Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Gulf Shores Rehabilitation & Healthcare Center during CMS and state inspections, most recent first.
Surveyors found that the facility failed to keep several hazard-prone areas secured, including an open chemical storage room with cleaning agents on one hall, an unlocked shower room containing hair and body cleaning products on another hall, and an unlocked supply closet housing an unprotected electrical fuse box. Staff interviews revealed that a housekeeper and CNAs had left these doors open or unlocked after retrieving supplies or transporting a resident, despite acknowledging that residents with dementia or Alzheimer's could enter these areas, slip and fall, lock themselves in, ingest chemicals, or access the fuse box.
A resident with dementia, ESRD on dialysis, impaired vision, and a severely impaired BIMS score had a designated responsible party, but the facility’s BOM bypassed this representative and obtained the resident’s signature on a retirement income address‑change form so the facility could receive pension checks directly. The BOM did not verify the resident’s cognitive status or consult the MDS nurse, despite acknowledging that low BIMS scores indicate inability to make informed decisions and that policy requires the representative’s signature. The resident’s representative, who worked part‑time at the facility, reported she was not contacted, questioned the authenticity of the printed signature, and stated the resident could not make such financial decisions. A CNA reported she did not witness the resident sign the form and described the resident’s cognition as poor, while the Administrator maintained that the resident could make his own decisions regardless of the low BIMS score, resulting in the facility failing to honor the representative’s authority.
The facility did not promptly report suspected abuse, neglect, or theft, nor did it communicate the results of its investigation to the proper authorities as required.
A deficiency was cited when a facility area was found to contain accident hazards and lacked adequate supervision to prevent accidents. The environment did not meet required safety standards, resulting in insufficient oversight.
Surveyors found that the facility did not have an infection prevention and control program in place, resulting in a lack of established measures to prevent and control infections among residents and staff.
The facility did not post daily nurse staffing data for 43 days, as required by policy. The DON admitted the HR person responsible for this task was absent, and he was too busy to maintain the postings. This lapse could prevent access to important staffing information.
The facility failed to implement comprehensive care plans for three residents, leading to deficiencies in addressing medical needs. A resident's care plan lacked Enhanced Barrier Precautions for a dialysis catheter, another resident's plan did not address frequent removal of oxygen, and a third resident's arterial wound was not included in their care plan. These oversights were acknowledged by staff but not corrected in the care plans.
A resident with type 2 diabetes and moderate cognitive impairment did not receive her prescribed Tresiba FlexTouch Solution Pen Injector on 8 out of 9 occasions in November. RN A held the medication without notifying the physician or documenting it, despite no hold parameters. The DON was unaware of the pattern and acknowledged the importance of following physician orders. The facility's policy requires medications to be administered as prescribed and any concerns to be discussed with the prescriber.
A resident with diabetes did not receive their prescribed insulin, Tresiba, on 8 out of 9 occasions, and the facility failed to notify the physician. The resident's medical records showed a pattern of missed doses without a physician's order to hold the medication. Interviews with staff revealed a lack of communication and documentation, and the DON was unaware of the issue, leading to a deficiency identified by surveyors.
A facility failed to update a resident's care plan to reflect the removal of a urinary catheter, despite the change being noted in the quarterly MDS. The resident, with severe cognitive impairment and multiple diagnoses, had the catheter removed, but the care plan still indicated its presence. Staff interviews revealed that the MDS Coordinator missed updating the care plan, and the DON acknowledged the oversight.
A facility failed to ensure a resident's medi-port was accessed and flushed according to policy and physician's orders. The resident, with multiple health conditions, had inconsistencies in the documentation of medi-port procedures. Despite the resident expressing concerns about dehydration and urinary health, these were not documented or addressed by staff. The DON admitted that nurses lacked proper training for medi-port maintenance, contributing to the deficiency.
A facility failed to ensure proper placement of fall mats for a resident with a history of falls, as only one side of the bed had a mat despite the care plan requiring mats on both sides. Staff interviews confirmed the oversight, acknowledging the importance of mats in preventing injuries. The facility's Fall Prevention Program policy was not adequately followed, potentially risking resident safety.
A facility failed to ensure nursing staff were trained in managing an implanted medi-port for a resident, leading to missed flushes and improper documentation. The resident, with multiple health conditions, had inconsistencies in her Medication Administration Records, and staff interviews revealed a lack of training and confusion about orders. The Director of Nursing acknowledged the lapse in resuming orders for the saline flush, contributing to the deficiency.
Unsecured Chemical, Shower, and Supply Rooms Create Accident Hazards
Penalty
Summary
The facility failed to ensure that multiple areas were secured to keep the resident environment as free of accident hazards as possible. During an initial observation of the 400 wing, surveyors found the chemical storage room door wide open, with kitchen cleaning agents and other cleaning supplies accessible and no staff present in the hallway to monitor the area. On the 500 wing, the shower room was observed left unlocked after use, with hair and body cleaning agents inside. A CNA assigned to the 500 hall reported that she had taken a resident back to their room after a shower and left the shower room door open while transporting the resident. She acknowledged that leaving the door open posed a danger to residents with dementia or Alzheimer's, who could enter, slip and fall, lock themselves in, or ingest cleaning solutions like shampoo. On the 200 wing, the supply closet door was observed unlocked, and the closet contained an electrical fuse box that itself had no lock. A CNA and the ADON stated that only they had keys to this supply room and that it was their responsibility to ensure the door remained closed and locked. The CNA stated she must have left the door unlocked after retrieving supplies and recognized that a cognitively impaired resident could enter, lock themselves in, and open the fuse box, leading to electrocution. Another CNA assigned to the 200 hall stated she did not know the supply room had been left unlocked but understood that it was normally kept locked and that it was dangerous for residents to enter due to the fuse box. Staff interviews across these incidents consistently acknowledged that unsecured chemical rooms, shower rooms, and supply rooms with an electrical fuse box posed dangers to residents, particularly those with Alzheimer's or dementia.
Failure to Honor Resident Representative’s Authority in Financial Decision‑Making
Penalty
Summary
The deficiency involves the facility’s failure to recognize and honor the authority of a resident’s representative in financial decision‑making, despite the resident’s severe cognitive impairment. The resident was a 97‑year‑old male with dementia, end‑stage renal disease requiring dialysis, restlessness and agitation, hypertension, impaired vision, and a BIMS score of 3 indicating severe cognitive impairment. His care plan identified impaired cognitive function/dementia and directed staff to monitor and report changes in decision‑making ability and mental status. The face sheet listed a family member as the responsible party. During observation, the resident appeared flustered, had difficulty hearing, and was unable to understand and respond to surveyor questions, making interview attempts unsuccessful. The Business Office Manager (BOM) learned from the state that the resident had additional retirement income, which increased his monthly liability for room and board and resulted in an outstanding balance. The BOM reported that the responsible party had been keeping the extra retirement check and had entered into a promissory note to pay the balance. Instead of obtaining the responsible party’s signature, the BOM approached the resident directly in the hallway with a retirement income address‑change form so the facility could receive the retirement checks. The BOM stated she assumed the resident could make his needs known and did not verify the resident’s BIMS score or consult the MDS nurse, despite acknowledging that a low BIMS score would indicate the resident was not cognitively able to make an informed decision and that policy and procedure required obtaining the responsible party’s or appointed family member’s signature. The resident’s representative reported she did not understand why the BOM did not contact her at the facility where she worked part‑time and stated she believed the resident could not make such financial decisions due to his BIMS of 3. She also questioned the authenticity of the resident’s signature on the address‑change form, noting that the signature was printed while the resident normally signed in cursive. The BOM claimed a CNA had witnessed the signature, but the CNA stated she never saw the resident sign the form and only saw the BOM later waving the paper and saying she had obtained a signature. The CNA also described the resident’s cognitive status as poor, with difficulty remembering recent events and uncertainty about whether he could understand what he was signing. The Administrator stated that the resident could make decisions for himself regardless of the low BIMS score and that the state would have to deem a resident incompetent by court for the facility to take over financial responsibility, reinforcing that the facility treated the resident’s signature as valid rather than deferring to the designated representative.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on the facility's lack of prompt action in notifying the appropriate agencies when an incident of suspected abuse, neglect, or theft occurred. The report indicates that the required notifications and investigation results were not communicated as mandated.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified due to the failure to ensure that a specific area within the facility was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, which resulted in the presence of accident hazards and insufficient oversight to prevent potential incidents. No additional details regarding the specific hazards, the individuals involved, or their medical conditions at the time of the deficiency are provided in the report.
Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program. This deficiency was identified during the survey process, as the facility did not have an established or operational program to prevent and control infections among residents and staff. The absence of such a program was directly observed and documented by surveyors.
Failure to Post Daily Nurse Staffing Data
Penalty
Summary
The facility failed to post daily nurse staffing data at the beginning of each shift in a prominent place accessible to residents and visitors. This deficiency was observed for 43 consecutive days, from early February to late March. During an observation on March 22, the surveyor noted that the nurse staffing data displayed was outdated, showing a date from early February. The Director of Nursing (DON) acknowledged the lapse, explaining that the Human Resources (HR) person responsible for completing and posting the form had not been working for about a month. In the HR person's absence, the DON was responsible for this task but admitted to being too busy to maintain the postings. The facility's policy requires that within two hours of each shift's start, the number of licensed and unlicensed nursing personnel responsible for direct resident care be posted in a clear and readable format. This information should include the facility name, date, resident census, shift schedule, and the type and category of nursing staff working each shift. The failure to adhere to this policy could prevent residents, families, and visitors from accessing important information about the staffing levels responsible for resident care.
Failure to Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for three residents, which did not include measurable objectives and timeframes to meet their medical, nursing, and psychosocial needs. Resident #14's care plan did not reflect the need for Enhanced Barrier Precautions for his right chest wall dialysis catheter, despite having severe cognitive impairment and being dependent on renal dialysis. The care plan lacked specific interventions for managing the Perma catheter, which is crucial for preventing infections and complications. Resident #24, who is cognitively intact, frequently removed her oxygen cannula and tubing, yet her care plan did not address this behavior. Despite physician orders for continuous oxygen therapy, observations and interviews revealed that she often did not wear her oxygen, and staff were aware of this issue. The Director of Nursing acknowledged that the care plan should have included this behavior to ensure proper management and intervention. Resident #37 had an arterial wound on his right heel, which was not included in his care plan. Despite having a moderate cognitive impairment and being at risk for pressure ulcers, the care plan did not reflect the wound care orders. Interviews with the MDS Coordinator and DON revealed that the wound was overlooked in the care planning process, although the resident was receiving wound care and weekly skin assessments. The facility's policies emphasize the importance of updating care plans as residents' conditions change, but this was not adhered to in these cases.
Failure to Administer Tresiba as Prescribed
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically regarding the administration of Tresiba FlexTouch Solution Pen Injector. The resident, a female with type 2 diabetes mellitus and moderate cognitive impairment, was supposed to receive 62 units of Tresiba subcutaneously once a day. However, RN A did not administer the medication on 8 out of 9 opportunities in November 2024, despite there being no hold parameters for the medication. The resident's blood sugar levels were recorded on the days the medication was held, but the physician was not notified of the medication being withheld, nor was it documented in the progress notes. The Director of Nursing (DON) was unaware of the pattern of missed doses and stated that the facility's process involved pulling an orders report daily, but it did not indicate when medications were not given. The DON acknowledged the importance of following physician orders to prevent undesired consequences and stated that any held medication should be communicated to the physician immediately. The facility's Medication Administration Policy requires medications to be administered as prescribed and any concerns about dosages to be discussed with the prescriber. The physician was also unaware of the medication being held and expressed that he would have expected to be notified to provide clarification and ensure effective care for the resident.
Failure to Notify Physician of Held Medication
Penalty
Summary
The facility failed to immediately inform a resident, consult with the resident's physician, and notify the resident's representative when there was a significant change in the resident's status. Specifically, the facility did not notify the physician when a resident's prescribed medication, Tresiba, was not administered on 8 out of 9 occasions. This failure was identified during a review of the resident's medical records and interviews with facility staff. The resident involved was a female with a history of type 2 diabetes mellitus with hyperglycemia and diabetic polyneuropathy, as well as a cognitive communication deficit. The resident's medication administration record indicated that the prescribed insulin, Tresiba, was held by a registered nurse on multiple occasions without a physician's order to do so. The facility's Director of Nursing (DON) and other staff members were unaware of the pattern of missed doses and did not notify the physician, which could have led to complications in the resident's health. Interviews with facility staff revealed that there was a lack of communication and documentation regarding the held medication. The DON and other staff members acknowledged the importance of following physician orders and notifying the physician when medications are held. However, the facility's procedures for monitoring medication administration and notifying physicians were not effectively implemented, leading to the deficiency identified by the surveyors.
Failure to Update Care Plan for Resident Without Urinary Catheter
Penalty
Summary
The facility failed to ensure that the comprehensive care plan for a resident was periodically reviewed and revised by a team of qualified persons after each assessment. Specifically, the care plan for a resident who no longer had a urinary catheter was not updated to reflect this change. The resident, a male with severe cognitive impairment and multiple diagnoses including end-stage renal failure and dementia, had his urinary catheter removed on a specific date, but this change was not documented in his care plan. Despite the removal of the catheter being noted in the resident's quarterly MDS, the care plan still indicated the presence of a Foley catheter. Interviews with facility staff revealed that the MDS Coordinator was responsible for updating care plans as conditions and needs changed, but missed the removal of the urinary catheter for this resident. The Director of Nursing (DON) acknowledged that the catheter should have been removed from the care plan when the orders were discontinued, attributing the oversight to a lapse in their process. The facility's policy requires that care plans be revised when there is a significant change in a resident's condition and at least quarterly, but this was not adhered to in this instance.
Failure to Properly Access and Flush Resident's Medi-Port
Penalty
Summary
The facility failed to ensure that a resident's implanted medi-port was accessed and flushed according to policy and physician's orders. The resident, a cognitively intact female with multiple diagnoses including epilepsy, heart failure, and dysphagia, had a medi-port that was not consistently accessed or flushed as required. The Medication Administration Records (MAR) showed discrepancies in the documentation of the medi-port access and flushes, with several instances where the procedures were either not signed off or not performed as scheduled. Interviews with the resident revealed that she felt dehydrated and had concerns about her urinary health, which she communicated to the nursing staff. However, the staff interviews indicated that these concerns were not documented or addressed. The resident also mentioned that she was told the facility would not pay for the necessary kits to flush her port if she did not allow the procedure to be done correctly. Additionally, the resident's care plan indicated the presence of an implanted port, but there was no clear documentation of the orders to resume or discontinue the flushes after they were put on hold. The facility's Director of Nursing (DON) acknowledged that the nurses were not properly trained or in-serviced on accessing and maintaining the medi-port. The facility's policies required staff to have training and demonstrated competency in intravenous therapy, but this was not adhered to. The lack of proper documentation and training, along with the failure to follow physician orders, contributed to the deficiency in providing appropriate treatment and care for the resident.
Failure to Ensure Proper Placement of Fall Mats
Penalty
Summary
The facility failed to ensure that the environment for a resident was free from accident hazards and that adequate supervision and assistance devices were provided to prevent accidents. Specifically, the facility did not ensure that floor mats were in place on both sides of the bed for a resident who had a history of falls. Observations revealed that the resident had a floor mat on the left side of the bed but not on the right side, despite the care plan indicating the need for fall mats as an intervention following multiple unwitnessed falls. Interviews with staff, including a CNA, an LVN, and the DON, confirmed that the floor mats were intended to prevent injuries in case of a fall and should have been placed on both sides of the bed. The staff acknowledged their responsibility to ensure the mats were correctly positioned but admitted they had not noticed the missing mat. The facility's Fall Prevention Program policy required assessments and specific interventions to minimize falls, but the lack of proper mat placement indicated a failure to adhere to these guidelines, potentially placing the resident at risk for injury.
Inadequate Training and Management of Implanted Medi-Port
Penalty
Summary
The facility failed to ensure that nursing staff were adequately trained and competent in managing and maintaining an implanted medi-port for a resident, leading to potential risks for the resident's health. The resident, a cognitively intact female with multiple diagnoses including epilepsy, heart failure, and dysphagia, had an implanted medi-port that required regular flushing. However, the facility did not provide the necessary education to the nursing staff on the protocols for accessing and flushing the medi-port, resulting in missed flushes and improper documentation. The resident's Medication Administration Records (MAR) and Treatment Administration Records (TAR) showed inconsistencies and omissions in the scheduled flushes of the medi-port. For instance, the MAR for November 2024 indicated that a scheduled saline flush was not signed as performed, and similar issues were noted in previous months. Additionally, there was confusion among the nursing staff regarding the orders for flushing the medi-port, with some staff members incorrectly believing that the port was being flushed with heparin, despite no such order existing. Interviews with the nursing staff and the Director of Nursing (DON) revealed a lack of training and annual skills checkoffs for managing implanted medi-ports. The DON acknowledged that the order for the saline flush was put on hold and never resumed, leading to further confusion and improper care. The facility's policies on intravenous catheter management and documentation were not adhered to, contributing to the deficiency in care for the resident.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Falfurrias
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Lone Star Ranch Rehabilitaion And Healthcare Cente | 25.7 mi | — | 3 | 0 |
| Kingsville Nursing And Rehabilitation Center | 26.1 mi | — | 5 | 0 |
| Meridian Care Of Hebbronville | 33.7 mi | — | 6 | 0 |
| Meridian Care Of Alice | 36.8 mi | — | 9 | 4 |
| Windsor Nursing And Rehabilitation Center Of San D | 37.5 mi | — | 0 | 0 |
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