint
Deficiencies: 0
Date: Jul 28, 2020
Visit Reason
No deficiencies noted during this complaint inspection.
Findings
No deficiencies noted during this complaint inspection.
Inspection Report
Complaint
Deficiencies: 0
Date: Mar 18, 2020
Visit Reason
No deficiencies noted during this complaint inspection.
Findings
No deficiencies noted during this complaint inspection.
Inspection Report
Complaint
Deficiencies: 0
Date: Oct 28, 2019
Visit Reason
No deficiencies noted during this complaint inspection.
Findings
No deficiencies noted during this complaint inspection.
Inspection Report
Deficiencies: 0
Date: Mar 28, 2019
Visit Reason
No deficiencies noted during this expansion inspection.
Findings
No deficiencies noted during this expansion inspection.
Inspection Report
Deficiencies: 0
Date: Feb 13, 2019
Visit Reason
No deficiencies noted during this monitor inspection.
Findings
No deficiencies noted during this monitor inspection.
Inspection Report
Routine
Deficiencies: 2
Date: Oct 3, 2018
Visit Reason
Deficiencies related to background screening clearinghouse and compliance attestation were identified.
Findings
Deficiencies related to background screening clearinghouse and compliance attestation were identified.
Deficiencies (2)
Tag CZ814 — BACKGROUND SCREENING CLEARINGHOUSE
Tag CZ816 — BACKGROUND SCREENING-COMPLIANCE ATTESTATION
Inspection Report
Complaint
Deficiencies: 0
Date: Mar 21, 2018
Visit Reason
No deficiencies noted during this complaint inspection.
Findings
No deficiencies noted during this complaint inspection.
Inspection Report
Deficiencies: 0
Date: Mar 21, 2018
Visit Reason
No deficiencies noted during this monitor inspection.
Findings
No deficiencies noted during this monitor inspection.
Inspection Report
Deficiencies: 0
Date: Mar 6, 2017
Visit Reason
No deficiencies noted during this initial licensure inspection.
Findings
No deficiencies noted during this initial licensure inspection.
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