Complaint Investigation

Gulf Coast Village

May 26, 2026 · Cape Coral, FL · 1333 Santa Barbara Blvd

Citations 1

Beds 85

Provider ID 105672

Healthcare Facility

Gulf Coast Village

Cape Coral, FL · View full profile →

Source Document

Official CMS Inspection Report (Medicare.gov)

Downloaded from CMS/Medicare.gov. Reflects what state inspectors documented and does not include the facility's plan of correction, which is submitted separately. Facilities may have taken corrective actions since this report was released.

Inspection Summary

GULF COAST VILLAGE in CAPE CORAL, FL — inspection on May 26, 2026.

Found 1 citation. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

Inspection Findings

FF0689

Quality of Life and Care Deficiencies

the floor on provided floor mats. Resident #1 was confused and unable to express how the incident

9:07 a.m., Resident #1's room was observed. A perimeter mattress was in place on the bed with

she could not remember any other fall. A reddish purple discoloration was observed under the resident's right eye. On 5/26/26 at 1:00 p.m., in an interview OT Staff B said that on 5/19/26 around 11:00 a.m. she was walking in the hallway across from Resident #1's room.

She said a resident alerted her to look at the resident across the hall. OT Staff B said that she observed Resident #1's legs out of bed with her knees on the floor mat.

She notified RN Staff A. OT Staff B said that RN Staff A came in and assisted Resident #1 back to bed. OT Staff B said she observed the bruising around Resident #1's right eye.On 5/26/26 at 2:00 p.m., in an interview, the Director of Nursing (DON) said that a fall is any change in plane.

She said someone being lowered to the ground, sliding out of a wheelchair, or two knees on the floor next to the bed is a fall.

The DON said that she did not know that Resident #1 was found with her knees on the floor on 5/19/26 and must have missed the OT statement that Resident #1's knees were on the fall mats.

She said the nurse should have done an incident report because it was a fall.

She verified that no new fall interventions were put into place on 5/19/26 and verified that on 5/21/26 Resident #1 was found on the floor on the fall mats.On 5/26/26 at 2:40 p.m., in an interview, RN Staff A said he found out about the bruise to Resident #1's right eye on 5/19/26 around 11:30 a.m., when the family came in. He said that on 5/19/26 around 11:00 a.m., Resident #1 was slipping off the bed. He said Resident #1's legs were off the bed. RN Staff A, RN said OT staff B was in the room when he put Resident #1 back to bed. RN Staff A said that he did a full assessment and observed an abrasion to Resident #1's right lower leg. RN Staff A said that a fall is when a resident is lying on the ground. RN Staff A said he did not complete an incident report on 5/19/26 when Resident #1 was found with her knees on the floor mat next to the bed.On 5/26/26 at 4:14 p.m., during an interview, the Nursing Home Administrator (NHA) and the DON, said they were not aware of Resident #1's fall on 5/19/26 until today.

The DON said that no one told her about the fall or the abrasion to Resident #1's right lower leg.

The DON said they completed an investigation for the bruise to the resident's right eye but she did not read OT Staff B's statement during the investigation.

The DON said that since they did not know about the fall, no interventions were put into place on 5/19/26.

She said that RN Staff A did not mention the fall to her, the facility, or the police.

The DON said that it was possible that the resident's fall on 5/21/26 could have been prevented if new interventions were put into place when Resident #1 fell on 5/19/26 but there was no way of knowing.

Frequently Asked Questions

What is an F-tag violation?

F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.

Were these violations corrected?

Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.

How often do nursing home inspections happen?

CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.

What should families do about these violations?

Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in CAPE CORAL, FL, (5) Report new concerns to state authorities.

Where can I see the full inspection report?

Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from GULF COAST VILLAGE or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.

More Reports

About This Inspection Report

Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.

Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.

Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.