Inspection visit
Inspection
14 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 14 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0585
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must
establish a grievance policy and make prompt efforts to resolve grievances.
Based on interview and record review, the facility failed to make prompt efforts to resolve a grievance for
one (Resident #77) of one resident reviewed for personal property (missing clothing) from a total sample of
53 residents.
The findings include:
On 02/13/24 at 12:54 pm, Resident #77 stated he lost his pants on two different occasions. He could not
remember the exact dates, but stated it was around August 2023 and December 2023. He added that he
notified the certified nursing assistant (CNA), but he could not recall the employee's name. He also notified
the housekeeping director. Per the resident, the facility had not done anything about it. He stated at one
time he even provided the receipt when he bought replacement pants, but the facility never reimbursed him.
He stated he had already lost the new pants that he bought despite putting his name on them. He was
frustrated because he liked a particular brand of pants.
The quarterly minimum data set (MDS) assessment, with an assessment reference date (ARD) of
12/11/23, revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15
possible points, indicating that he was cognitively intact.
A review of the facility's Grievance Log from August 2023 through February 2024 revealed that there were
no grievances documented for Resident #77.
In an interview on 02/14/24 at 10:59 am, the Housekeeping Supervisor stated when residents were
admitted to the facility she introduced herself within 24 hours. If the resident chose to have their laundry
done by the facility, she took the clothing to the laundry for labeling. She added that she also encouraged
residents who wanted family to do their laundry to have their clothing labeled in case the clothing was
inadvertently sent to the laundry. When asked how residents' clothing was sent to the laundry, she said,
Residents' clothes are sent to the laundry with the linen. When it gets to the laundry, it is sorted and
washed separately. Normally residents have their clothes back within 24 hours. She was asked to explain
the process if she was notified that a resident had missing clothing items. She stated she checked the lost
and found, and if the items could not be located, the resident was asked for the clothing receipt and social
services took over from there for reimbursement of the lost items. She was asked if she was aware that
Resident #77 had missing pants. She confirmed that the facility did this resident's laundry. She stated the
resident reported his missing pants but she could not find them. She added that she reported this to the
Social Services Director and the resident provided the receipt, but she was not sure if the resident was
reimbursed.
On 02/14/24 at 11:32 am, an interview was conducted with the Assistant Administrator. She stated
(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 18
Event ID:
106135
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
106135
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/15/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Dolphin Pointe Health Care Center
5355 Dolphin Point Blvd
Jacksonville, FL 32211
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)
F 0585
Level of Harm - Minimal harm
or potential for actual harm
she was stepping in for the Social Sservices Director who was on leave. She was asked to explain the
facility's process for residents' personal items that went missing. She stated if the laundry department could
not locate the missing items, the resident was asked to provide the receipts for reimbursement. She was
asked if Resident #77 had a grievance related to missing clothing items, and she replied, I am not sure but I
will check. For the grievance I am aware of, I think the daughter was reimbursed.
Residents Affected - Few
On 02/14/24 at 3:06 pm, the Assistant Administrator stated she checked the facility's records and she could
not find a formal grievance filed for Resident #77. She stated she contacted the daughter, who mentioned
that she had replaced the pants and she provided the receipts. When asked to describe the grievance
process, the Assistant Administrator stated the person who received the grievance should write it down,
then pass the grievance to the Social Services. Social Services then assigned someone to investigate, and
once resolved, got back with the resident about the resolution. She added that she had re-initiated the
grievance. (Copies obtained)
A review of the facility's policy and procedure titled Grievances/Complaint reports (effective 2008), revealed:
The policy purpose read, To document receipt of a grievance or complaint, facility action and resolution. A
grievance is defined as a concern or complaint that is unable to be immediately resolved and requires
further investigation and action by facility leadership to achieve a resolution.
The procedure guideline included:
Responsible person:
-May be initiated by any staff member upon identification of grievance or complaint.
-Follow up conducted by Grievance Official, Administrator or the Director of Social Services or Designee.
When:
- Upon identification of a grievance /complaint.
- Follow up done as soon as possible after identification.
Instructions:
Receipt and documentation of the grievance /Complaint.
1. Enter the date notified of the grievances/ complaint.
2. Print the name of the staff member receiving the grievance /complaint.
3. Enter a check to indicate the person (s) initiating the grievance/ compliant.
4. Print the individual's name initiating the grievance/complaint.
5. Print the phone number of the individual initiating the grievance/ complaint.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
106135
If continuation sheet
Page 2 of 18
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
106135
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/15/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Dolphin Pointe Health Care Center
5355 Dolphin Point Blvd
Jacksonville, FL 32211
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)
F 0585
6. Document the factual description of the concern.
Level of Harm - Minimal harm
or potential for actual harm
7. Sign as the staff member documenting the concern.
Assignment of Actions
Residents Affected - Few
8. Identify and document the individual (s) designated to take action on the concern.
9. Enter the date assigned and the date to be resoled by
10. Note: Initial investigation and report will occur within three (3) working days , of the receipt of the
grievance.
.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
106135
If continuation sheet
Page 3 of 18
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
106135
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/15/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Dolphin Pointe Health Care Center
5355 Dolphin Point Blvd
Jacksonville, FL 32211
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)
F 0644
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Coordinate assessments with the pre-admission screening and resident review program; and referring for
services as needed.
Based on observation, medical record review, and staff interviews, the facility failed to ensure a new
Pre-admission Screening and Resident Review (PASARR) was conducted for one (Resident #38) of two
residents reviewed for PASARR completion from 53 residents in the sample. Resident #38 had psychiatric
diagnoses that were not documented on the original PASARR and should have been screened for a Level II
after admission to the facility.
The fndings include:
A review of the medical record for Resident #38 revealed an admission date of 12/13/23 and included the
following diagnoses: schizophrenia and dementia with mood disorder. The current PASARR received by the
facility on 12/12/23 noted no diagnoses checked under Section I, and under Section II, a diagnosis of
dementia was checked no.
An interview was conducted with the Assistant Administrator on 02/15/24 at 11:38 a.m. She stated she was
filling in for the Social Services Director while she was on leave. She stated a PASARR was needed for
admission to the facility and was reviewed and discussed in morning meetings. The PASARR was reviewed
for accuracy, and if there was a diagnosis of schizophrenia, bipolar disorder and other psychiatric
diagnoses, [Beneficiary and Family Centered Care Quality Improvement Organization] would be contacted
online and a new PASARR would be generated. Notification would be sent if a Level II was needed. The
Assistant Administrator reviewed the PASARR for Resident #38 with the resident's admission diagnoses on
electronic medical record. She stated nothing was checked. The resident was diagnosed with schizophrenia
and dementia, and a new PASARR should have been generated. She did not know if this happened and
stated she would check the [Beneficiary and Family Centered Care Quality Improvement Organization]
website.
An interview was conducted with the Assistant Administrator on 02/15/24 at 1:42 p.m. She confirmed that
there was no new PASARR generated for Resident #38 and she would notify the nurse to initiate a new
one.
.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
106135
If continuation sheet
Page 4 of 18
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
106135
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/15/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Dolphin Pointe Health Care Center
5355 Dolphin Point Blvd
Jacksonville, FL 32211
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)
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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observations, interviews, and medical record reviews, the facility failed to ensure that one (Resident #6) of
four residents reviewed for wound care, from a total sample of 53 residents, received wound care according
to professional standards of practice to promote healing.
Residents Affected - Few
The findings include:
A review of the medical record revealed that Resident #6 was admitted to the facility on [DATE] with
diagnoses including acute obstructive pulmonary disease with acute exacerbation, hypertension, sleep
apnea, chronic pain, unspecified dementia - unspecified severity with psychotic disturbance, and
depression - unspecified.
On 02/13/24 at 9:50 AM, Resident #6 was observed with an undated adhesive wound care wrapping on her
right forearm.
On 02/14/24 at 10:05 AM, a second observation was made of Resident #6. She had the same undated
adhesive wound care wrapping on her right forearm.
On 02/15/24 at 10:47 AM, a third observation was made of Resident #6 with the same undated adhesive
wound care wrapping on her right forearm. The resident reported she was scheduled to have wound care
performed yesterday (02/14/24) and didn't receive the scheduled wound care.
A review of the 01/25/24 physician's order for wound care revealed: Clean right forearm biopsy site with
soap and water, apply ointment, cover bandage daily until site heals. The start date was noted as 01/25/24.
A review of the resident's care plan, dated 10/19/23, revealed the following focus area: The resident has a
potential for impaired skin integrity r/t impaired mobility. Date initiated 10/19/23. Revision on 10/19/23. Goal:
The resident will be free from skin breakdown through the review date. Interventions: Administer/monitor
effectiveness of medications as ordered. Administer treatments as ordered and monitor for effectiveness.
Encourage good nutrition and hydration in order to promote healthier skin. Encourage patient to float heals
whenever in bed. Identify potential causative factors and eliminate/resolve when possible. If skin breakdown
occurs, treat per facility protocol and notify MD (physician), family. Keep skin clean and dry. Use lotion on
dry scaly skin. Turn and reposition as needed. Weekly skin checks per facility protocol.
On 02/15/24 at 11:48 AM, Registered Nurse (RN) N was interviewed. She reviewed Resident #6's
electronic medical record and reported that the order for wound care documented: Clean right forearm
biopsy site with soap and water, apply ointment, cover with bandage daily until site heals with at start date
of 01/25/24. She reported that the standard practice for wound care should include initialing wound care
dressings by the nurse who provided wound care and then documenting the date wound care was
administered. She explained that according to the resident's electronic medical record, the last time the
resident received wound care was on 02/14/23 at 18:43 (6:43 PM).
On 02/15/24 at 11:54 AM, RN N verified that Resident #6 had no date or initials on her wound care
dressing.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
106135
If continuation sheet
Page 5 of 18
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
106135
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/15/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Dolphin Pointe Health Care Center
5355 Dolphin Point Blvd
Jacksonville, FL 32211
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)
F 0684
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
On 02/15/24 at 11:58 AM, the Assistant Director of Nursing (ADON) was interviewed. She explained that
when wound care was provided by nursing staff, the date should be entered on the wound care dressing so
staff were aware that wound care was provided. She further explained that she preferred to put her initials
on the wound dressing so staff were aware of who provided the wound care.
On 02/15/24 at 12:01 PM, Resident #6 showed her wound care dressing to the ADON, who verified that the
wound care dressing had no date indicating the last date of wound care. The ADON removed the bandage
and reported that she observed a wound approximately four to five centimeters in length and two and a half
centimeters in width.
On 02/15/24 at 2:22 PM, an interview with the Wound Care Nurse was conducted. She reported she had
been employed at the facility for two years. Wound care rounds and rounds with the facility assigned wound
care physician occurred once a week on Thursdays. During each shift, the expectation was for her to learn
about new admissions who required wound care. She was not familiar with Resident #6's wound care order
and reviewed the electronic medical record. She explained that according to Resident #6's electronic
medical record, the order instructed nursing staff to clean the right forearm, cover with a band aid daily until
site heals with a start date of 01/25/24. She further explained that the standard of practice for wound care
was to date wound care dressings with the date of wound care and to initial them identifying who provided
the wound care.
The resident's Medication Administration Record/Treatment Administration Record (MAR/TAR) was
reviewed and revealed that Resident #6 did not receive wound care treatment on 01/29/24, 02/06/24,
02/07/24, or 02/11/24.
On 02/15/24 at 5:02 PM, the Wound Care Nurse was again interviewed. She reported she did not know
how to review blank spaces on the MAR/TAR to research why Resident #6 did not receive wound care
treatment on 01/29/24, 02/06/24, 02/07/24, or 02/11/24. She verified that wound care treatment for
Resident #6 was not documented as having been provided on 01/29/24, 02/06/24, 02/07/24, or 02/11/24.
She confirmed that care not documented in the electronic medical record reflected that the care was not
provided.
A review of the facility's Skin Integrity policy (Copyright 2008), revealed: Clinical Guideline Manual and
Subject: Skin integrity documentation should address . A description of dressings and treatments.
A review of Nursing.Com Wound Care - Dressing Change (1) (s) (Accessed on 02/15/24) revealed: Best
standard of practice for wound care process is to time, date and initial wound care dressings.
.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
106135
If continuation sheet
Page 6 of 18
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
106135
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/15/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Dolphin Pointe Health Care Center
5355 Dolphin Point Blvd
Jacksonville, FL 32211
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)
F 0686
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observations, interviews, and medical record reviews, the facility failed to ensure that one (Resident #22) of
two residents reviewed for pressure ulcers, from a total sample of 53 residents, received pressure ulcer
care according to professional standards of practice to promote healing, prevent infection, and prevent new
ulcers from developing.
Residents Affected - Few
The findings include:
On 02/13/24 at 11:16 AM, Resident #22, was observed lying in an upright position in bed, covered by a
blanket with a nasal cannula in place. When greeted, she moaned and pointed to the corner where a family
member was seated. The family member introduced herself as Resident #22's daughter, and stated her
mother recently returned from the hospital and should be receiving treatment for the two sores on her
bottom. She said the hospital ordered wound care treatment along with frequent re-positioning, but she felt
the facility was not addressing the wounds, and she feared the wounds would worsen.
A review of Resident #22's record revealed her initial admission date was 2/9/2022 with a readmission on
[DATE]. Her diagnoses included COVID-19, acute and chronic respiratory failure with hypoxia, and
dementia. The facility's admission notice, dated 2/10/24 at 18:51 (6:51 PM), and signed by the authorized
RN, revealed that the resident was alert and oriented x2 (She knew who she was and where she was, but
not what time it was or what was happening to her). She was incontinent of bowel and bladder, and had two
sacral pressure ulcers that were open to air with wound care orders to apply ointment and leave open to air.
(Photographic evidence obtained)
A review of the Admission/readmission Minimum Data Set (MDS) assessment, dated 2/11/24, revealed that
Resident #22 had a left thigh (front) skin tear, a left buttock stage 2 pressure ulcer, and a right buttock stage
2 pressure ulcer.
A review of the active physician's orders revealed there were no active orders for wound care treatment in
place addressing Resident #22's left buttock stage 2 pressure ulcer, or right buttock stage 2 pressure ulcer.
(Photographic evidence obtained)
A review of the care plan addressing skin integrity and wound care, provided by RN, Regional Director of
Clinical Services/Interim DON, revealed no updates or revisions had been made since 01/18/24, no
mention of the left or right buttock stage 2 pressure ulcers was noted, and no baseline care plan was
provided. (Photographic evidence obtained)
On 2/14/24 at 10:23 AM, a second observation was made of Resident #22, who was joined by her
daughter. Her daughter stated, You just missed her Certified Nursing Assistant (CNA) changing her and
providing wound care. She put that cream over her sores and left them uncovered. The daughter pointed to
a yellow tube of cream that was uncapped. [NAME] residue was observed on the outside of the tube
located on top of Resident #22's dresser that read, Triad Hydrophilic Wound Dressing Pansement
hydrophile, Coloplast 2.5 oz. (An over-the-counter zinc oxide-based wound treatment for difficult to dress
sacral wounds. It can be used on wet, eroded skin, including macerated skin.) (Photographic evidence
obtained)
On 2/14/24 at 12:54 PM, an interview was conducted with Licensed Practical Nurse (LPN) C, who had
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
106135
If continuation sheet
Page 7 of 18
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
106135
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/15/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Dolphin Pointe Health Care Center
5355 Dolphin Point Blvd
Jacksonville, FL 32211
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)
F 0686
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
been assigned to Resident #22, and who confirmed that upon admission and readmission, all discharge
orders should be verified, skin issues documented, and a head-to-toe assessment completed within the
first 24 hours. She reported not being aware of any skin conditions for Resident #22, but after reviewing the
electronic medical record, she stated the resident had two pressure wounds to the sacrum, and the
physician's orders for wound treatment could be found in the MAR/TAR. She was asked to review the
MAR/TAR showing the wound care orders. After her review, she confirmed there were no current active
physician's orders for wound care treatment located on the MAR/TAR or in the electronic medical record.
On 2/14/24 at 1:35 PM, Resident #22's wounds were observed by a registered nurse surveyor (RNS) along
with LPN C. Per the RNS, the wound was approximately 5 cm x 7 cm (centimeters), with a pink-red wound
base and no slough (dead tissue). (Photographic evidence obtained)
On 2/15/24 at 2:20 PM, the Wound Care Nurse reported all new admissions and readmissions were
discussed in the facility's morning meetings. She was then provided with a list of all the residents who
triggered with new skin/wound orders that she made rounds on for treatment that day. When asked if she
was familiar with Resident #22, she stated she was. She visited with her yesterday evening and confirmed
that the resident did come in with a stage 2 pressure ulcer, and the admitting nurse should have obtained
the order. She added that she reached out to the physician to evaluate the wound and mentioned that the
measurements were approx. 11 cm x 7 cm because the physician clustered all three open areas into one.
She added that treatment orders were put in place as of 2/15/24 and barrier cream was being applied for
treatment. When asked if barrier cream would require a doctor's order she stated, Yes, there should be an
order to apply the barrier cream. She further confirmed there were no active physician's orders in place for
Resident #22 for barrier cream and stated, If the order wasn't there, that means the admitting nurse missed
it. The Wound Care Nurse was asked to look at the photo of Triad Hydrophilic Wound Dressing Pansement
hydrophile, Coloplast 2.5 oz. that was observed in Resident #22's room. She was then asked to identify the
item. She stated the item was not barrier cream, but what appeared to be wound cream. She further
confirmed that the wound cream observed in the photo would be applied by a licensed nurse, not a CNA.
A review of the facility's policy on Pressure Ulcers (CCHC 0312, with a copyright year of 2016), noted on
page 1, item #8: Perform wound care as per the physician's orders.
A review of the facility's policy on admission Completion Check-Off List Mandatory Forms (copyright year of
2016), noted on page 1, Item #10: Skin and Wound Evaluation Completed. Page 1, Item #13:
Admit/Re-Admit orders verified with MD (physician). Two nurses sign off for accuracy. On page 2, Item line
#11: Treatment orders for all skin areas/wounds noted upon admission. On page 3, Item line #7: 2nd Skin
Sweep Completed by Unit Manager. On page 3, Item #9: Unit Manager to review admission Orders for
Accuracy.
.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
106135
If continuation sheet
Page 8 of 18
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
106135
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/15/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Dolphin Pointe Health Care Center
5355 Dolphin Point Blvd
Jacksonville, FL 32211
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)
F 0695
Provide safe and appropriate respiratory care for a resident when needed.
Level of Harm - Minimal harm
or potential for actual harm
Based on observations, record review, staff interviews, and a review of the policy and procedure for Oxygen
Therapy, the facility failed to ensure oxygen was administered at the physician-ordered flow rate for two
(Residents #29 and #129) of six residents reviewed for oxygen use, from a total sample of 53 residents.
Residents Affected - Few
The findings include:
1. An observation was made of Resident #29 in her room on 2/12/14 at 11:00 a.m. She was observed with
oxygen infusing via a concentrator through a nasal cannula. She reported her oxygen flow rate should have
been set at 3 liters per minute (LPM). Her oxygen concentrator was observed with a flow rate set at 2.5
LPM.
A medical record review for Resident #29 revealed an admission date of 1/22/24 with the following
diagnoses: chronic obstructive pulmonary disease (COPD), obstructive sleep apnea, and atrial fibrillation. A
1/23/24 physician's order noted oxygen at 2 LPM as needed (PRN) for oxygen saturations of less than 92%
for COPD.
The care plan, updated on 1/23/24, noted: Resident has altered respiratory status/difficulty breathing
related to COPD and sleep apnea. Interventions included to elevate the head of the bed, and administer
oxygen as ordered.
On 2/12/24 at 2:00 p.m., an observation was made of the resident in her room using oxygen and the
concentrator was set at 3 LPM.
On 2/13/24 at 9:30 a.m., an observation was made of the resident in her room using oxygen and the
oxygen flow rate was set at 2.5 LPM.
On 2/14/24 at 9:20 a.m., an observation was made of the resident in her room using oxygen in bed, which
was set at a flow rate of 3 LPM.
A review of the February 2024 Medication Administration Record (MAR), noted oxygen at 2 LPM via nasal
cannula PRN for oxygen saturations of less than 92%. Vital signs were documented with oxygen
saturations at 94% or above on all days except 2/1/24, when her saturation was documented at 84%.
An interview was conducted with Licensed Practical Nurse (LPN) A on 2/14/24 at 1:38 p.m. She reviewed
the oxygen order for Resident #29 and reported the oxygen was to be set at 2 LPM PRN. She was not
aware that the resident is wearing the oxygen constantly. She confirmed the order was as needed (PRN)
with parameters for oxygen saturations. LPN A walked into the resident's room and confirmed that the
oxygen was set at 3 LPM. She changed the oxygen to 2 LPM and confirmed the resident was using the
oxygen.
2. An observation and interview was conducted with Resident #129 on 2/12/24 at 12:52 p.m., which noted
the resident sitting up in bed with the head of the bed elevated and oxygen infusing at 2.5 LPM via nasal
cannula. The resident reported being on 2 LPM of oxygen.
A medical record review was conducted which noted an admission date of 11/20/23 with a diagnosis of
COPD. The physician's orders were reviewed, which noted continuous oxygen at 3 LPM via nasal
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
106135
If continuation sheet
Page 9 of 18
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
106135
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/15/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Dolphin Pointe Health Care Center
5355 Dolphin Point Blvd
Jacksonville, FL 32211
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)
F 0695
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
cannula on 11/22/23. The MAR was reviewed, which noted continuous oxygen at 3 LPM, dated 11/22/23.
The current care plan, updated on 11/22/23, noted: Resident has altered respiratory status related to
COPD. Interventions included to administer medications and respiratory therapy as ordered.
An observation was made of the resident in her room on 2/13/24 at 9:25 a.m. Her oxygen flow rate was set
at 2.5 LPM.
An observation was made on 2/14/24 at 9:39 a.m. The resident was sitting up in bed with oxygen infusing at
2.5 LPM.
An observation was made on 2/14/24 at 1:15 p.m. The resident was sitting up in a wheelchair with an
oxygen canister attached to the back of it. The oxygen canister was set at 2 LPM.
An interview was conducted with LPN B on 2/14/24 at 1:26 p.m. She reviewed the resident's physician's
order for oxygen and reported it was ordered for 3 LPM. LPN B walked into the resident's room and
confirmed the resident had an oxygen canister on the back of her wheelchair with a flow rate set at 2 LPM.
The resident wanted her oxygen saturation taken and asked when the oxygen order was changed to 3
LPM. The resident removed her oxygen while the LPN was retrieving the pulse oximeter. The LPN took the
resident's oxygen saturation which was 87%. The resident applied the oxygen cannula and the LPN
changed the oxygen to 3 LPM. The oxygen saturation went to 95%.
A review of the facility's policy for Oxygen Therapy (2019) revealed under Purpose, a statement that oxygen
must be prescribed by an appropriate clinician and administered by appropriate clinical staff. Under
procedure .5, a statement to check the oxygen prescription, administer according to prescription, and use
the appropriate delivery device was in place.
.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
106135
If continuation sheet
Page 10 of 18
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
106135
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/15/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Dolphin Pointe Health Care Center
5355 Dolphin Point Blvd
Jacksonville, FL 32211
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)
F 0759
Ensure medication error rates are not 5 percent or greater.
Level of Harm - Minimal harm
or potential for actual harm
Based on observations, record reviews, and staff interviews, the facility failed to ensure a medication error
rate of 5% or less. There were six errors out of 26 opportunities for error, resulting in an error rate of 23%
and involving two (Residents #123 and #166) of three residents observed for medication administration.
Failure to administer medications appropriately as ordered could result in side effects leading to harm to the
residents.
Residents Affected - Few
The findings include:
During a medication administration observation on 2/14/24 at 8:52 a.m., Licensed Practical Nurse (LPN) A
was observed preparing medication for Resident #123. She obtained Potassium Chloride (KCL), 20
miliequivalent (meq) tablet and Rytary extended release (ER) 48.75 -195 milligrams (mg) capsule (A
combination of carbidopa and levodopa used to treat symptoms of Parkinson's disease). She crushed each
medication separately and mixed with applesauce. She did not crush the KCL she mixed in apple sauce.
She opened the Rytary capsule and poured the powder in applesauce. She then proceeded to the
resident's room and administered the medication to the resident .
In an interview on 2/14/24 at 9:10 a.m., LPN A was asked why she did not crush the KCL. She stated
Resident #123 took the medication crushed but the the label for KCL indicated do not crush. She was then
asked about the Rytary capsule. She said, That's the medication label noted do not crush, but the capsule
cannot be crushed, it can be opened and that's why I opened it. She was asked why she did not administer
the Lidoderm patch, Omega 3 or Vitamin D. She stated the medications were not in the cart and she would
have to get them from central supply. She added that she also had to wait for the resident to finish breakfast
so she could apply the Lidoderm patch.
On 2/14/24 at 9:35 a.m., Registered Nurse (RN) L was observed preparing medication for Resident #166.
She obtained a blister pack of Gabapentin 100 mg (milligrams) and popped one tablet into the medication
cup. She then obtained Breo Elipta Inhalation aerosol powder breath activated 100-25 mcg (micrograms).
RN L confirmed that there was only one 100 mg gabapentin pill. (Photographic copy of the blister pack
obtained) She then proceeded to the resident's room and administered the medication. The resident was
not offered water to rinse her mouth after the inhaler treatment.
A review of the Breo Ellipta medication package insert revealed instructions to use water to rinse/gargle
and spit after dose to prevent yeast infection (candidiasis/thrush). (Copy obtained)
A review of the medication label revealed Gabapentin 100 mg, give 2 tablets once a day. A review of the
physician's order, dated 1/17/24, revealed Gabapentin 400 mg, give one tablet three times a day. (Copy
obtained)
In an interview on 2/14/24 at 9:45 a.m., RN L stated Resident #166 had two blister packs of Gabapentin
(400 mg and 100 mg). She stated she was confused and chose the wrong dosage.
A follow-up interview was conducted with LPN A on 2/14/24 at 10:17 a.m. She confirmed that she had still
not given the medication (Lidocaine patch, Omega 3 and Vitamin D) to Resident #123. She added that she
was to obtain medications from central supply.
During an interview on 2/14/24 at 10:20 a.m., LPN N/Unit Manager said, If the medications are not
available in the cart, the nurse should stop and check to see if the medication is in the Pyxis. If
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
106135
If continuation sheet
Page 11 of 18
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
106135
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/15/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Dolphin Pointe Health Care Center
5355 Dolphin Point Blvd
Jacksonville, FL 32211
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)
F 0759
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
it is not available, she should notify the physician and also contact the pharmacy to check when the
medication was ordered. For the over-the-counter (OTC) medication, the facility has stock in the medication
room and central supply. LPN N was made aware that Resident #123 had not received all of his medication
(Lidoderm patch, Omega 3, and Vitamin D). She stated they should be on the cart because she had just
restocked all of the medication carts. She proceeded to the medication cart that LPN A was assigned to.
She opened the top drawer, obtained the medication fish oil, vitamin D and a Lidocaine patch, and placed
the medication on top of the cart. She educated LPN A about medications' generic names. Upon review of
Resident #123, LPN A confirmed that she had already checked the medications as having been
administered before administering them.
A review of the active physician's orders for Resident #123, revealed Cholecalciferol, 1000 units, give one
tablet by mouth one time a day. Omega 3 capsule, 1000 mg one time a day for nutritional support. Lidoderm
Patch 5 %, apply to lower back topically one time a day.
Another follow-up interview was conducted on 2/14/24 at 10:20 a.m. with RN L, who was asked if she had
completed medication administration. She replied, I still have around ten residents to give medications to.
She was asked when medications were due and she replied, They were due at 9:00 a.m. She added that
medications could be administered up to an hour before or an hour after they were scheduled. She
confirmed that she was running behind schedule because it was her first time working on the unit. She was
then asked what she would do now that she was behind schedule. She said, I will continue to pass them. I
was assigned 28 residents and I have to pass to all of them. The nurse was not familiar with the facility's
process for late medication administration. A review of the computer screen revealed that 16 residents had
not yet received their medication.
During an interview with the RN Regional Director of Clinical Services (RDCS)/Interim Director of Nursing
(DON) on 2/14/24 at 1:38 p.m., she was informed of the concerns identified during medication
administration. She stated additional education would be initiated.
A review of the facility's policy and procedure titled Medication Pass Guideline (2008), revealed the
Purpose read, To safely and accurately administer medications according to physicians' orders and patient
needs.
The procedure was outlined as follows:
2 .Read transcribed physicians' orders on MAR, patient name, medication name, dosage, route and interval
ordered.
- remove medication from the cart
- compare MAR with medication label for accuracy
3. If medication is new for the resident, or the medication is unfamiliar or physician order is questioned
-read original physician order
-compare original physician order with MAR for accuracy
-verify allergy status
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
106135
If continuation sheet
Page 12 of 18
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
106135
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/15/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Dolphin Pointe Health Care Center
5355 Dolphin Point Blvd
Jacksonville, FL 32211
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)
F 0759
-contact physician for clarification as needed
Level of Harm - Minimal harm
or potential for actual harm
4. Read special medication instructions
Residents Affected - Few
Tablet and Capsule - Do not crush medication when contraindicated in a cautionary statement on MAR, if
appears on pharmacy list of non-crushable or without a physician's order.
7 . Administration of medications;
-Administer medication in accordance with the frequency prescribed by the physician.
.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
106135
If continuation sheet
Page 13 of 18
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
106135
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/15/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Dolphin Pointe Health Care Center
5355 Dolphin Point Blvd
Jacksonville, FL 32211
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)
F 0761
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted
professional principles; and all drugs and biologicals must be stored in locked compartments, separately
locked, compartments for controlled drugs.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observations and staff interviews, the facility failed to ensure medications were stored in locked medication
carts for three (Residents #16, #22, and #77) of 53 residents in the total sample. Pain creams and other
creams were found in residents' rooms, which could lead to overdosing or harm to other residents.
The findings include:
1. An observation was made of Resident #16 in her room on 2/12/24 at 11:57 a.m. She was sitting up in
bed with a neck brace on and Voltaren, Triamincolone, and Bacitracin were sitting on her dresser at
bedside. The resident reported using her Voltaren for arthritis pain. She was asked about the other creams
but did not respond.
An observation was made of Resident #16's room on 2/13/24 at 9:30 a.m. The resident was not in the
room. Voltaren and Triamincolone were observed at bedside.
An observation was made of Resident #16 on 2/14/24 at 9:20 a.m. in her room. She reported not using
Triamincoline. She said it came from the hospital. She used Voltaren before therapy and at bedtime.
Voltaren and Triamicolone were observed at bedside in a drawer.
A review of Resident #16's medical record noted an admission date of 9/16/22 with a re-entry date of
1/18/24 and a diagnosis of Osteoarthritis of first carpometacarpal joint (thumb). The active physician's
orders were reviewed, which noted to apply Voltaren gel 1% one application transdermally three times a
day for pain, apply 2 grams (gm) to thumb for pain. A review of the current Medication Administration
Record (MAR) noted nurses signing out the application of the Voltaren. There was no order for the
Triamincolone.
An interview was conducted with Licensed Practical Nurse (LPN) B on 2/14/24 at 1:26 p.m. She reported
the resident had Voltaren ordered for her thumb pain. She reviewed the order which indicated the
medication was to be used three times a day and apply 2 gms to the resident's thumb. She stated the
resident wanted it applied to her hip and leg, but there was no physician's order, and the physician would
have to be notified to obtain an order for the hip and leg applications. The LPN entered the resident's room
and explained to the resident the medication (Voltaren) was on the medication cart, and the medications
needed to be locked in the cart. The Voltaren was being applied by the nurses. She asked the resident if
she could remove the medications, and the resident became upset, stating, You are going to do what you
want, just take it. LPN B took the creams and locked them in the medication cart.
An interview was conducted with the Administrator on 2/15/24 at 10:43 a.m. He stated upon admission
medications were reviewed with the residents/families and they were made aware that mwdications could
not be brought in or left in the resident room. The Welcome Committee also addressed this when meeting
with the resident. Residents liked to order things online and receive medications that way. The facility was
trying to have residents open packages in front of them to prevent this, but some would not agree to do
that. Angel rounds were utilized for opportunities and not meeting the practice. Angel rounds were
conducted daily during the week and turned in on Fridays. If there was an issue, it was brought to the
Director of Nursing immediately. He was apprised of the creams left in Resident
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
106135
If continuation sheet
Page 14 of 18
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
106135
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/15/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Dolphin Pointe Health Care Center
5355 Dolphin Point Blvd
Jacksonville, FL 32211
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)
F 0761
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
#16's room and he acknowledged receiving the information. He also stated a new improvement plan was
started on 2/12/24 recognizing no medications or prescription creams should be left at the bedside of
residents.
2. On 02/13/24 at 11:16 AM, Resident #22 was observed lying in an upright position in bed, covered in a
blanket, with a nasal cannula in place. When greeted, she moaned and pointed to the corner where a family
member was seated. The family member introduced herself as Resident #22's daughter, and reported her
mother recently returned from the hospital, and should be receiving treatment for the two sores on her
bottom. She said the hospital ordered wound care treatment, along with frequent re-positioning, but felt the
facility wasn't addressing the wounds, and feared the wounds would get worse.
A review of Resident #22's record revealed her initial admission date was 2/9/2022 and she was readmitted
on [DATE]. The facility's admission notice dated 2/10/2024 at 18:51 signed by the authorized Registered
Nurse (RN), revealed she was alert and oriented x2, incontinent of bowel and bladder, and had two sacral
pressure ulcers that were open to air with wound care orders to apply ointment and leave open to air.
(photo evidence obtained)
On 2/14/2024 at 10:23 AM, a second observation was made of Resident #22, who was joined by her
daughter. Her daughter stated you just missed her Certified Nursing Assistant (C.N.A.) changing her and
providing wound care. She put that cream over her sores and left them uncovered. The daughter pointed to
a yellow tube of cream that was uncapped, white residue observed on the outside of the tube located on
top of Resident #22's personal dresser that read Triad Hydrophilic Wound Dressing Pansement hydrophile,
Coloplast 2.5 oz. (Photographic evidence obtained)
3. On 2/13/24 at 1:57 p.m,, Diclofenac cream for Resident #77 was observed on his activity table in his
room.
In an interview on 2/13/24 at 2:00 p.m., Resident #77 stated he was supposed to apply the cream on his
wrist four times a day, but he did not remember to apply it. He said he used it when he remembered.
(Photographic evidence obtained)
A record review indicated that Resident #77 was admitted to the facility on [DATE] with a diagnosis of acute
on chronic systolic congestive heart failure. The quarterly minimum data set (MDS) assessment with an
assessment reference date (ARD) of 12/11/23, indicated that the resident had a Brief Interview for Mental
Status (BIMS) score of 15 out of 15 possible points, indicating that he was cognitively intact.
A review of Resident #77's physician's order dated 10/16/23, revealed Diclofenac Sodium gel 1%, apply to
both wrists topically two times a day for arthritis pain.
Another observation was made of the resident's room on 2/14/24 at 9:00 a.m. and the medication was still
at bedside.
During an interview with LPN A on 2/14/24 at 10:17 a.m., she confirmed that the medication was at bedside
and stated that it should be in the medication cart.
.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
106135
If continuation sheet
Page 15 of 18
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
106135
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/15/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Dolphin Pointe Health Care Center
5355 Dolphin Point Blvd
Jacksonville, FL 32211
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)
F 0812
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve
food in accordance with professional standards.
Based on the kitchen food service observations, staff interviews, facility record review, and facility policy
and procedure review, the facility failed to document temperatures and sanitation, and clean and maintain
kitchen foodservice equipment to prevent the outbreak of foodborne illness, with the potential to affect all
residents who consumed foods from the facility. The facility failed to maintain temperature logs for the
3-compartment sink and maintain the kitchen oven in a clean and sanitized condition. Food safety and
sanitation is important in health care settings serving nursing home residents. Kitchen equipment shall be
maintained and kept free of food residue and other debris to avoid a potential source of pathogen exposure.
The findings include:
An initial tour of the kitchen was conducted on 2/12/24 at 10:55 AM. During the tour, there was no
temperature log sheet maintained for the 3-compartment sink.
During the initial tour on 2/12/24 at 11:05 AM, [NAME] G reported that he washed, rinsed, and sanitized
dishes in the 3-compartment sink and there was no sheet to document temperatures. He confirmed that he
had not documented temperatures and sanitation after washing dishes in the 3-compartment sink.
During the initial tour of the kitchen on 2/12/24 at 11:10 AM, the Certified Dietary Manager (CDM) was
asked to provide the temperature log for the 3-compartment sink. The CDM initially stated staff mostly used
the dish machine and had not used the 3-compartment sink, but later provided a blank temperature log
dated 9/2023. The CDM later confirmed there were no 3-compartment sink temperature logs for the past 6
months. (Photographic evidence obtained)
A follow-up kitchen tour was conducted on 2/14/24 at 12:15 PM. Two ovens had food residue, a white
powdery substance, and grease deposits on the floor below the rack and on and around the doors. The
bottom convection was covered with food debris and grease build-up on and around the inside oven door.
The mixer, located next to the prep table, with clear plastic covering, had food debris stuck on and around
the safety guard. The same observations of the two ovens were made again on 2/15/24 at 1:40 PM.
(Photographic evidence obtained)
An interview was conducted on 2/15/24 at 1:45 PM with [NAME] H. She reported the cook was responsible
for documenting temperatures and sanitation for the 3-compartment sink. The cook or any staff that use
equipment outside of the cook area was responsible for cleaning after each use or as needed. When asked
how often the ovens and mixer were cleaned, she replied, It varies depending on its use. The oven was
cleaned yesterday. Before that day, it had been a while since it was last cleaned.
An interview was conducted on 2/15/24 at 1:54 PM with [NAME] I, who reported the cook was responsible
for documenting 3-compartment sink temperatures daily after breakfast, lunch, and dinner. He also stated
the cook was responsible for cleaning the oven. Other kitchen equipment was cleaned after each use or
weekly if not used and kept covered with plastic.
A second interview was conducted on 2/15/24 at 1:57 PM with the CDM. She reported the cooks or any
kitchen staff were responsible for cleaning the kitchen and food service equipment. Ovens were cleaned
weekly by the cook and mixers were cleaned as needed. She stated, I just created job flows for
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
106135
If continuation sheet
Page 16 of 18
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
106135
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/15/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Dolphin Pointe Health Care Center
5355 Dolphin Point Blvd
Jacksonville, FL 32211
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)
F 0812
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
all the positions. When asked who was responsible for documenting temperatures and sanitation for the
3-compartment sink, she confirmed it was the cook. When asked what the requirement for documenting
temperatures for the 3-compartment sink was, the CDM stated staff had not used the 3-compartment sink
due to the CDM cleaning and organizing the dish area. They had not really started using the sink because
there were no stoppers. The stoppers were received about one month ago, but the staff used the
3-compartment sink mainly to soak pans.
An interview was conducted on 2/15/24 at 2:05 PM with Dietary Aide K. She reported the cook cleaned the
oven. The mixer was cleaned by whoever used it last or weekly if not used. When asked how often the oven
was cleaned, she replied, weekly. When asked what the requirement for documenting the 3-compartment
sink temperatures was, Dietary Aide K was not sure of the requirement for documenting the 3-compartment
sink. She stated it was the cook's responsibility. When asked how often the 3-compartment sink was
utilized, she confirmed it was used daily, three times a day and as needed. Whoever washed dishes was
responsible for documenting the temperature and sanitation.
A review of the facility's policy and procedure titled HACCP Tips for Food Safety (dated 2015) revealed:
Staff to be educated and supervised on HACCP information and procedures. Procedure #8. Dishwashing:
Be sure the wash and rinse temperatures are appropriate for your dish machine. Document temperatures
regularly on a temperature log. Policy and Procedure entitled Sanitation - Overview dated 2015 revealed:
Standards established by the U.S. Public Health Service FDA Food Code are followed regarding safe food
handling techniques and food temperatures. Procedure #18. Clean and sanitize food-contact surfaces and
equipment: before and after every use, at least every 4 hours during continual use. 19. Maintain clean and
sanitary kitchen facilities and equipment by following cleaning instructions procedures. (Copy Obtained)
Reference: 2022 Food Code, United States Food and Drug Administration. Chapter 4, Page 127 and 165.
https://www.fda.gov (Accessed on 2/20/24). Equipment, Utensils, and Linens. 4-601.11 Equipment,
Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (A) Equipment Food-Contact Surfaces
and Utensils shall be clean to sight and touch. (B) The food-contact surfaces of cooking equipment and
pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) NonFood-Contact
Surfaces of Equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris.
.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
106135
If continuation sheet
Page 17 of 18
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
106135
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/15/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Dolphin Pointe Health Care Center
5355 Dolphin Point Blvd
Jacksonville, FL 32211
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)
F 0842
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in
accordance with accepted professional standards.
Based on record reviews, interviews, and a review of the Medication Pass Guideline Policy and Procedure,
the facility failed to ensure to maintain complete, accurately documented medical records for one (Resident
#50) of 53 sampled residents for blood pressure medication with parameters. Documenting the blood
pressures before administration ensures nurses are following the physician's orders and not administering
medication if the resident's blood pressure is too low.
The findings include:
On 2/14/24 at 9:45 a.m., Resident #50 was observed in her room sitting up in bed. She reported she had a
sore throat this morning. She reported receiving her medications this morning.
A medical record review was conducted for the resident which noted an admission date of 1/20/22 with
diagnoses including dementia and hypertension. The active physician's orders were reviewed, which noted
Lisinopril 2.5 milligrams (mg) every day for blood pressure and Metoprolol extended release 25 mg daily,
hold if systolic blood pressure is below 110. The February 2024 Medication Administration Record (MAR)
was reviewed, which noted Lisinopril and Metoprolol were being administered daily with no blood pressures
documented. A physician's order dated 6/18/23, noted blood pressures to be taken weekly which was also
noted on the February 2024 MAR.
An interview was conducted with Licensed Practical Nurse (LPN) C at 3:55 p.m. on 2/14/24. The LPN
reviewed the MAR and reported the resident had two blood pressure medications with parameters
(Lisinopril and Metoprolol) and whoever put them in did not add space to write in blood pressures. She
reported taking residents' blood pressures before administering the medications. When she was asked
where she documented those blood pressures, she replied that she documented that information under
Vital Signs in the electronic record.
An interview was conducted with the Registered Nurse (RN)/Assistant Director of Nursing (ADON) at 1:33
p.m. on 2/15/24. The ADON was asked about inputting orders for medications such as Digoxin (apical pulse
needed), and blood pressure medications with parameters. He stated a batch order could be pulled up in
the electronic medical record. The nurse would click on the medication and it would give the dosage,
parameters, etc. Blood pressures were attached to blood pressure medications with parameters and should
be documented on the MAR. The RN reviewed the MAR for Resident #50. The ADON reported the orders
were not input correctly, and blood pressures would be taken before administering the medications. He
confirmed the blood pressures were not being documented on the MAR or under Vital Signs consistently.
He stated, It is not clear whether the blood pressures were taken since it is not documented.
A review of the facility's policy and procedure for Medication Pass Guideline, noted to safely and accurately
prepare and administer medication according to the physician's order and patient needs. Under procedure
5. it was noted to obtain vital signs if applicable and record results on the MAR.
.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
106135
If continuation sheet
Page 18 of 18
Reading this as a family member? Your long-term care ombudsman is a free advocate for residents and families.
Back to topCitations
14 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F585 - Grievances
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
F644 - Coordination
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
F686 - Skin Integrity
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
F695 - Respiratory care, including tracheostomy care and tracheal suctioning
Provide safe and appropriate respiratory care for a resident when needed.
F759 - Medication Errors
Ensure medication error rates are not 5 percent or greater.
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
F842 - Resident-identifiable information
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
F761 - Labeling of Drugs and Biologicals
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
- 0211GeneralS&S Epotential for harm
Keep aisles, corridors, and exits free of obstruction in case of emergency.
- 0345GeneralS&S Epotential for harm
Have approved installation, maintenance and testing program for fire alarm systems.
- 0521GeneralS&S Epotential for harm
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
F915 - Buildings must have an outside window or outside door in every
Have proper power supply for life support equipment.
F920 - Dining and Resident Activities
Ensure proper usage of power strips and extension cords.
FAQ · About this visit
Common questions about this visit
What happened during the February 15, 2024 survey of DOLPHIN POINTE HEALTH CARE CENTER?
This was a inspection survey of DOLPHIN POINTE HEALTH CARE CENTER on February 15, 2024. The surveyor cited 14 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at DOLPHIN POINTE HEALTH CARE CENTER on February 15, 2024?
Yes, 14 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grie..."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.