Health inspection·May 1, 2025

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on record review and interview, the facility failed to ensure physician's orders received via text for 1 (Resident #92) of 3 residents reviewed for change in condition were immediately documented, signed, dated, and implemented, creating the potential for a negative outcome. Residents Affected - Few The findings included: On 4/28/25 at 12:32 p.m., in a telephone interview Resident #92's son said he visited his father on 12/23/24. He said his father had not been feeling right, had been cold and shaky. The son said he explained to the nurse that his father had problems in the past with potassium levels and asked if they could get the doctor to check his potassium levels. Record Review of Resident #92's chart revealed no progress notes were documented on 12/23/24, no documentation of notification to the physician was found for 12/23/24, no orders were found to be entered on 12/23/24 and no lab work was taken on 12/23/24. Further review of Resident #92's chart revealed a change of condition note dated 12/24/24 at 4:34 a.m., indicating the resident was exhibiting Altered mental status and Diarrhea. A progress note dated 12/24/24 at 5:16 a.m., documented the Resident was observed with acute change in condition at 4:15., a.m. EMS (Emergency Medical Services) was called, Resident #92 was emergently transferred to stretcher via EMS at 4:30 a.m. EMS noted Resident #92 was without pulse and breath as transferring to ambulance and began chest compressions. EMS observed coding patient while in ambulance in parking lot for approximately 20-25 minutes prior to departure for hospital and writer was told resident in cardiac arrest when departing parking lot at 5:05 a.m. Resident transferred to hospital. On 4/30/25 at 11:00 a.m., the Advanced Practice Registered Nurse (APRN) reviewed Resident #92's medical record. In an interview, she said she found nothing in the nursing log with a request from the family. She said his last lab draw was on 12/14/24, the potassium level was normal. The last time she saw Resident #92 on12/6/24, he was at baseline with no complaints. She said in the progress notes it looked like Resident #92's diarrhea started around December 20 or 21st. She said, normally they would order lab work with persistent diarrhea. On 4/30/25 at 11:57 a.m., the APRN returned and explained she found a text message in her phone dated 12/23/24 at 3:32 p.m. from the facility. The text message said Resident #92, is trembling and complaining of being cold, his son believes something isn't right since he recently was admitted to hospital for hypokalemia, vital signs within normal limits, alert and oriented times 3, blood sugar 148. Son is requesting lab work. Last labs was 12/14. The APRN responded to the text on 12/23/24 at (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 105672 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105672 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/01/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gulf Coast Village 1333 Santa Barbara Blvd Cape Coral, FL 33991 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)