Below average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Coral Bay At Pensacola, Llc during CMS and state inspections, most recent first.
The facility failed to adequately assess and mitigate the risk posed by a resident with a documented history of aggressive and violent behaviors who was roomed with a cognitively impaired, non-verbal, limited-mobility roommate. Staff had observed the aggressive resident verbally cursing at the vulnerable roommate and described prior incidents of verbal abuse, threats toward other residents, and sufficient physical strength to move others, yet there was no documentation of enhanced supervision or targeted precautions for the vulnerable resident. After the vulnerable resident was found with significant bleeding, lacerations, and later diagnosed intracranial bleeding, facility leadership initially attributed the injuries to bed rails and the resident’s own teeth and did not include the aggressive roommate in the incident investigation, despite the aggressive history and later acknowledgment that the cheek puncture wounds could not have been self-inflicted.
The deficiency concerns the facility’s failure to thoroughly investigate several abuse-related incidents. In one case, a resident sustained facial lacerations and an intracranial hemorrhage, and leadership attributed the injuries to self-inflicted contact with bed siderails without investigating a former roommate known to have aggressive behaviors, despite external concerns about that roommate’s violent history. In another incident, a staff member reported seeing a CNA pull a resident by the wheelchair arm and yell at him, but the facility deemed the allegation unsubstantiated after the reporting employee resigned and conducted no further inquiry. In a third case, a resident reported that an RN threw a clipboard at him, resulting in a hand bruise, yet the facility relied on a reported retraction and the resident’s decision not to press charges to label the allegation unsubstantiated and document “confabulation,” even though the resident later stated he had not retracted the allegation and the only written investigation was a brief statement from the Risk Manager.
Surveyors found that the facility did not ensure accurate, resident-centered assessments and care plans when leadership directed the addition and repeated use of the term "confabulation" in several residents’ care plans and nursing notes without clear clinical rationale. One resident had confabulation added to the care plan after retracting an abuse allegation, another had a grievance about delayed incontinence care characterized as involving "some sort of confabulation," a third had multiple refusals of care documented as confabulation, and a fourth was described as confabulating after requesting to be changed again. The DSS, Administrator, and DON could not provide adequate justification for this pattern of documentation.
Surveyors found that staff documentation did not accurately reflect the actual condition and care needs of three residents. One paraplegic, bed-bound resident was charted as ambulating and transferring independently or with minimal assistance, despite staff confirming he was unable to walk or transfer. Another resident was documented on CNA flow sheets as independent with toileting, transfers, and lower body dressing and as having call light access and fluids at the hospital, while her care plan and staff interview described her as totally dependent with limited movement and needing feeding assistance. A third resident was charted as independent with toilet transfers and having no behaviors, even though nursing notes described episodes of yelling and screaming, the care plan showed total assistance needs and non-ambulatory status, and observation revealed he could not reposition himself in bed; a CNA stated he required total care and that behaviors were reported to nursing and recorded on a behavior flow sheet.
Staff used personal cell phones to photograph and video a resident experiencing pain and behavioral changes, as well as to routinely capture wound images, and then texted these images to the NP for assessment and treatment recommendations. A RN and the Wound Care Nurse reported storing these images on their personal devices and were unaware of any signed consents authorizing this method of communication. The Administrator did not object to the practice for medical purposes but acknowledged she could not ensure confidentiality once images were on staff devices. Facility policy required explicit written consent for imaging, prohibited unauthorized transmission of resident images, and treated photographs as health care records, yet there was no evidence of resident consent, authorization, or secure, encrypted transmission for the use of personal devices.
A resident with cognitive impairment sustained facial puncture wounds from contact with bed side rails, requiring sutures and hospital transfer. Although facility leadership was aware of the incident, it was not reported to authorities until after an APS investigator arrived, well beyond the facility’s policy requirement to report suspected abuse or injury of unknown origin within 2 hours when serious bodily injury is involved. The Risk Manager acknowledged that staff are expected to immediately report suspected abuse and injuries of unknown origin, but provided no reason for the reporting delay, resulting in noncompliance with the facility’s abuse reporting policy.
A dietary aide reported witnessing a staff member verbally and physically mistreat a resident in a wheelchair and then experienced ongoing harassment and retaliatory behavior from nursing and kitchen staff, including threatening comments, refusal to sign meal-tray forms, and aggressive, profane interactions. The aide, described by a coworker as quiet and respectful, ultimately resigned by phone, citing fear for personal safety and difficulty identifying harassing staff because they were not wearing name badges. Leadership, including the Administrator, DON, Risk Manager, Unit Manager, and HR Director, acknowledged awareness of harassment concerns but did not conduct an investigation into the reported retaliation, despite a written policy requiring protection of individuals who report suspected abuse.
AFSS Out of Service, Room Sanitation Issues, and Resident Room Fire Event: The facility allowed the sprinkler system and fire pump to remain red tagged for months without documented interim fire safety measures, while staff also left soiled, unlabeled resident care items and used briefs in room bathrooms and trash containers. In a separate event, a resident’s cell phone caught fire while charging in the room, producing smoke and activating the room alarm; the resident extinguished the fire herself, and two residents were moved from the area.
The facility failed to repair a red-tagged AFSS and fire pump for months, and staff could not provide interim fire safety measures or fire/evacuation training. The facility also failed to promptly report and protect a resident who alleged sexual abuse by a former PTA, with the resident stating she feared retaliation and did not want the matter disclosed.
The facility failed to keep the AFSS and fire pump repaired after both systems were red tagged for months, and the Administrator could not provide interim fire safety measures or staff training on fire and evacuation protocols. The facility also did not report a resident's allegation of sexual misconduct by a former therapist; the resident, who had a BIMS of 15 and said she feared retaliation, described inappropriate sexual advances and told the RM she did not want police contacted, but the RM and Administrator decided not to file an abuse report.
Nonfunctional Fire Sprinkler System and Fire Pump: The AFSS and fire pump were red tagged and had remained out of service for months, with additional red tags noted later. Surveyors found the system would not function as expected in a fire, and the facility had not completed repairs or notified the State Survey Agency as required. The Maintenance Director knew of the issue, while the Administrator could not provide interim fire safety measures or staff training on fire and evacuation protocols.
Governing body failed to act in a timely manner after the AFSS and fire pump were red tagged for months, despite the CEO being notified and aware of the issues. Surveyors found the sprinkler system and fire pump still impaired, with no documented effective plan showing residents were protected from the fire hazard, affecting all 187 residents.
Failure to use QAPI to address fire safety deficiency: The AFSS and fire pump were red tagged and remained unrepaired, with additional red tags later documented. The Administrator confirmed the facility was not conducting fire watches after the red tags were received, and the issue was only discussed in monthly QAPI meetings without a formal PIP.
Failure to maintain the AFSS and fire pump left both systems red tagged for months, and the Administrator could not provide interim fire safety measures or staff training on fire and evacuation protocols. In a separate incident, a resident’s cell phone caught fire while charging on a window sill; the room smoke detector activated, but the building fire alarm and sprinklers did not activate. Staff extinguished the fire, moved two residents from the area, and the incident was not reported to the state agency as required.
Failure to Perform Hand Hygiene and Follow EBP During Resident Care: Staff did not perform hand hygiene or change gloves during wound care, PEG tube care, and perineal/catheter care for multiple residents. An RN placed clean dressing supplies on a resident’s bed without a barrier and dressed wounds without hand hygiene; CNAs used the same gloves for contaminated and clean tasks, and one CNA used contaminated gloves to handle clean clothing. Staff also did not follow EBP for residents with EBP orders, and some staff could not explain EBP requirements.
A resident with severe cognitive impairment and total ADL dependence was observed wearing only a cardigan or shirt with an adult brief, with exposed body areas and no readily available clean clothing in the closet. The resident stated she did not have any clothes and later said she did not get out of bed because she was not wearing pants. A CNA confirmed the resident lacked clean clothes and did not notify the nurse, and the UM confirmed the resident had been dressed only in a shirt and brief.
A resident reported that CNAs would not help her get out of bed for showers and instead gave her bed baths, despite her preference for showers and her statement that she felt cleaner with a shower. She also said staff told her she could not receive therapy or restorative services to improve strength and transfers unless she had Medicaid. Therapy records showed she had limited PT/OT services, was discharged due to benefits exhausted, and still required significant assistance with bed mobility and transfers.
Failure to provide privacy during incontinent care. A CNA performed bedside care for a resident with the room door fully open and the privacy curtain not closed, leaving the resident exposed and visible from the hallway while others passed by. The resident was alert and oriented to self only, required total assistance with ADLs, and was incontinent of bowel and bladder.
Grievance handling was not properly completed for a resident’s complaints about incontinence care and delayed response to a call light. The SW and Grievance Official documented an inappropriate response to one grievance and no clear resolution to another, with no evidence supporting the conclusion that the resident was confabulating. The Grievance Official also declined to provide notes documenting grievance resolutions, and the Administrator confirmed the grievance protocol was not being followed.
Failure to timely report an allegation of sexual abuse occurred when a resident told staff that a former therapy aide had made inappropriate sexual comments and requests, including asking for oral sex. The RM did not report the allegation to the state agency, stating the resident could decline law enforcement and that the resident said it was not abuse; the Administrator later confirmed the report should have been filed when staff first learned of the allegation.
Failure to timely report and investigate sexual abuse allegation: A resident disclosed that a former therapy aide made inappropriate sexual comments and requests, including asking for oral sex. Facility leadership was notified, but the allegation was not reported to the state agency within the required timeframe, and interviews and witness statements were delayed. The RM stated she did not report because the resident could decline law enforcement and said it was not abuse, despite the facility abuse policy requiring immediate reporting and thorough investigation.
A resident’s quarterly MDS did not include PTSD as an active diagnosis even though the care plan and mental health assessment documented PTSD-related trauma history and symptoms. The MDS Coordinator reviewed the assessment and confirmed the omission was her responsibility and an oversight.
Incomplete and Unimplemented Person-Centered Care Plans: A resident dependent on tube feeding was observed lying flat while feedings were infusing despite a care plan calling for HOB elevation. Another resident’s care plan was not updated to reflect hospice enrollment, DNR status, or dementia, and listed the resident as full code. A third resident was not effectively involved in the care plan meeting process; the invitation process did not confirm receipt, and the SW did not verify why the resident missed the meeting or offer a bedside conference.
Failure to Provide Ordered Bathing and Incontinence Care: Two residents did not receive ADL assistance as planned. One resident repeatedly requested showers but was given bed baths instead after CNAs said they did not have time to get her up, and an LPN confirmed staff were refusing showers. Another resident, who was dependent for toileting and transfers and had intact cognition, reported staff did not provide incontinence care and said they did not have time; she also reported not having a shower for about 3 weeks.
Failure to provide ROM and restorative services for a resident with contractures and severe mobility impairment. A resident with paraplegia, cervical spinal injury, and functional quadriplegia was observed with bilateral hand contractures and inability to open his hands or grasp objects, while stating he was not receiving therapy, restorative exercises, or splints. Records showed no current PT, OT, ST, or restorative nursing program, prior restorative ROM had been discontinued for lack of participation, and a therapy referral noted he would benefit from therapy to improve sitting tolerance and use his electric wheelchair.
Failure to Maintain a Safe Environment and Assess Smoking Safety: A resident’s cell phone caught fire while charging on a windowsill, with smoke, active flames, and visible burn and soot damage noted in the room; staff moved two residents from the area after the event. In a separate issue, a resident with DM, HTN, COPD, dyslipidemia, arthritis, and atrial fibrillation was observed smoking even though the resident was not on the facility’s smoking list, and no safe smoking assessment or care plan had been completed.
Failure to maintain proper positioning during tube feeding. A resident with a gastrostomy, brain injury, chronic respiratory failure, muscle wasting, and dysphagia was ordered NPO with HOB elevated 30-45 degrees during tube feeding, but was repeatedly observed receiving TF at 55 mL/hr while sliding down in bed and lying flat/supine. An LPN and the UM both confirmed the resident should not be flat during infusion, and staff later noted bilateral leg contractures made positioning difficult.
An unlabeled personal insulin pen was found stored in a resident-accessible nourishment refrigerator on the 2nd floor. The Dietary Manager stated it was not supposed to be there, and a CNA later said the pen belonged to him and that he knew the refrigerator was in the dining area and easily accessible to residents.
Inaccurate and incomplete documentation was found for two residents. One resident with a urinary catheter had blank TAR entries for ordered catheter care, even though a CNA said care was provided and the unit manager confirmed it should have been documented. Another resident who was a bilateral BKA was repeatedly observed in bed, yet ADL charting incorrectly showed bed-to-chair transfers and ambulation, which the ADON could not explain.
Improper Storage of Oxygen Cylinder in Oxygen Room: A free-standing E size O2 cylinder was observed at the entrance of the 3rd floor oxygen storage room instead of being secured in a rack. The UM confirmed cylinders were to be stored in racks, and the facility’s Oxygen Safety policy required cylinders to be chained or supported in racks or other fastenings, with empty cylinders segregated from full cylinders.
A resident with a history of physical aggression was involved in an incident where they struck a nurse. Although staff began 15-minute checks following the event, this enhanced monitoring was not documented in the care plan or as a physician order. Interviews with the DON, social worker, and MDS nurse confirmed the omission of this intervention from the care plan.
A facility failed to assess a resident's capability to self-administer medications before allowing him to do so. The resident was observed performing his own tracheostomy care and had an unsecured tube of mupirocin ointment. Despite the facility's policy requiring an interdisciplinary team assessment and documentation, no such assessment was conducted for this resident.
A resident with a contracted hand and limited range of motion did not receive proper nail care, resulting in excessively long fingernails. The resident's care plan indicated dependency on staff for personal hygiene, but there was no documentation of nail care being performed or refused. The facility's policy required regular nail maintenance to prevent infections, which was not adhered to in this case.
A resident was observed with an undated dressing on the left lower arm over several days, with no order or documentation in the EMR for the skin tear. The wound care nurse confirmed the lack of documentation, and the DON stated that nurses are expected to notify providers of new skin issues and obtain treatment orders, which should be documented in the EMR.
A resident receiving Magnesium Oxide four times daily did not have their magnesium levels monitored as ordered by the physician. Despite an order for a magnesium level check every six months, no monitoring or documented refusal was found in the resident's record. The DON confirmed the oversight, which was contrary to the facility's policy requiring staff to arrange for necessary tests.
The facility failed to properly dispose of garbage and refuse, as observed during inspections of the kitchen and outside garbage bins. Trash was found around the garbage compactor, and a cardboard box bin had a hole, allowing contents to be visible. The Dietary Manager and Administrator acknowledged these issues, which were not in compliance with the facility's policy requiring safe and efficient disposal practices.
A facility failed to implement Transmission-Based Precautions (TBP) for a resident with an ESBL urinary tract infection (UTI). The resident's room lacked TBP signage and isolation setup, confirmed by the unit manager and infection preventionist. The facility's policy requires TBP for transmissible infections, but there was no clear process for monitoring new infections when the infection preventionist was not on site.
Failure to Address Aggressive Roommate Risk and Provide Adequate Supervision
Penalty
Summary
The deficiency involves the facility’s failure to ensure an environment free from accident hazards and to provide adequate supervision and precautions for a vulnerable resident when roomed with another resident who had a documented history of aggressive and violent behaviors. Resident #1 was a cognitively impaired, non-verbal, limited-mobility adult who sustained unwitnessed physical injuries on 01/30/2026, including lacerations that required transfer to a higher level of care, suturing, and diagnostic testing that revealed intracranial bleeding. Resident #6, who moved into Resident #1’s room on 12/23/2025, had a clinical record documenting aggressive and violent behaviors such as yelling and physically acting out toward other residents and staff. Despite this, Resident #1’s record contained no documentation of enhanced supervision or other specific precautions related to being roomed with Resident #6. Staff interviews further described a pattern of concerning behavior by Resident #6 that was not fully assessed or incorporated into supervision plans for Resident #1. A hospice CNA reported witnessing Resident #6 verbally cursing at Resident #1 prior to the 01/30/2026 incident. Another CNA, who discovered Resident #1 with significant blood on the bed rail, in her mouth, and on the floor, recalled that Resident #6 had previously become upset when Resident #1 made noise, had threatened another resident who sat in her chair, was often verbally abusive to other residents, and was physically strong enough to move Resident #1, though she had not personally witnessed physical altercations between the two roommates. A RN reported she had requested a room change for Resident #1 after staff notified her of Resident #6’s violent behaviors and that she had multiple attempts to contact the Administrator about this request. The facility’s Risk Manager and Administrator stated that the initial belief was that Resident #1’s injuries were caused by contact with the bed rails and her own teeth, and the Administrator acknowledged that the investigation of the 01/30/2026 incident did not include Resident #6 as a possible source of the injuries, despite Resident #6’s documented aggressive history and the later acknowledgment that the puncture wounds on the outside of Resident #1’s cheek could not have been caused by her teeth.
Failure to Thoroughly Investigate Multiple Abuse Allegations
Penalty
Summary
The deficiency involves the facility’s failure to conduct thorough investigations into multiple abuse-related incidents involving three residents. For one resident, the facility documented facial gashes after an event that required transfer to a higher level of care, suturing of two right lower facial lacerations, and identification of an intracranial hemorrhage. Facility leadership concluded the resident caused the injuries by striking her teeth on the bed siderails and stated they had no reason to investigate the resident’s former roommate, despite that roommate’s documented history of aggressive behaviors and prior episodes of becoming upset with other residents. Hospice staff had emailed the Administrator requesting the resident be moved due to concerns about the roommate’s history of violent behaviors, and the resident was moved several days after returning from the hospital. In a separate incident, the facility received an allegation of verbal abuse in which a dietary staff member reported witnessing a CNA pull a resident by the arm of his wheelchair and yell at him. The facility’s investigation concluded the allegation was unsubstantiated, citing an inability to obtain adequate information from the reporting staff member after his resignation, even though leadership knew he resigned due to workplace harassment following his report, and no further investigation was conducted. In another case, a resident alleged that an RN became upset and threw a clipboard at him, resulting in a documented bruise on his hand when he blocked the clipboard. Facility leadership stated the allegation was unsubstantiated based on a reported retraction relayed by the ADON and a note that the resident had signed something with the police; the IDT added “confabulation – allegations of staff abuse” to the resident’s record. However, the resident later stated he only declined to press charges and did not retract the allegation. The police report documented that the resident declined to press battery charges and that the Risk Manager questioned why the incident was reported two days after it occurred, and the facility’s investigation consisted only of the Risk Manager’s written statement that the resident declined to press charges, with no additional investigative documentation provided.
Inaccurate and Non–Resident-Centered Use of Confabulation in Care Plans and Documentation
Penalty
Summary
The deficiency involves the facility’s failure to ensure that resident assessments and care plans were documented accurately and in a resident-centered manner for four residents. During interviews, the MDS LPN identified the Director of Social Services (DSS) as the person responsible for entering behavior items on residents’ care plans, and the DSS stated that such directives could come from upper management, including the Administrator, Risk Manager, or DON. When surveyors questioned why a care plan entry for confabulation was added for one resident shortly after that resident made allegations of abuse, the team did not answer, and the DSS deferred responsibility to the Administrator. In a follow-up interview, the Administrator and DON stated that this resident had retracted his statement of abuse and that this was the reason confabulation was added to his care plan. Further review showed that the term confabulation was also used in the documentation of three additional residents without clear clinical rationale provided by facility leadership. For one resident, confabulation was referenced in the summary of an investigation into a grievance in which the resident reported not being changed for 30 minutes after activating the call light, with the investigation summary stating there was “some sort of confabulation.” For another resident, confabulation was used in four nurses’ notes documenting that the resident refused care. For a fourth resident, confabulation was used in a nurse’s note stating that the resident requested to be changed after it had already been done. When asked, the Administrator and DON did not provide further explanation for the frequent use of confabulation in these residents’ charts.
Inaccurate ADL and Behavior Documentation for Dependent, Non-Ambulatory Residents
Penalty
Summary
The deficiency involves inaccurate and inconsistent medical record documentation for three residents, failing to reflect their actual functional status and behaviors. For one resident diagnosed with paraplegia, ADL documentation showed that he ambulated 150 feet independently or with varying levels of assistance and transferred from bed to chair independently or with supervision on multiple dates. However, observations on two consecutive days showed that he was bed bound with no active movement in his lower extremities, and both an LPN and a CNA confirmed he was paralyzed and unable to walk or transfer independently, stating that the documented entries would be impossible. For another resident, CNA flow sheets over a specified period documented independence with toilet and bed transfers, independence with lower body dressing, call light within reach, and fluids provided while at the hospital, while the resident’s care plan indicated total staff assistance. Observation showed this resident lying on her back with limited body movements, and a CNA later stated she required total care, had not been able to turn from side to side for several years, and required assistance with feeding. A third resident’s CNA flow sheets documented independence with toilet transfer and no behaviors, despite nursing notes on multiple dates describing the resident as upset, yelling, and screaming, and a care plan indicating a self-care deficit with total staff assistance for toileting, hygiene, and transfers, and that the resident was non-ambulatory. Observation showed this resident sliding down in bed and unable to reposition without assistance, and a CNA stated he required total care, while also explaining that behaviors were reported to the nurse and documented in a behavior flow sheet.
Unauthorized Use of Personal Cell Phones for Resident Images and Clinical Communication
Penalty
Summary
The facility failed to protect residents' personal privacy and the confidentiality of medical information when staff used personal cell phones to photograph and video residents for clinical communication with the facility’s Nurse Practitioner (NP). Nursing documentation showed that one resident was observed sliding on the floor while yelling and screaming with abdominal pain, and staff contacted the NP for clinical guidance. The NP’s written statement confirmed that staff provided a video of this resident and requested guidance based on the behaviors shown in the recording. During interviews, a RN admitted to taking a video of the resident on her personal cell phone to send to the NP and acknowledged knowing that personal devices were technically not permitted, though she believed the restriction related to posting on social media. The RN also reported that staff take photographs of residents’ skin concerns to send to the NP. The Wound Care Nurse stated that she routinely uses her personal cell phone to take and store pictures of residents’ wounds and sends them via text message to the NP for assessment and treatment recommendations, and both staff members were unaware of any signed consents from residents for this form of communication. The Administrator did not oppose the practice if done for medical purposes but acknowledged she could not ensure confidentiality once images were on personal devices. Review of the facility’s policy on videotaping, photographing, and imaging of residents showed requirements for explicit written consent, prohibition of unauthorized transmission of images, and treatment of photographs as health care records, but there was no evidence of consent, authorization, or secure, encrypted transmission for the use of staff personal devices as practiced.
Failure to Timely Report Suspected Abuse/Injury of Unknown Origin
Penalty
Summary
The deficiency involves the facility’s failure to timely report an alleged incident of abuse/neglect within the required 2-hour timeframe. An incident report filed on 02/03/2026 at 4:00 PM documented an event as occurring on 02/03/2026, but further review showed the incident actually occurred on 01/30/2026. The event involved Resident #1, described as a vulnerable adult with cognitive impairment, who was found with her face pressed against the side rails of her bed on 01/30/2026, sustaining puncture wounds to the outside of her cheek that required sutures and a transfer to a local hospital. Although the report indicated the Administrator was notified on 02/03/2026, the Administrator was already aware of the incident that occurred on 01/30/2026. The incident was not reported to the appropriate authorities until after an Adult Protective Services investigator arrived at the facility on 02/03/2026 at 4:00 PM to investigate the allegation. During an interview on 02/09/2026, the facility Risk Manager stated she decided to report the incident after the APS investigator entered the facility and confirmed that her expectation is that any suspected abuse observed by staff must be reported immediately so she can initiate an investigation. She also stated that any injury of unknown origin must be reported within two hours, followed by a five-day report with investigation findings. The facility’s written policy on Abuse, Exploitation or Misappropriation-Reporting and Investigating, last revised 04/2021, requires that suspected abuse, neglect, or injury of unknown source be reported immediately to the administrator and other officials, defining “immediately” as within two hours for allegations involving abuse or resulting in serious bodily injury. The Risk Manager did not provide an explanation for the delay in reporting this incident, resulting in noncompliance with the facility’s policy and regulatory reporting timeframes.
Failure to Protect Abuse Reporter From Retaliation and Harassment
Penalty
Summary
The deficiency involves the facility’s failure to implement its abuse-prevention and anti-retaliation policies to protect an employee who reported alleged abuse of a resident. A dietary aide (Staff Q) reported witnessing a staff member pull Resident #4 by the wheelchair arm and tell the resident, “get your ugly *** out here,” and he immediately reported this to a Unit Manager, who then notified the Risk Manager. After making this report, Staff Q stated that staff spoke loudly about him in a threatening manner, made retaliatory remarks, refused to sign meal-tray forms, and used aggressive tones and profanity toward him. He reported ongoing harassment from both kitchen and nursing staff, but had difficulty identifying those involved because staff were not wearing name badges. Staff Q ultimately resigned by phone, stating he feared for his safety and reiterating that he could not positively identify all involved staff due to the lack of visible name badges. Multiple interviews with facility leadership and staff showed that no investigation into the reported harassment and retaliation was conducted, despite the facility’s written policy stating that the administrator ensures the person reporting suspected violations is protected from retaliation or reprisal. The Dietary Manager reported that when Staff Q told her he was resigning due to harassment after reporting abuse, she did not investigate the harassment herself but notified the Administrator and Risk Manager. The 3rd Floor Unit Manager acknowledged hearing that Staff Q resigned due to harassment but stated staff-to-staff harassment was outside her scope and should be handled by HR. The Risk Manager stated she attempted to contact Staff Q twice, was unable to reach him, and then unsubstantiated the abuse allegation without further investigation. The Administrator confirmed awareness that Staff Q reported being harassed but acknowledged that no investigation into the harassment occurred. A former dietary staff member (Staff R) also reported experiencing harassment from nursing and kitchen staff during his employment and stated he had reported it to HR, who told him to speak with his supervisor, who was allegedly involved in the harassment. The HR Director recalled a harassment report from Staff R, acknowledged uncertainty about the timeline, and admitted staff were “bad about wearing badges,” despite repeatedly instructing them to wear them.
AFSS Out of Service, Poor Room Sanitation, and Resident Room Fire Event
Penalty
Summary
The facility failed to provide a safe living environment for 187 residents by allowing the Automatic Fire Sprinkler System (AFSS) to remain non-operational for more than eight months after it was red tagged. The system had been out of service since 05/05/2025, with additional red tags documented in August 2025 and November 2025. The report states there was no documented corrective action, interim safety measures, or appropriate notification to regulatory authorities during that period, and the facility did not begin fire watch protocol until after being notified by the Life Safety Surveyor on 01/12/2026. Facility leadership and maintenance staff acknowledged awareness of the red-tagged sprinkler system and fire pump. The maintenance director stated he had requested repairs from ownership, but the repairs were not completed. The administrator stated the facility had not conducted a fire watch after receiving the red tags in May and was unable to provide a reason for the repair delay other than emails showing that additional vendor opinions had been sought. The administrator also stated the facility did not receive confirming documentation from the local fire marshal until October 2025, but still could not provide interim fire safety plan measures or staff training regarding fire and evacuation protocols. The report also identified sanitation and environmental concerns in resident rooms. In two sampled rooms, multiple unlabeled and soiled personal care items were observed in bathrooms, including wash basins, a bedside commode basin, a toilet hat, and an orange-stained urinal bottle. Used adult briefs were also observed in a garbage container, causing a foul odor. In a separate incident involving a resident, the resident reported that her cell phone caught fire while charging on the window sill in her room, and staff observed smoke and a phone actively on fire. The resident extinguished the fire herself with her shoe. Staff reported that two residents were moved to the dining room, and the maintenance director later described the event as smoke from the phone activating the room smoke alarm while the building fire alarm did not activate.
Failure to Repair Fire Protection Systems and Report Sexual Abuse Allegation
Penalty
Summary
The facility neglected the safety and wellbeing of all 187 residents by failing to repair the automatic fire sprinkler system and fire pump, both of which had been red tagged since May 5, 2025. During the life safety tour, the surveyor observed that the sprinkler system and fire pump remained red tagged, with additional red tags issued later in August 2025 and November 2025. The facility had not completed the repairs by the annual survey, and the sprinkler system was identified as not functioning as expected in the event of a fire. Interviews with the Administrator and Maintenance Director showed that both were aware of the red tags, but the repairs had not been completed. The Administrator stated that the facility did not receive confirming documentation from the local fire marshal until October 2025 and could not provide a reason for the delay other than emails showing that additional opinions were sought. The Maintenance Director stated he had requested repairs from ownership, but the repairs were not completed. The Administrator was also unable to provide interim fire safety plan measures or staff training regarding fire and evacuation protocols. The facility also failed to protect a resident from abuse. Resident #205 reported that a former physical therapy assistant had made sexual comments and requested oral sex, and that the staff member would place his crotch in her face while rolling her for exercises. The resident stated she did not report the conduct at the time because the employee had quit and she feared retaliation. The resident later told staff she had disclosed the matter in confidence and did not want anyone to get in trouble. The Administrator later acknowledged that the allegation should have been reported when it was first brought to staff attention, but the report was not filed until later.
Failure to Maintain Fire Safety Systems and Report Sexual Abuse Allegation
Penalty
Summary
The facility administrative staff failed to use available resources effectively and efficiently to maintain the facility in a safe manner and ensure the fire suppression system was repaired in a timely manner. During a tour on 1/12/2026, the Life Safety surveyor observed that the Automatic Fire Sprinkler System and fire pump were red tagged and had been since 5/5/2025, indicating the fire suppression system would not function as expected in the event of a fire. The surveyor also noted two subsequent red tags on each system dated August 2025 and November 2025. When interviewed, the Administrator could not produce documentation until October 2025 from the local fire marshal confirming the problem and was unable to provide a reason for the repair delay other than emails showing that additional opinions were sought. On 1/13/2026, the Administrator was again unable to provide interim fire safety plan measures or training to staff regarding fire and evacuation protocols. The facility also failed to ensure a resident was kept safe from sexual abuse by not addressing a report of staff-to-resident sexual advances involving Resident #205. A note written by the Risk Manager documented that the resident described inappropriate conduct by a former therapist, including requests for oral sex and the therapist having his crotch in her face during exercises. The resident said she did not want to report it, did not want police called, and stated she did not think it was abuse. The Risk Manager confirmed she did not file an abuse report because the resident was alert and oriented with a BIMS of 15 and because she believed reporting against the resident's wishes would violate her rights; she and the Administrator decided not to file a report.
Nonfunctional Fire Sprinkler System and Fire Pump
Penalty
Summary
The facility failed to comply with Federal, State, and local laws, regulations, codes, and accepted professional standards by not having a functional fire suppression system. During a Life Safety tour on 1/12/2026, the Automatic Fire Sprinkler System (AFSS) and fire pump were observed to be red tagged, and the tags had been in place since 5/5/2025. The report states there were two additional red tags on each system dated August 2025 and November 2025, and that the sprinkler system and fire pump would not function as expected in the event of a fire. The facility had not completed repairs to the AFSS by the annual survey. The report also states the facility did not contact the State Survey Agency within one business day after the sprinkler failure, as required by Florida Administrative Code 59a-4.130. The Maintenance Director confirmed awareness of the red tags and said repairs had been requested from ownership but were not completed. The Administrator could not provide documentation of interim safety measures until October 2025 from the local fire marshal and was unable to provide a reason for the repair delay beyond emails showing that additional opinions were sought. The Administrator also could not provide interim fire safety plan measures or staff training on fire and evacuation protocols, and the local Fire Marshal stated he believed the facility was under contract with an engineer for the repairs.
Governing Body Failed to Address Fire Suppression System Impairment
Penalty
Summary
The governing body failed to assume responsibility for the protection of all 187 residents by not acting in a timely manner regarding a failing fire suppression system. During the annual survey on 1/12/2026, the Life Safety surveyor observed that the automatic fire sprinkler system and fire pump were red tagged and had been since 5/5/2025, showing that the fire suppression system would not function as expected in the event of a fire. The report also states there were two additional red tags on each system, dated August 2025 and November 2025. Record review and email correspondence showed the CEO was notified of the fire pump and sprinkler issues on or about 5/9/2025. In response, the CEO stated there had been ongoing communication with the facility, that additional vendors were engaged, and that later inspections by other companies downgraded the red tag to yellow. The CEO also stated the facility pursued testing of city water pressure and had not yet received written documentation from the utility, which prevented retention of an engineer for a formal water flow study. The report states there was no additional information or documentation showing implementation of an effective plan to ensure residents were protected against the dangers of a fire. The survey findings identified that the facility remained with the sprinkler system and fire pump in impaired status for months before the annual survey, while the governing body had knowledge of the issue. The report documents that the governing body did not act in a timely manner to address the failing fire suppression system, and that the deficiency involved all 187 residents in the facility.
Failure to Use QAPI to Address Fire Safety Deficiency
Penalty
Summary
The facility failed to utilize its QAPI process to identify and correct quality deficiencies related to fire safety. On 1/12/2026, the Life Safety surveyor observed that the automatic fire sprinkler system and fire pump were red tagged and had been since 5/5/2025, showing that the fire suppression system was not functioning at full operational capacity. The surveyor also noted that there were two additional red tags on each system, dated August 2025 and November 2025, and the facility had not completed the repairs by the annual survey. During interview, the Administrator confirmed that the facility was not actively conducting fire watches and had not done any fire watches after receiving the red tags on 5/5/2025. On 1/19/2026, the Administrator stated the issue had been discussed in monthly QAPI meetings but that no formal PIP had been completed, and no reason was given for not developing one. The facility’s QAPI plan included maintenance and engineering and described PIPs, but the report states the facility failed to use the QAPI process to address the fire safety deficiency.
Failure to Maintain Fire Suppression System and Respond to Room Fire
Penalty
Summary
The facility failed to maintain the Automatic Fire Sprinkler System (AFSS) and fire pump after both systems were red tagged beginning in May 2025 and remained unrepaired at the time of the annual survey in January 2026. During the Life Safety tour, the surveyor observed that the AFSS and fire pump were still red tagged, and the Maintenance Director confirmed he knew about the tags and had requested repairs from ownership, but the repairs had not been completed. The Administrator also acknowledged awareness of the red tags and was unable to provide interim fire safety plan measures or staff training on fire and evacuation protocols. The report also describes a fire-related incident involving one resident whose cell phone caught fire while charging on a window sill in the resident’s room. The resident reported that the phone was actively burning, the fire alarms were sounding, and she extinguished the fire herself using her shoe. The windowsill showed residual smoke damage and burned plastic, and burn marks and soot were visible on the blinds and window. A staff member reported seeing smoke from the doorway, finding the room smoke detector activated, and observing the phone on fire while plugged in. Two residents were moved to the dining room, and staff reported eye irritation from smoke exposure. During interviews, the Maintenance Director stated the room smoke alarms activated but the building fire alarm did not activate, and he confirmed the sprinklers did not activate. The Administrator stated the fire department responded, but the incident was not reported to the state agency despite reporting requirements. The Administrator and Maintenance Director also confirmed there was no second-floor corridor evacuation and only two residents were moved from the immediate area.
Failure to Perform Hand Hygiene and Follow EBP During Resident Care
Penalty
Summary
The facility failed to prevent the spread of infections by not performing hand hygiene during wound care and catheter/perineal care, and by not following Enhanced Barrier Precautions (EBP) for residents with orders requiring them. During wound care for Resident #53, Staff B, RN, placed clean dressing supplies on the resident’s bed without a barrier, removed the soiled dressing, and did not remove gloves or wash hands before applying the clean dressing. During wound care for Resident #32, who was on contact isolation for an infected heel wound, Staff B again placed clean supplies on the bed without a barrier, placed the soiled dressing on the bed next to the clean supplies, and cleaned and dressed the wound without hand hygiene or donning clean gloves. Staff B later stated the expected process included handwashing, use of a barrier, glove changes, and hand hygiene between dirty and clean steps, and confirmed those steps were not followed. Resident #15 had a tube feeding bottle hanging from an IV pole with the end of the tubing uncapped and open to air. Staff X, LPN, stated she did not know where to obtain a cap for the end of the tubing. On the following day, Staff K, LPN, performed PEG tube care for Resident #15 without using EBP, even though EBP signage was posted on the room door, a PPE cart was available outside the room, and the resident’s record showed an active provider order for EBP during PEG tube-related care every shift. For Resident #17 and Resident #144, CNAs provided perineal care and indwelling urinary catheter care without hand hygiene before care, between perineal care and catheter care, or after care. They used the same pair of gloves throughout contaminated and clean tasks, and after glove removal moved between residents without hand hygiene. For Resident #144, one CNA also used contaminated gloves to open the resident’s closet and retrieve clean clothing. Both CNAs stated handwashing was not required when wearing gloves and said they did not know what EBP was, incorrectly describing it as a cream used after pericare. Facility policy required hand hygiene before and after resident contact, before handling dressings, when moving from contaminated to clean body sites, after glove removal, and during glove use for aseptic or contact precaution care.
Failure to Maintain Resident Dignity Through Inappropriate Clothing
Penalty
Summary
The facility failed to ensure Resident #106’s dignity was maintained by not providing appropriate clothing. Resident #106’s Quarterly MDS showed a BIMS score of 03, indicating severe cognitive impairment, and she was dependent on staff for ADLs. On 1/12/2026 at approximately 12:45 PM, she was observed sitting in her room in a wheelchair wearing a cardigan with only one middle button secured, with her upper chest and lower abdomen exposed, wearing an adult brief while eating lunch. She stated, “I don’t have any clothes.” Her closet door had a sign stating her family was responsible for doing her laundry, and an observation of the closet found no clothes hanging, with sheets and a plastic bag of clothes on the bottom of the closet. On 1/13/2026 at approximately 8:30 AM and 3:00 PM, Resident #106 was observed lying in bed and indicated she did not get out of bed because she was not wearing pants and was only clothed in a shirt and an adult brief. During an interview at approximately 3:05 PM, Staff HH, CNA, confirmed the resident did not have clean clothes and said she would go to the laundry room to find clothing for her, but she did not notify the nurse. Staff HH later opened the closet and noted one pair of pants hanging inside. At approximately 3:15 PM, Staff P, UM, confirmed the resident had been wearing only a shirt and an adult brief, inspected the closet, noted the jeans, and stated, “this should never happen, Staff HH should have dressed [the resident]."
Failure to Honor Resident Bathing Preferences and Provide Requested Therapy Services
Penalty
Summary
The facility failed to ensure a resident was able to exercise her right to self-determination regarding daily care and services. Resident #123 stated she preferred showers, but reported that CNAs would not get her out of bed for a shower and instead gave her bed baths, telling her they did not have time and that it took too long. She also stated that staff would fuss at her when she asked for anything and that she felt cleaner when she had a shower. The resident’s MDS documented that choosing between a tub bath, shower, bed bath, or sponge bath was very important to her. The facility also failed to provide appropriate therapy or restorative services to improve the resident’s mobility and strength. Resident #123 stated she had repeatedly asked for therapy services to help with strength and transfers, but was told she could not have therapy or restorative services because she did not have Medicaid and would have to wait until she obtained it. Therapy records showed she received services only on 10/7/25 and 10/08/25 before being discharged due to benefits exhausted. The discharge note documented she required partial to moderate assistance with bed mobility and substantial maximal assistance with transfers, and a later quarterly therapy screen stated she would benefit from continued skilled services for ADLs and functional mobility, while the recommendation recorded was that no skilled therapy intervention was indicated.
Failure to Provide Privacy During Incontinent Care
Penalty
Summary
The facility failed to provide appropriate privacy while personal care was being administered to one resident. During an observation, the resident’s room door was fully open and the privacy curtain was not closed while a CNA was performing incontinent care at the bedside. The resident was wearing a facility gown that had been pulled up to the upper torso, no incontinent brief was on, and no bed covers were in place, leaving the resident’s body exposed and visible from the hallway while other residents passed by the room. When the CNA finished the task, she told the surveyor to come in because she was just wiping the resident’s face, and later stated she should have shut the door and pulled the privacy curtain during care. The resident was alert and oriented to self only and required total assistance with all ADLs, including bathing, personal care, toileting, and dressing; she was also incontinent of bowel and bladder and dependent on staff for those care and services.
Grievance Process Not Properly Followed
Penalty
Summary
The facility failed to maintain a grievance protocol to properly identify, investigate, and resolve grievances for one resident. Review of the grievance log with the Social Worker and Grievance Official identified a grievance in which the resident stated staff refused to dry her after providing incontinence care. The documented action for that grievance stated, "It appears to be lunch time when staff cannot toilet residents," and the Social Worker acknowledged this was not an appropriate resolution and did not know what actions the unit manager took to address the concern. A second grievance for the same resident stated she waited 30 minutes after activating the call light before being changed. The documented action stated, "some sort of confabulation," but there was no evidence showing how the facility determined the resident was confabulating and no grievance resolution was documented. During interview, the Grievance Official declined to provide access to notes documenting grievance resolutions. The Administrator later confirmed the Social Worker and Grievance Official were not following proper grievance protocol and stated she educated them regarding the protocol.
Failure to Timely Report Allegation of Sexual Abuse
Penalty
Summary
The facility failed to immediately identify and timely report an allegation of sexual abuse involving one resident. A note written by the facility Risk Manager documented that the resident confided in an employee on 1/13/26 that a former therapy aide, who no longer worked at the facility, had engaged in inappropriate sexual conduct. During interviews the same day, the resident stated that the former therapy aide would ask to be her boyfriend and would ask inappropriate things, including asking for oral sex. During interviews on 1/15/26, the Risk Manager stated she did not report the allegation to the state agency because the resident had the right to decline law enforcement and said the resident claimed it was not abuse. She later stated she was not mandated to report the allegation because of the resident’s rights and high cognitive score. The Administrator stated she learned of the allegation on 1/15/26, reviewed the Risk Manager’s note, and instructed the Risk Manager to investigate further and submit a report, and confirmed the report should have been filed when the allegation was first brought to staff’s attention. The facility’s abuse policy stated suspected abuse must be reported immediately to the administrator and other officials according to state law.
Failure to Timely Report and Investigate Sexual Abuse Allegation
Penalty
Summary
The facility failed to ensure an allegation of sexual abuse involving Resident #205 was reported to the State Survey Agency, Law Enforcement, and Adult Protective Services within the required timeframe, and failed to ensure a thorough investigation was conducted to protect residents. During the survey, the Risk Manager and Administrator were informed by the Director of Rehabilitation of an allegation involving a former therapy aide and Resident #205. In interviews on 1/13/26, Resident #205 stated that the former therapy aide would ask to be her boyfriend and would ask inappropriate things, including asking for oral sex. The facility did not report the allegation to the state survey agency until 1/15/26 at 5:55 PM, 57 hours later. The facility’s investigation was also delayed. The Director of Rehabilitation stated that Staff GG, a Physical Therapy Assistant, reported the allegation to him on 1/13/26 between 8:00 AM and 9:00 AM, and he immediately notified the Administrator. The Risk Manager stated she did not report the abuse because the resident had the right to decline law enforcement and because Resident #205 said it was not abuse. Review of the investigation showed that witness statements and interviews with staff and other residents were not completed until 1/16/26, the day after the report was filed and three days after the allegation was made. The facility’s abuse policy stated that suspected abuse must be reported immediately and thoroughly investigated, with immediate defined as within two hours for abuse allegations.
MDS Assessment Did Not Accurately Reflect PTSD Diagnosis
Penalty
Summary
The facility failed to ensure an accurate MDS assessment for one resident when the quarterly MDS did not code PTSD as an active diagnosis. Record review showed the resident’s care plan identified PTSD related to a history of childhood sexual abuse/violence and a serious car accident with major injuries or complications, and a licensed mental health counselor’s diagnostic assessment documented extensive childhood sexual trauma and symptoms and nightmares stemming from two major motor vehicle accidents. The resident’s diagnosis list did not include PTSD in the medical history, but the MDS Coordinator reviewed the most recent MDS and confirmed that PTSD was not included, stating that this was her responsibility and that the omission was an oversight.
Incomplete and Unimplemented Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans with measurable objectives and timeframes to meet residents’ medical, nursing, mental, and psychosocial needs for three sampled residents. For Resident #181, the record showed dependence on tube feeding, and the care plan included an intervention to keep the head of the bed elevated during feedings and for the appropriate length of time afterward. However, observations on multiple occasions showed the resident lying flat on her back while tube feeding was infusing. During interview, an LPN stated the resident had contractures in both legs that made proper positioning difficult and said therapy would need to evaluate positioning techniques. The facility policy required elevating the head of the bed at least 30 degrees during tube feeding and for at least 1 hour afterward. For Resident #10, the record showed a significant change MDS after readmission from the hospital, with the resident electing hospice care after failing a swallowing test and choosing not to have a feeding tube. The resident also elected DNR status, with the POA and physician signatures documented. The MDS identified dementia not related to Alzheimer’s disease. The care plan, however, did not include a comprehensive care plan with interventions and goals for dementia or hospice, and the advanced directives section listed the resident as full code. During interview, the MDS Coordinator confirmed the care plan should have been updated to reflect hospice admission, DNR status, and dementia, and stated it appeared the care plan was not updated. For Resident #17, the care plan reflected that the resident established his own goals, used a wheelchair for mobility, had completed the 8th grade, and enjoyed being outdoors in good weather. The chart contained a scanned invitation for a care plan meeting, but the resident stated he was not aware of the meeting, never received an invitation, and had never attended a care plan meeting. The social worker stated invitations were printed and delivered to resident rooms, but acknowledged that scanning the invitation did not confirm receipt or comprehension, did not verify why the resident did not attend, did not contact nursing staff, and did not notify floor staff that the resident was scheduled to attend. The DON stated that if a resident is unable to attend, the resident should still be involved and care plan meetings can be held at the bedside.
Failure to Provide Ordered Bathing and Incontinence Care
Penalty
Summary
The facility failed to provide care and services for activities of daily living for two residents who were unable to complete those tasks independently. One resident stated she was not getting showers as preferred and was instead given bed baths because CNAs said they did not have time to get her up for a shower. She also reported that a CNA told her she did not have time to deal with getting her up on shower days and would only give her a bed bath. Her MDS showed that choosing between a tub bath, shower, bed bath, or sponge bath was very important to her, and her shower schedule called for showers or baths three times weekly. Treatment records showed she received six bed baths and only one shower during the review period. A staff LPN confirmed the resident had repeatedly asked for showers but staff continued to refuse and would mark showers as refused if they did not feel like giving them. A second resident, who had a BIMS score of 15 and was dependent on staff for toileting and transfers, stated that Staff R did not wipe or clean her after incontinence episodes and told her she did not have time to deal with it. She also stated she had not had a shower in about 3 weeks. Her care plan required hands-on assistance with toileting and incontinence care, with interventions to keep her clean, dry, and odor free, and also required assistance with personal care tasks, bathing, dressing, and mobility. Her shower schedule called for showers or baths three times weekly, and treatment records showed she received two bed baths and six showers during the review period.
Failure to Provide ROM and Restorative Services
Penalty
Summary
The facility failed to provide appropriate treatment and services for a resident with limited range of motion to prevent further decline of ROM. Resident #132 was observed with bilateral hand and finger contractures and was unable to open either hand, grasp a pen, or pick up a small object without difficulty. During interviews, he stated he was not receiving therapy services or restorative exercises, did not have splints, and had only received exercises from restorative over a year earlier. He also stated that if services were being provided, he would not be in the condition he was in now. Record review showed the resident was admitted with diagnoses including paraplegia after blunt trauma with cervical spinal injury, polyneuropathy, contracture of muscle, depression, and hypertension, and a history of functional quadriplegia after a boating accident. The MDS indicated impairment to both upper and lower extremities, wheelchair use, dependence for bed mobility, transfers, bathing, dressing, and personal hygiene, and no speech therapy, occupational therapy, physical therapy, or restorative nursing program. A restorative ROM order for bilateral lower extremity stiffness had been resolved months earlier, and a therapy referral noted the resident would benefit from therapy to improve sitting tolerance and use his electric wheelchair. The DOR stated restorative services had been discontinued due to lack of participation, progress notes showed missed restorative weeks, and the DOR confirmed the resident currently had no skilled therapy. The Administrator and Maintenance Director stated the facility did not fix residents’ personal electric wheelchairs and were not aware of any repair need for this resident’s wheelchair.
Failure to Maintain a Safe Environment and Assess Smoking Safety
Penalty
Summary
The facility failed to keep a resident room free of accident hazards when a resident’s cell phone caught fire while charging on the window sill in the resident’s room. The resident reported that the fire alarms were sounding and that the phone was actively in flames, and she extinguished the fire herself using her shoe. Staff later reported seeing smoke coming from the doorway, opening the door, and finding the cell phone on the window sill actively on fire while plugged in and charging. Two residents were moved to the dining room for safety, and staff reported eye irritation from smoke exposure. The windowsill, blinds, and window showed residual smoke damage, burned plastic, burn marks, and soot residue consistent with the event. The facility also failed to assess a resident for safe smoking practices. A resident was observed smoking a cigarette and was not listed by the facility as a known smoking resident. The resident had diagnoses including DM type II, HTN, COPD, dyslipidemia, arthritis, and atrial fibrillation. Record review found no documentation that the resident had been assessed as a safe smoker, and the Risk Manager confirmed that the safe smoking assessment and care plan had not been completed after the resident had recently started smoking again.
Failure to Maintain Proper Positioning During Tube Feeding
Penalty
Summary
Appropriate care was not implemented for a resident with a feeding tube. Resident #181 had a history significant for brain injury, chronic respiratory failure, gastrostomy status, muscle wasting, and difficulty swallowing. Her physician’s orders included NPO status and head of bed elevation to 30-45 degrees when tube feeding was administered, and there were no orders for snacks or pleasure meals. During review and observation, the resident was seen receiving tube feeding at 55 mL/hr while lying in bed with the head of the bed mechanically elevated only about 30-35 degrees, but her body had slid toward the foot of the bed so that her torso was flat or supine. This same condition was observed on multiple occasions. On one observation, staff turned off the tube feeding pump and repositioned the resident after she was found lying flat; the LPN stated the resident moves around a lot and slips down in bed, and confirmed she should not lie flat while tube feeding was infusing. On another observation, the Unit Manager also confirmed the head of bed should be elevated between 30 and 45 degrees during tube feeding. On a third observation, the resident was again found lying flat while the tube feeding continued to infuse. Staff later stated the resident had contractures in both legs, which made it difficult to raise the head and foot of the bed for proper positioning. The facility policy on enteral feedings required elevating the head of the bed at least 30 degrees during tube feeding and for at least 1 hour afterward, or using reverse Trendelenburg if head-of-bed elevation was medically contraindicated.
Unlabeled Insulin Pen Stored in Resident-Accessible Nourishment Refrigerator
Penalty
Summary
The facility failed to ensure food was stored under sanitary conditions when staff stored a personal, unlabeled insulin pen inside 1 of 3 resident-accessible nourishment refrigerators. On 01/12/2026 at approximately 9:30 AM, surveyors observed all four floors had nourishment refrigerators that were easily accessible to residents. During inspection of the 2nd Floor #2 nourishment refrigerator, an unlabeled insulin pen was found in the door shelf. The Dietary Manager stated the insulin pen was not supposed to be in the refrigerator. At approximately 11:00 AM, the insulin pen was no longer in the refrigerator. Staff L, a CNA, later stated the insulin pen belonged to him and acknowledged he knew the nourishment refrigerator was in the dining area and easily accessible to residents.
Inaccurate and Incomplete Resident Care Documentation
Penalty
Summary
The facility failed to provide accurate and complete documentation for resident care for 2 of 35 residents reviewed. For one resident with a urinary catheter, an observation found orange-colored sediment in the urine, and the resident stated she was waiting for staff to assist with perineal care. The physician’s order required catheter care with soap and water daily and as needed every night shift, but the Treatment Administration Record had blank nurse signature areas for the catheter care entries. A CNA stated she performed catheter care more than once per shift, but her documentation did not reflect it because the charting was not specific, and the unit manager confirmed the catheter care should have been documented. For another resident who was a bilateral below-the-knee amputee, repeated observations showed the resident lying in bed and stating he had not been out of bed during the day. However, the ADL documentation completed by a CNA consistently recorded that the resident was assisted from bed to chair and ambulated 10 feet and 150 feet, with additional entries stating he was assisted to his chair or wheelchair. The ADON reviewed the record and could not explain why these tasks were documented because the resident was unable to ambulate, and the CNA stated that sometimes the computer messes up and he would let the nurse know when that happened.
Improper Storage of Oxygen Cylinder in Oxygen Room
Penalty
Summary
The facility failed to ensure oxygen cylinders were stored in a safe and secure manner in 1 of 4 designated oxygen storage rooms, the 3rd floor oxygen storage room. During observation on 1/15/2026 at approximately 8:45 AM, one E size oxygen cylinder was found standing freely at the entrance of the storage room in front of the rack rather than being secured within a rack. During an interview at approximately 9:25 AM, the Unit Manager confirmed that oxygen cylinders were to be stored in racks and that empty oxygen cylinders were stored in a separate rack from full cylinders. Review of the facility’s Oxygen Safety policy stated that cylinders shall be properly chained or supported in racks or other fastenings to secure all cylinders from falling, whether connected, unconnected, full, or empty.
Failure to Update Care Plan with Enhanced Monitoring After Aggressive Incident
Penalty
Summary
The facility failed to maintain a complete and comprehensive care plan for a resident with a history of physical aggression, including behaviors such as striking out, hitting, kicking, throwing objects, spitting at staff, and refusing care. On the morning of 5/27/25, staff responded to an incident where the resident was observed hitting a nurse in the dining room. Following the incident, the resident was seen by a Psychiatric APRN, and staff implemented 15-minute checks for the next 48 hours as a monitoring intervention. However, review of the resident's electronic medical record revealed that while the care plan for physical aggression was revised on the same day as the incident, no new interventions were documented, and the enhanced rounding of 15-minute checks was not added to the care plan. Additionally, there was no physician order for the enhanced rounding. Interviews with the DON, social worker, and MDS/care plan nurse confirmed that the care plan update for enhanced rounding was missed, and the intervention was not included in the resident's care plan.
Failure to Assess Resident's Capability for Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that the interdisciplinary team (IDT) assessed and determined if a resident was capable of self-administering medications before allowing a resident to do so. This deficiency was identified during an observation of a resident who was performing his own tracheostomy care and had an unsecured tube of mupirocin ointment on the sink. The resident had been declining tracheostomy care from staff and providing his own care on multiple occasions without an assessment to determine his capability to self-administer medications and treatments. The Director of Nursing (DON) acknowledged that the facility has a process to assess residents before allowing them to self-administer medications, but this process was not followed for the resident in question. The facility's policy requires that the IDT assess each resident's cognitive abilities to determine if self-administration is safe and appropriate, and this should be documented in the medical record and care plan. However, no such assessment or documentation was found for the resident, leading to the deficiency.
Failure to Provide Adequate Nail Care
Penalty
Summary
The facility failed to provide adequate nail care to a resident who was dependent on staff for activities of daily living (ADL). During an observation, the Director of Nursing (DON) noted that the resident's fingernails on the right hand were excessively long, with the 5th digit's nail measuring 1.5 cm past the nail bed. The resident's right hand was contracted, making it difficult to measure the 4th digit's nail, which was also noted to be long. The DON confirmed that the nail length was unacceptable given the resident's condition. A review of the resident's records showed that the resident had a functional limitation in the range of motion on one side of the upper extremity and required supervision or assistance for personal hygiene. The care plan indicated the resident was dependent on staff for various personal care tasks, including nail care. However, there was no documentation of nail care being performed or any refusal of such care by the resident. The facility's policy on nail care, revised in February 2018, emphasized the importance of regular cleaning and trimming to prevent infections, but there was no record of compliance with this policy for the resident in question.
Failure to Document and Order Treatment for Skin Tear
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards and facility policy for a resident with a non-pressure related skin condition. Observations revealed that the resident had an undated dressing on the left lower arm over several days. The wound care nurse confirmed that the dressing was not dated and that there was no order for the dressing or documentation of the skin tear in the resident's electronic medical record (EMR). The wound was new to the wound care nurse that week, and no order had been obtained for the treatment. The Director of Nursing (DON) confirmed the absence of a documented order in the EMR for the resident's left lower arm/wrist area. The DON stated that it is expected for the nurse to notify the provider of any new skin issues, obtain an order for treatment, and document it in the EMR. Additionally, the resident's representative should be notified. The facility's policy on skin tears and minor breaks in the skin requires obtaining a physician's order, documenting physician notification, and reviewing the resident's care plan and current orders.
Failure to Monitor Magnesium Levels
Penalty
Summary
The facility failed to appropriately monitor the magnesium levels for a resident who was receiving Magnesium Oxide 400 mg by mouth four times a day since September 15, 2023. The physician had ordered a magnesium level to be checked every six months along with other routine labs, as per the order dated July 6, 2023. However, a review of the resident's record revealed that there was no monitoring of the magnesium level or any documented refusal of the test since the order date. An interview with the Director of Nursing confirmed that the magnesium level was not completed, and there were no documented attempts or refusals in the resident's record. The facility's policy, Lab and Diagnostic Test Results-Clinical Protocol, revised in November 2018, states that the physician will identify and order diagnostic and lab testing based on the resident's needs, and the staff will process test requisitions and arrange for tests. Despite this policy, the necessary monitoring was not conducted, leading to a deficiency in the resident's care.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to properly dispose of garbage and refuse, as observed during an inspection of the kitchen and outside garbage collection bins. On the initial tour, trash was found around the garbage compactor, and a cardboard box trash bin was on the ground with a visible hole in the forklift port, allowing cardboard boxes to be seen through it. The Dietary Manager acknowledged the issues, indicating plans to notify the Maintenance Manager about the hole and to clean up the area. A follow-up observation confirmed the ongoing issues, with the Administrator noting the hole in the cardboard box bin and trash scattered on the ground around the bins. The facility's policy, dated October 2019, requires that garbage and refuse be collected and disposed of safely and efficiently, with specific responsibilities assigned to the Dining Services Director and the Director of Maintenance to maintain cleanliness and proper disposal practices.
Failure to Implement Transmission-Based Precautions for ESBL UTI
Penalty
Summary
The facility failed to implement Transmission-Based Precautions (TBP) for a resident diagnosed with an extended-spectrum B-lactamase (ESBL) urinary tract infection (UTI). On September 10, 2024, the room of Resident #8 was observed without TBP signage or any isolation setup, including personal protective equipment (PPE). This was confirmed by the unit manager, Staff K, who acknowledged that residents with ESBL UTI should be on contact precautions, which include TBP signage and isolation setup by the door. The infection preventionist (IP) confirmed that an order for antibiotics was placed on September 6, 2024, and that the resident should have been placed on contact isolation at that time. Further interviews revealed a lack of a clear process for monitoring new infections when the IP is not on site. Staff K was unaware of any such process, and the Director of Nursing (DON) stated that the house supervisor reviews orders on weekends for residents being readmitted from the hospital. However, there was no indication that this process was followed for Resident #8. The facility's policy on Isolation-Initiating Transmission Based Precautions, revised in August 2019, states that such precautions should be initiated when a resident has a laboratory-confirmed infection and is at risk of transmitting it to others, which was not adhered to in this case.
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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.
Illustrative
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Nursing homes near Pensacola
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Arabella Health & Wellness Of Pensacola | 1.5 mi | ★★★★★ | 12 | 3 |
| Rosewood Healthcare And Rehabilitation Center | 2.1 mi | ★★★★★ | 2 | 0 |
| Havens At Pensacola, The | 3.9 mi | ★★★★★ | 4 | 0 |
| Pensacola Nursing & Rehabilitation Center | 4.4 mi | ★★★★★ | 20 | 0 |
| Bayside Health And Rehabilitation Center | 5.8 mi | ★★★★★ | 0 | 0 |
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