Gulf Coast Village
1333 Santa Barbara Blvd · Cape Coral, FL · 33991 · 2397721333
85 certified beds Non profit - Corporation Chain: Volunteers of America Senior Living Part of a CCRC
Why this verdict
- On the federal Special Focus list of the most persistently poor performers.
- Inspection record is far worse than the national median (deficiency count and severity).
- Federal penalties on record: $19,920 in fines in the last 24 months.
- Staffing hours comfortably above national benchmarks.
- Inspection results have improved across recent cycles.
Red flags
Special Focus Facility
CMS has designated this facility one of the most persistently poor performers in the country — it is under increased inspection and enforcement.
4 immediate-jeopardy citations in prior inspection cycles
Serious past findings — check whether the underlying problems were fixed and stayed fixed.
Cited under the freedom-from-abuse rule
Cited 1 time under F600 (freedom from abuse/neglect) below the actual-harm level — worth asking about on a tour.
If someone you love was harmed at a facility with findings like these, you have options — read this.
Score breakdown
Quality-measure stars are deliberately excluded — they're largely self-reported by facilities. Full method.
CMS ratings & staffing
Overall: not rated Inspections: not rated Staffing: not rated Quality measures: not rated
| Total nurse hours / resident-day | 5.11 | 3.48 min · 4.1 strong |
|---|---|---|
| RN hours / resident-day | 1.38 | 0.55–0.75 |
| Weekend hours / resident-day | 4.80 | ≈ weekday level |
| Nursing turnover / year | 51% | median 45% |
| Fines (3-yr window) | 3 · $37,092 |
Inspection citations (27 in the current record)
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Actual harm · G November 20, 2025
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected January 12, 2026 · Quality of Life and Care
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Potential for harm · D November 20, 2025
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected January 12, 2026 · Resident Rights
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Potential for harm · D November 20, 2025
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected January 12, 2026 · Resident Rights
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Potential for harm · E November 20, 2025
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected January 12, 2026 · Resident Rights
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Potential for harm · D November 20, 2025
Provide activities to meet all resident's needs.
Corrected January 12, 2026 · Quality of Life and Care
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Potential for harm · D November 20, 2025
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.
Corrected January 12, 2026 · Pharmacy Service
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Potential for harm · F November 20, 2025
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected January 12, 2026 · Nutrition and Dietary
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Potential for harm · E November 20, 2025
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected January 12, 2026 · Resident Assessment and Care Planning
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Potential for harm · E November 20, 2025
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected January 12, 2026 · Administration
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Potential for harm · E November 20, 2025
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected January 12, 2026 · Environmental
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Potential for harm · D May 1, 2025 · found via complaint
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected May 30, 2025 · Quality of Life and Care
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Potential for harm · D May 1, 2025
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected May 1, 2025 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D May 1, 2025
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected May 30, 2025 · Quality of Life and Care
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Potential for harm · F May 1, 2025
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected May 28, 2025 · Nutrition and Dietary
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Potential for harm · E November 7, 2024
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected December 5, 2024 · Resident Rights
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Potential for harm · D November 7, 2024
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected December 5, 2024 · Resident Assessment and Care Planning
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Potential for harm · D November 7, 2024
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected December 5, 2024 · Resident Assessment and Care Planning
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Potential for harm · E November 7, 2024
Provide activities to meet all resident's needs.
Corrected December 5, 2024 · Quality of Life and Care
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Potential for harm · D November 7, 2024
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected December 5, 2024 · Quality of Life and Care
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Potential for harm · D November 7, 2024
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected December 5, 2024 · Quality of Life and Care
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Potential for harm · D November 7, 2024
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.
Corrected December 5, 2024 · Pharmacy Service
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Potential for harm · F November 7, 2024
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected December 5, 2024 · Nutrition and Dietary
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Potential for harm · D November 7, 2024
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Corrected December 5, 2024 · Administration
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Immediate jeopardy · K April 2, 2024 · found via complaint
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected April 12, 2024 · Resident Rights
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Immediate jeopardy · K April 2, 2024 · found via complaint
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Corrected April 12, 2024 · Quality of Life and Care
Showing the 25 most recent. The Safety Report includes every citation with full findings.
Federal penalties
| Date | Type | Amount / length |
|---|---|---|
| November 20, 2025 | Fine | $19,920 |
| April 2, 2024 | Fine | $8,586 |
| April 2, 2024 | Fine | $8,586 |
Family & resident reviews — a separate signal, never mixed into the score
No approved reviews yet. If your family has experience with this facility, yours could be the review that helps the next family decide.
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Source: CMS Care Compare (public domain), data as of June 1, 2026 · CCN 105672 · certified since August 28, 1989. The score is a screen, not a verdict on any one resident's experience — read how it's computed, then visit in person.