Every finding on record at Coral Bay at Pensacola, LLC

Based on observations, interviews and record reviews, the facility failed to take reasonable precautions, including adequate supervision and failed to assess and address the foreseeable risk of harm posed by a resident with documented violent behaviors when roomed with a vulnerable resident and failed to implement sufficient interventions to mitigate that risk for 2 of 10 residents reviewed (Residents #1 and #6)The findings include:Review of medical records dated from 01/01/2026-02/11/2026 revealed Resident #1 was a vulnerable adult with cognitive impairment, who was non-verbal and had limited mobility. Resident #1 sustained unwitnessed physical injuries on 01/30/2026, including lacerations requiring transfer to a higher level of care and medical attention including sutures. Diagnostic testing at the hospital revealed Resident #1 had intracranial bleeding.Resident #6 moved into Resident #1's room on 12/23/2025. A review of Resident #6's clinical record revealed a documented history of aggressive and violent behaviors including yelling and physically acting out towards other residents and staff. Resident #1's record had no documentation to reflect enhanced supervision despite the documented aggressive behavior her roommate had.On 02/11/2026 at approximately 8:45 AM, an interview was conducted with Staff F, Hospice Certified Nursing Assistant (CNA). Staff F reported witnessing Resident #6 verbally cursing at Resident #1 prior to the incident that happened on 01/30/2026.On 02/11/2026 at approximately 1:30 PM, an interview was conducted with Staff G, CNA. Staff G revealed she had discovered Resident #1 on 01/30/2026 with significant amounts of blood on her bed rail, in her mouth, and on the floor surrounding her bed. She recalled in the past, Resident #6 became upset when Resident #1 was making noise and described a prior incident in which Resident #6 had threatened another resident who had sat in her chair. She added that Resident #6 was often verbally abusive to other residents and was physically strong enough to move Resident #1. She then added she had not witnessed any physical altercations between Resident #1 and Resident #6. On 02/11/2026 at approximately 9:56 AM, an interview was conducted with Staff B, Registered Nurse (RN). She confirmed that she initiated the request to transfer Resident #1 to a different room after Resident #1's primary nurse, Staff C, RN, had reported that facility staff notified her of Resident #6 having violent behaviors. Staff B stated that she had an email exchange dated 02/05/2026 after multiple attempts to contact the facility Administrator regarding the request to move Resident #1 to a different room.On 02/09/2026 at approximately 2:46 PM, an interview was conducted with the facility Risk Manager. The Risk Manager explained that, at the time staff discovered Resident #1 with the wounds, the Nurse Practitioner was under the impression that Resident #1's wounds originated internally caused by her teeth because of the presence of blood in her mouth and confirmed that there were no witnesses to the incident. The Risk Manager acknowledged that the punctures were located on the outside of Resident #1's cheek and could not have been caused by her teeth.On 02/11/2026 at approximately 3:30 PM, a combined interview was conducted with the facility Administrator, Director of Nursing (DON), and Risk Manager (RM). They explained that Resident #1 had resided in a different room for several months and was transferred to her new room last week. They explained that Resident #1's room change was initiated by the facility after Resident #1 sustained unwitnessed physical injuries on 01/30/2026 including a laceration requiring transfer to a higher level of care. They indicated the reason for the room change was to improve roommate compatibility with a resident who was similarly alert, talkative, and ambulatory, as they were consider a better match in terms of cognitive status and functional abilities. Regarding the incident for Resident #1 that occurred on 01/30/2026, the Administrator added that, based on observations, statements, and the Nurse Practitioner's assessment, it was believed that the injuries were consistent with contact from the bed side rails and that the injury resulted from the resident's teeth. She explained that her investigation did not include Resident #1's roommate, Resident #6, as she had no reason to believe Resident #6 would have caused the injuries, despite her documented history of aggressive behaviors.

Based upon record review and interview, the facility failed to conduct a thorough investigation into allegations of abuse involving 3 of 4 residents (Resident #1, #4, and #9). The findings include:Resident #1Review of the incident report submitted on 02/03/2026 for Resident #1 showed the facility reported that Resident #1 sustained injuries that required a transfer to a higher level of care for medical attention and sutures. The injuries that were documented on 1/30/2026 showed the skin assessment performed on Resident #1 revealed gashes to right chin and jaw. The facility's internal investigation concluded Resident #1 caused the injuries to her own skin by striking her teeth on the siderails. Review of hospital records revealed Resident #1 had 2 lacerations to her right lower face which required repair and an intracranial hemorrhage.An interview was conducted on 02/11/2026 at 1:30 PM with Staff G, Certified Nursing Assistant (CNA). Staff G stated Resident #1's former roommate, Resident #6 had a history of behaviors and becoming upset with other residents at the facility. She recalled Resident #6 had gotten upset with Resident #1 for making noises at one point. Employee G also recalled Resident #6 became upset with another facility resident for sitting in her chair.During an interview on 02/11/2026 at 2:45 PM, the facility Administrator, Director of Nursing, and Risk Manager stated they believed Resident #1 created her injuries by wiggling herself from side to side into the bed siderail. When asked if they had investigated Resident #1's prior roommate, Resident #6 based on her documented history of aggressive behaviors, they stated they had no reason to investigate Resident #6 but that they had moved Resident #1 into a room with a more compatible resident.Review of an email dated 02/05/2026 from Hospice staff revealed they had requested the Administrator move Resident #1 because of concerns about Resident #6's history of violent behaviors. The facility moved Resident #1 five days after she returned from the hospital.Cross reference issues in F689Resident #4Review of the incident report submitted on 02/01/2026 for Resident #4 showed the facility reported an allegation of verbal abuse involving Resident #4. The report stated that Staff Q, Dietary Personnel witnessed Staff S, CNA pull Resident #4 by the arm of his wheelchair and yell at him. The facility's internal investigation concluded the allegation was unsubstantiated, stating they could not gather adequate information from Staff Q due to his resignation. Facility leadership was aware that Staff Q resigned due to workplace harassment after reporting the abuse allegation. The facility Administrator confirmed that no further investigation was conducted. Cross reference F895 for failure to implement retribution policies.Resident #9Review of the incident report submitted on 01/07/2026 for Resident #9 revealed the facility reported an allegation of abuse that Resident #9 stated occurred on 01/06/2026. Resident #9 reported that Staff X, Registered Nurse, became upset with him and threw a clipboard at him. He reportedly used his hand to block her clipboard from hitting his abdomen. Staff documented a bruise on Resident #9's hand after the incident.During an interview conducted on 02/11/2026 at approximately 3:25 PM, the facility Administrator, Director of Nursing, and Risk Manager stated that the Assistant Director of Nursing (ADON) reported Resident #9 had retracted his allegation and had signed something with the Police Department. The facility's internal investigation concluded that the allegation was unsubstantiated based on this reported retraction. The Interdisciplinary Team subsequently added confabulation - allegations of staff abuse dated 1/09/2026 to Resident #9's medical record.When informed that Resident #9 stated he only declined to press charges and did not retract the allegation, the Risk Manager stated Resident #9 was upset about not receiving his medication timely and that was the reason he verbalized the allegation of abuse.Review of the Police Report dated 01/08/2026 revealed the responding officer questioned the Risk Manager why the facility reported the incident two days after it occurred. The Risk Manager stated Adult Protective Services (APS) advised her to call and make the report. The Police Report also documented that Resident #9 declined to press battery charges against Staff X.Review of the investigation provided by the facility showed the Risk Manager made a written statement that Resident #9 declined to press charges. No other investigation was provided for review.

Based on a review of records and staff interviews, the facility failed to ensure that resident assessments and care plans were documented accurately and in a resident-centered manner for 4 of 5 residents reviewed for care plans (Residents #9, #11, #12, and #13) The findings include:During an interview conducted on 02/11/2026 at approximately 11:17 AM, the facility Director of Social Services (DSS), Grievance Officer, and Minimum Data Set (MDS) Registered Nurse (RN) and Licensed Practical Nurse (LPN) were asked about a clinical rationale for labeling Resident #9 with confabulation on the care plans (Confabulation is a neuropsychiatric symptom, often referred to as honest lying, where a person generates false or distorted memories without the intent to deceive. It is not a standalone medical diagnosis but rather a clinical indicator of an underlying neurological or psychological condition.). The MDS LPN identified the DSS as the individual responsible for entering behavior items onto resident's care plans. The DSS indicated that such directives could originate from any member of upper management, including the Administrator, Risk Manager, or Director of Nursing. When asked why Resident #9's care plan for confabulation was added shortly after allegations of abuse, the team did not answer. When asked if they reviewed documentation to support adding confabulation to any resident's care plan, the DSS deferred the responsibility to the Administrator. During a follow up interview conducted on 02/11/2026 at 3:25 PM, the facility Administrator and Director of Nursing (DON) stated that Resident #9 retracted his statement of abuse which was the reason why they added confabulation to his care plan. On 02/12/2026 at 10:01 AM, the DON provided documentation of confabulation being used for Residents #11, #12, and #13. Resident #11 - After 1 grievance where the resident stated, resident says she has not been changed for 30 minutes after activating the call light The summary of the investigation stated, there is some sort of confabulation.Resident #12- Confabulation was used in 4 nurses' notes showing that Resident #12 refused care.Resident #13- Confabulation was used in 1 nurse's note stating that the resident requested to be changed after it had already been done.The administrator and DON did not give further reasoning for why confabulation was being used so frequently in the resident's charts.

Based on observations, interviews, and record reviews, the facility failed to ensure a resident's medical record accurately reflected the resident condition for 3 out of 3 resident records reviewed (Resident #1, #2, #9).The findings include: Resident #9 A review of Activities of Daily Living (ADL) task documentation for Resident #9 showed entries indicating that he ambulated 150 feet independently on 02/11/2026 at 3:41 AM, with partial assistance on 02/07/2026 at 2:59 PM, and with supervision on 02/03/2026 at 2:59 PM and 01/31/2026 at 6:59 AM. Documentation also reflected that Resident #9 transferred from bed to chair independently on 02/11/2026 at 3:40 AM, with supervision on 02/03/2026 at 2:59 PM, 01/31/2026 at 6:59 AM, and 01/30/2026 at 6:37 AM. A review of diagnoses confirmed that Resident #9 was a paraplegic. Observations made on 2/11/2026 and 2/12/2026 revealed that Resident #9 was bed bound with no active movement in his lower extremities. During an interview on 2/11/2026 at 2:25 PM, Staff T, Licensed Practical Nurse (LPN) and Staff U, Certified Nursing Assistant (CNA) confirmed that Resident #9 i=was paralyzed and unable to walk or transfer independently. When presented with the above charting entries Staff T and Staff U stated it would be impossible. Resident #1 A review of the clinical record from 01/13/2026 to 02/11/2026 revealed CNA flow sheets that documented Resident #1 as independent with toilet and bed transfer, independent with lower body dressing, call lights within reach and that fluid was provided while the resident was at the hospital. A review of the clinical record for Resident #1 care plan revealed total staff assistance. On 02/09/2026 at approximately 9:00 AM, an observation was made of Resident #1. The resident is lying on her back and has limited body movements. Resident #2 A review of the clinical record from 01/13/2026 to 02/11/2026 revealed CNA flow sheets that documented Resident #2 as independent with toilet transfer and recorded no behaviors. A review of the clinical record dated 02/10/2026, 1/20/2026 and 1/17/2026 reveals nursing documentation of Resident #2, as upset, yelling and screaming. A review of Resident #2's care plan dated 02/02/2026 revealed self-care deficit with total staff assistance with toileting, hygiene, chair/bed transfer and note that the resident is non-ambulatory. On 02/09/2026 at approximately 8:55 AM, an observation was made of Resident #2. He was sliding down on the bed and did not appear to be able to reposition self without assistance. On 02/09/2026 at approximately 9:15 AM, an interview was conducted with Staff E, CNA. He stated that Resident #1 required total care and had not been able to turn from side to side for several years. He added that she required assistance with feeding. He stated that Resident #2 required total care. On 02/09/2026 at approximately 12:05 PM, an interview was conducted with Staff D, CNA. She explained that patient's behaviors were reported to the nurse and document in the behavior flow sheet.

Based on interviews and record review, the facility failed to ensure the protection of residents' personal privacy and confidentiality of medical information due to staff utilizing personal cellular phones to take photographs and videos of residents for the purpose of communicating clinical concerns to the facility's Nurse Practitioner for 1 of 3 residents reviewed for personal privacy (Resident #2).The findings include: Review of a narrative nursing note, dated 01/20/2026, revealed that Resident #2 was observed by nursing staff sliding himself on the floor while yelling and screaming with abdominal pain.A written email statement by the facility's Nurse Practitioner (NP), dated 01/21/2026, was reviewed. In her statement, she reported that she was contacted by staff who provided a video of Resident #2 and requested clinical guidance based on these behaviors.On 02/09/2026 at approximately 3:35 PM, an interview was conducted with Staff A, Registered Nurse (RN). Staff A stated that, on 01/21/2026, she took a video recording of Resident #2 on her personal cell phone to send to the NP. Staff A acknowledged awareness that the use of personal devices is technically not permitted. She stated she was aware that images were not to be posted on social media. Additionally, she stated that staff also take photographs of resident's skin concerns to send to the nurse practitioner. Staff A stated she was unaware if there were signed consents from residents regarding this form of communication with the facility's practitioners.On 02/10/2026 at approximately 4:20 PM, an interview was conducted with Staff L, Wound Care Nurse. Staff L explained that she routinely uses her personal cell phone to take pictures of residents' wounds and send them via text message to the Nurse Practitioner for assessment and treatment recommendations. She further indicated that this was her routine method of communication where the photographs are stored on her personal device. Staff L stated she was unaware if there were signed consents from residents regarding this form of communication with the facility's practitioners.On 02/11/2026 at approximately 3:30 PM, an interview was conducted with the facility's Administrator. She was informed of staff taking videos and photographs of residents and wounds on personal cellular phones to communicate with the NP, raising confidentiality and Health Insurance Portability and Accountability Act (HIPAA) concerns. The Administrator did not oppose the practice if done for a medical purpose and communication with the NP; however, she could not ensure confidentiality once images were captured and recorded on staff member's personal devices.The facility policy did not provide evidence of consent or authorization of the use of staff's personal devices for capturing, storing, or transmitting resident images, nor evidence of secured, encrypted transmission consistent with privacy standards. Review of the facility's policy titled Videotaping, Photographing, and Other Imaging of Residents, revised 04/2017 revealed the following:Residents will be protected from invasion of privacy and/or abuse that might occur from photographs, videotapes, digital images, and recording during resident care and other facility activities.Staff may not take or reduce images or recordings of any resident without explicit written consent.Transmitting unauthorized images of any resident through e-mail, Internet or social media is considered a violation of resident rights.Residents photographs are considered health care records and will be retained and released in accordance with current applicable regulations and statutes governing the release of protected health information.All resident photographs and consents will be retained in accordance with facility policy governing the safekeeping and retention of resident medical records.

Based on observations, interviews and record reviews, the facility failed to ensure timely reporting of alleged violations of abuse and neglect within 2 hours in 1 of 7 incident reports reviewed.The findings include:A report of abuse filed on 02/03/2026 at 4:00 PM was reviewed. The report placed the incident on 02/03/2026, however, further review revealed the incident occurred on 01/30/2026. The report stated that the facility Administrator was notified on 02/03/2026, however, the Administrator was aware of the incident that occurred on 01/30/2026. The incident was reported after an investigator from Adult Protective Services entered the facility on 02/03/2026 at 4:00 PM. The summary of the event described Resident #1, a vulnerable adult with cognitive impairment, with her face pressed against the side rails of her bed that sustained physical injuries on 01/30/2026, including puncture wounds to the outside of her cheek requiring sutures and a subsequent transfer to a local hospital.On 02/09/2026 at approximately 2:46 PM, an interview was conducted with the facility Risk Manager. The Risk Manager explained that she decided to report the incident involving Resident #1 after the investigator from Adult Protective Services entered the facility on 02/03/2026 at 4:00 PM to investigate the allegation. She further stated that her expectation is that any suspected abuse observed by staff must be reported immediately so she can initiate an investigation. She defined abuse as including pushing, hitting, kicking, slapping, mocking, verbal threats, or yelling to name a few. She noted that facility Certified Nurse Assistants should report any concerns of abuse to the nurse on duty, who will then contact her directly to begin the investigation. She also stated that any injury of unknown origin must be reported within two hours, after which she will submit a five-day report with the findings of the full investigation. The Risk Manager did not explain her reason for the delay in reporting this incident.Review of the facility policy titled Abuse, Exploitation or Misappropriation-Reporting and Investigating last revised 04/2021 revealed, All reports of resident abuse (including injuries of unknown origin), neglect . are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. If resident abuse, neglect . or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. Immediately is defined as: within two hours of an allegation involving abuse or result in serious bodily injury; or within 24 hours of an allegation that does not involve abuse or result in serious bodily injury.

Based on observation, interviews, and record review, the facility failed to implement its abuse prevention and anti retaliation policies to protect an employee from retaliation and harassment after reporting abuse. (Staff Q) The findings include:During an interview conducted on 02/10/2026 at 10:10 AM, the Dietary Manager reported that Staff Q, Dietary Aide, informed her on 02/09/2026 that he was resigning because staff were harassing him after he reported alleged abuse involving Resident #4. She stated she did not investigate the harassment allegation personally but did notify the facility Administrator and Risk Manager.On 02/10/2026, the 3rd Floor Unit Manager was interviewed and stated she was not present during the abuse incident. In a follow up interview conducted on 02/11/2026 at 2:45 PM, she acknowledged hearing that Staff Q resigned due to harassment but stated that staff to staff harassment was outside her scope and handled by Human Resources (HR).During a group interview conducted on 02/11/2026 at 3:25 PM with the facility Administrator, Director of Nursing (DON), and Risk Manager, the DON and Risk Manager stated Resident #4 was not a reliable witness. The Risk Manager reported she attempted to contact Staff Q twice but was unable to reach him and subsequently unsubstantiated the allegation of abuse and did not investigate further. The Administrator stated she was aware that Staff Q reported being harassed by staff but confirmed no investigation into the harassment had been conducted. Facility leadership stated staff did not witness harassment and they had relied on statements from individuals who were not present during the alleged incident, though the Administrator asserted they were staff from that same area [of the facility] at that same time.At approximately 1:30 PM on 02/11/2026, Staff R, former Dietary Personnel was interviewed. Staff R stating he was calling on behalf of Staff Q, who was anxious about repeated phone calls related to workplace harassment issues. Staff R reported that, during his six months at the facility, he experienced harassment from nursing and kitchen staff and had previously reported the harassment to the facility HR Director, who instructed him to speak with his supervisor. Staff R stated his supervisor was also involved in the harassment, so he did not pursue it further.At 1:36 PM on 2/11/2026, Staff Q was interviewed by phone. Staff Q was noted to be audibly upset. He confirmed he witnessed an incident in which a staff member pulled Resident #4 by the wheelchair arm and said, get your ugly *** out here, and that he immediately reported this to a Unit Manager, who notified the Risk Manager. Staff Q stated that, after reporting the incident, 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 staff and nursing staff but had difficulty identifying staff because they did not wear name badges. Staff Q stated he resigned by phone due to fear for his safety. He has reported no harassment since leaving his employment and reiterated he could not positively identify all involved staff due to lack of visible name badges.On 02/12/2026 at 9:10 AM, the HR Director stated she recalled Staff R reporting harassment but was unsure of the timeline. She stated Staff R also attempted to report concerns on behalf of another coworker but did not provide a name. She instructed him to report concerns to his supervisor or file a formal grievance so it could be forwarded to the contract company. When informed that staff were not wearing badges, she acknowledged that staff were bad about wearing badges and stated she had repeatedly told them to wear your badges.During an interview on 02/12/2026 at 10:24 AM, Staff T, Dietary Personnel described Staff Q as quiet and respectful. He stated he did not know why Staff Q left but heard he got into it with another nurse or aide and was unsure whether he was fired or resigned. He stated he believed Staff Q did the right thing by reporting abuse and that anyone who witnesses abuse should report it.Review of the facility policy titled Abuse, Neglect, Exploitation or Misappropriation-Reporting and investigating revealed, The administrator ensures the resident and the person(s) reporting the suspected violation are protected from retaliation or reprisal by the alleged perpetrator, or anyone associated with the facility.

Based on observations and record reviews, the facility failed to provide a safe living environment for 187 of 187 residents by failing to maintain the facility's Automatic Fire Sprinkler System (AFSS). The facility failed to implement proper fire watch protocol per statute to ensure the safety of the residents. This failure in maintaining fire protection equipment and practices has the potential to affect 187 residents.Additionally, the facility failed to store resident care equipment in a sanitary manner in 2 of 7 sampled resident rooms observed. (Rooms 306, 308)Additionally, the facility failed to ensure the environment remained free of potential hazards for 1 of 1 resident reviewed for accidents (Resident #160).The findings include: According to the Life Safety Survey, the facility was notified on 01/14/2026 that it was under Immediate Jeopardy due to the sprinkler system being non operational since 05/05/2025. The system had been red tagged, indicating it would not perform as required in the event of a fire. Additionally, there were two subsequent red tags on each system, dated from August 2025 and November 2025. The AFSS remained out of service for more than eight months without documented corrective action, interim safety measures, or appropriate notification to regulatory authorities. The facility did not initiate fire watch protocol to ensure the safety of the residents until notified by the Life Safety Surveyor on 1/12/26. This lack of correction provided an unsafe environment for all 187 residents, staff, and visitors for 8 months. During an interview with the maintenance director on 01/12/2026, he confirmed his awareness the AFSS was red-tagged. He stated he had requested repairs from the facility ownership but the repairs were not completed. In an interview with the Administrator on 01/12/2026 she was asked about interim safety measures implemented, including a fire watch. The Administrator confirmed they had not conducted a fire watch following the receipt of the red tags in May. She was unable to provide a reason for the repair delay aside from emails from various vendors showing that additional opinions had been sought by the facility. An interview was conducted with the facility Administrator on 01/12/2026 about what interim safety measures were put in place to ensure the safety of the residents while the sprinkler system and fire pump were red tagged. The Administrator confirmed she was aware the red tags were present since May 2025. The Administrator stated they did not receive confirming documentation from the local fire marshal until October 2025 confirming the problem. The Administrator was unable to provide reason for repair delay aside from emails from various vendors showing that additional opinions were sought. An interview was conducted with the local Fire Marshal on 01/13/2026. He stated he was aware of the red tags on the sprinkler and fire pump systems and that he was under the understanding that the facility was under contract with an engineer for the repairs to be completed. A secondary interview was conducted with the facility Administrator on 01/13/2026 at 10:00 AM. The Administrator was unable to provide interim fire safety plan measures. The Administrator was also unable to provide training to staff regarding fire and evacuation protocols. An interview was conducted with the local Fire Inspector on 01/14/2026. He stated his staff failed to note the red tags in their report written in August 2025. He further stated he was under the understanding that the facility had the system repaired in October 2025. An observation of room [ROOM NUMBER]'s bathroom was conducted on 1/12/26 at 11:00 AM and 2:45 PM, on 1/13/26 at 9:00 AM, 11:12 AM, and 3:10 PM, on 1/14/26 at 10:26 AM and 3:19 PM, and on 1/15/26 at 9:47 AM. Each time, four unlabeled, soiled wash basins, one unlabeled, soiled bedside commode basin, and one unlabeled, soiled toilet hat (used for specimen of urine, stool, kidney stones, etc.) were observed. An observation of room [ROOM NUMBER]'s bathroom was conducted on 1/15/26 at 10:00 AM. An unlabeled, orange-stained urinal bottle was observed sitting on the floor and used adult briefs were observed in the garbage, causing a foul odor. An interview was conducted with Staff W, Licensed Practical Nurse (LPN), who confirmed the unlabeled, soiled personal care items in the bathrooms of rooms [ROOM NUMBERS], stating the items should be labeled with the resident's room number and date. Staff W further stated these items should be cleaned after each use and placed in a plastic bag and stored separately for future use. When asked about the used adult briefs, Staff W stated the adult briefs should have been placed in a garbage bag, tied up and taken to the main garbage outside the resident's room immediately to prevent odors. An interview was conducted with Staff E, Unit Manager (UM) on 11/15/26 at approximately 12:45 PM. Staff E confirmed the findings of unlabeled, soiled personal care items and further confirmed these items should be labeled, cleaned, and bagged. Regarding similar issues, Staff E stated, I am having to check behind most of the staff I have on my floor. Staff E also confirmed that garbage with odors should be taken out of residents' rooms immediately to prevent odors and garbage with no odors should be taken out at the end of each shift or when it is full. 3. During an interview with Resident #160 at approximately 11:23 AM, the resident reported that her cell phone caught fire while it was charging on the window sill on 12/24/2025 at approximately 11:15 PM. She stated the fire alarms were sounding, and she observed the phone actively in flames. The resident extinguished the fire herself using her shoe. She reported that the fire department responded, checked the electrical outlets, and maintenance scraped melted plastic from the window area the next day (Photographic evidence obtained) The windowsill in Resident #160's room was noted to have residual smoke damage and burned plastic consistent with the resident's report of a phone fire on 12/24/2025. Burn marks and soot residue were also visible on the window blinds and window. A staff member provided an account of the fire event that occurred on 12/24/2025. Employee Y, Licensed Practical Nurse (LPN), reported that while staff were walking past Resident #160's room, they observed smoke coming from the doorway. When staff opened the door, the room's smoke detector was activated, but the building fire alarm did not activate. Staff observed a cell phone on the window sill actively on fire while plugged in and charging. The resident extinguished the fire using her shoe. Two residents were evacuated to the dining room for safety. Following the incident, staff reported eye irritation due to smoke exposure. Both residents were assessed and found safe, with no injuries documented. During an interview on 01/18/2026 at 1:43 PM, the Maintenance Director was asked to describe the events of 12/24/2025 regarding the fire in Resident #160's room. He stated that Resident #160's cell phone was plugged into the wall and charging on the window sill. He reported that smoke from the phone activated the room smoke alarms. He stated that there was no fire. He confirmed that the sprinklers did not activate. The Maintenance Director stated that the fire department did not respond to the incident. He reported that, after the event, he checked electrical outlets in all rooms and traced the circuits to the breakers, stating that everything was good. No further follow up was made. The Administrator, who was present during the interview, stated that the fire department did respond. The Administrator acknowledged that the incident was not reported to the state agency, despite reporting requirements. The Administrator and Maintenance Director confirmed there was no 2nd floor corridor evacuation conducted and only two residents were moved from the immediate area. On 01/19/2026, the facility submitted an acceptable Immediate Jeopardy removal plan which included the following measures: The Administrator immediately increased monitoring of the full facility by initiating a Fire Watch on 1/12/26 at 11:00am continuously 24 hours a day, 7 days a week. All residents in the facility were monitored for resident safety, and there was no adverse outcome to any residents in the building. The Administrator verbally notified the state agency of the Fire Watch on 1/12/26 at 11:00am. The Area Office emailed the Facility on 1/14/26 at 1:20pm regarding the need to notify the Office of Plans and Constructions. The Administrator notified the Office of Plans and Constructions on 1/14/25 at 1:58pm. The survey staff was verbally notified of the Fire Watch on 1/12/26. The 24-hour Fire Watch staff assigned were educated by the facility Director of Nursing and Administrator on role and their responsibilities with a written policy. All staff who worked on January 12, January 13, and January 14 were educated, for a total of 216 of 227 staff members. Education included that this role removes them from any other assignment, provides facility-wide coverage and monitoring resident units every hour with an accountability log. All remaining 11 staff will not be allowed to start their shifts until completion of their education. The Director of Nursing/designee re-educated Fire Watch staff on the use of a fire extinguisher and emergency response initiated on 1/12/26. The Maintenance Supervisor/Designee has overseen and reviewed the documentation of the Fire Watch checks daily initiated on 1/12/26. The Director of Nursing/designee educated all staff on fire watch procedures, their individual roles and responsibilities, use of fire extinguisher and emergency response for resident safety, initiated on 1/12/26. 216 of 227 employees (including contracted employees) have been educated. All remaining 11 staff will not be allowed to start their shifts until completion of their education. On 1/12/26 the Facility engaged and signed a contract with the Vendor to replace the sprinkler heads with an anticipated replacement within 30 days. The Facility confirmed the Fire Protection Service company will be inspecting and remediating the Fire Pump including the valve(s) and conduct effective functional testing post-remediation to verify it is operating at 100% on the week of 1/12/26. The Life Safety Consultant re-educated the Maintenance Supervisor and Administrator on Fire Incident Reporting and Systems Failure Fire Incident Reporting Requirement for Agency for Health Care Administration- Florida and Regulatory requirement K353 and K354 initiated on 1/12/26. On 1/13/26 smoking materials were verified as removed from all 30 residents who were care planned to safely maintain their smoking materials independently. Residents were educated by the facility Risk Manager at 1:24pm. Family members and visitors were notified via robocall on 1/15/26 at 8:00 am and 3:00 pm that the facility is currently on a Fire Watch with signage posted 1/14/26 at 3:10pm. Communications included that materials were being removed for the safety of all residents. Care plans were updated for the 30 residents that were assessed to safely hold their smoking materials. The Healthcare Risk Management Consultant/designee, initiated education for facility administration (LNHA and DON) on resident rights to a safe environment initiated on 1/19/26. Verification of the facility's removal plan was conducted by the survey staff on 02/02/2026 and 02/03/2026. The surveyors observed fire watches with 2 staff members on 02/02/26. The surveyors interviewed 10 staff members (including the Administrator and Maintenance Director) and 4 residents regarding the fire watches and removal of smoking materials. The surveyors verified signage was present throughout the facility regarding the fire watches. The surveyors verified education provided to staff from 01/12/26 to 01/14/26 regarding fire watch roles/responsibilities and policies, fire extinguishers, and emergency response. Fire Drills were conducted on 01/21/26, 01/28/26, and 01/29/26 (one on each shift). The surveyors verified the robocalls that took place on 01/15/26 and 01/18/26 regarding fire watch and smoking policies. The surveyors confirmed communication between the facility and the Fire Protection Service company, the Fire Safety and Protection company, the sprinkler vendor company, and the local Fire Marshal. During the survey, the survey staff verified the implementation of the facility's immediate actions to remove the Immediate Jeopardy.

Based upon interviews, observations, and record and policy reviews, the facility neglected the safety and wellbeing of all 187 residents of the facility by failing to repair the Automatic Fire Sprinkler System (AFSS). The sprinkler system and fire pump have been red tagged since May 5, 2025, with no attempts to fix the problems. The facility failed to implement proper fire watch protocol per statute to ensure the safety of the residents. Additionally, the facility failed to protect residents from abuse for 1 of 3 residents reviewed for abuse. (Resident #205)The findings include: 1) A tour of the facility was conducted on 1/12/2026 by the Life Safety surveyor at 12:00 PM. During this tour, the surveyor noted the automatic fire sprinkler system (AFSS) and Fire Pump were red tagged and had been since 5/5/2025, indicating that the fire suppression system would not function as expected in the event of a fire. As of this annual survey, the facility failed to make the repairs to the automatic fire sprinkler system. Additionally, there were two subsequent red tags on each system, dated from August 2025 and November 2025. An interview was conducted with the facility Administrator on 01/12/2026 about what interim safety measures were put in place to ensure the safety of the residents while the sprinkler system and fire pump were red tagged. The Administrator confirmed she was aware the red tags were present since May 2025. The Administrator stated they did not receive confirming documentation from the local fire marshal until October 2025 confirming the problem. The Administrator was unable to provide reason for repair delay aside from emails from various vendors showing that additional opinions were sought. An interview was conducted with the facility Maintenance Director on 01/12/2026 concurrent with the above observations. The Maintenance Director confirmed he was aware of the tags on the systems and stated he had requested repairs from the facility ownership but the repairs had not been completed. An interview was conducted with the facility Administrator on 01/12/2026 about what interim safety measures were put in place to ensure the safety of the residents while the sprinkler system and fire pump were red tagged. The Administrator could not produce documentation until October 2025 from the local fire marshal confirming the problem. The Administrator was unable to provide reason for repair delay aside from emails from various vendors showing that additional opinions were sought. An interview was conducted with the local Fire Marshal on 01/13/2026. He stated he was aware of the red tags on the sprinkler and fire pump systems and that he was under the understanding that the facility was under contract with an engineer for the repairs to be completed. A secondary interview was conducted with the facility Administrator on 01/13/2026 at 10:00 AM. The Administrator was unable to provide interim fire safety plan measures. The Administrator was also unable to provide training to staff regarding fire and evacuation protocols. An interview was conducted with the local Fire Inspector on 01/14/2026. He stated his staff failed to note the red tags in their report written in August 2025. He further stated he was under the understanding that the facility had the system repaired in October 2025. 2) During record review of Resident #205's medical record, a note was discovered, written on 01/13/26 at 9:00 AM by the facility Risk Manager. It stated, This nurse was notified of resident making an allegation of inappropriate conduct related to a prior employee. Resident then began to state that this allegation was against a former therapist who worked here last year and would provide her with exercises and stretches. Resident stated that this alleged staff member wanted her to do 'things'. When asked for clarification, resident stated 'Oral'. I asked resident if she meant 'oral sex' and she stated yes. I asked if alleged staff member requested anything else and she stated 'No, but he would have his crotch in my face when he would roll me on my side to stretch my arm out for exercise. Resident stated that she didn't want to report this, that it was said in confidence. When asked why she didn't report at the time of the allegation, resident stated Because he quit. He was dating a worker here and I didn't want retaliation. When asked if she had ever had any interactions with the named staff member, she stated, No, but I know she can be authoritative. When asked how she knew that, resident confirmed it was via rumor. Resident was asked if she wanted me to the call the police and she stated 'no'. On 1/15/26 at approximately 10:30 AM and approximately 1:15 PM, the Risk Manager (RM) was interviewed about the sexual abuse allegation involving Resident #205 reported on 1/13/26. During the interviews with the RM, the RM acknowledged that sexual misconduct was a form of abuse. On 1/17/2026 at approximately 12:45 PM, an interview was conducted with Resident #205. Resident #205 said she told Staff GG, Physical Therapy Assistant (PTA) in confidence that she was afraid of retaliation and said, They (indicating the facility) talk about a no retaliation policy, but the Certified Nursing Assistants will find a way. Resident #205 explained that she was sexually abused as a child, and when her father found out about the abuse, he was upset and almost went to jail. She stated she did not want anyone to get in trouble, and she was afraid of retaliation from the facility staff. On 1/15/26 at approximately 2:00 PM, an interview was conducted with the Administrator. She stated she had been informed of the allegation that day and had read the RM's note in Resident #205's chart. She stated she had instructed the RM to investigate further and submit a report. She confirmed the report should have been filed on 1/13/26, when the allegation was brought to the staff's attention. A review of Facility's Abuse policy (dated April 2021) reveals: all reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft / misappropriation of residents property are reported to local, state, and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. Under the section policy interpretation and implementation 1) if resident abuse, neglect, exploitation, misappropriation, is suspected, the suspicion must be reported immediately to the administrator and to other officials according to the state law. 2) the administrator or the individual making the allegation immediately reports his or her suspicion to the following agencies, 3) immediately is defined as within two hours of an allegation involving abuse or result in serious bodily injury or within 24 hours of an allegation that does not involve abuse or result in serious bodily injury. #6) Upon receiving any allegations of abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source, the administrator is responsible for determining what actions are needed for the protection of residents. #11) The administrator ensures that the resident and the person(s) reporting the suspected violation are protected from retaliation or reprisal by the alleged perpetrator, or by anyone associated with the facility. (Photographic evidence obtained) On 01/19/2026, the facility submitted an acceptable Immediate Jeopardy removal plan which included the following measures: Part A: Sprinkler System/Fire Pump The Administrator immediately increased monitoring of the full facility by initiating a Fire Watch on 1/12/26 at 11:00am continuously 24 hours a day, 7 days a week. All residents in the facility were monitored, and there was no adverse outcome to any residents in the building. The Administrator verbally notified the state agency of the Fire Watch on 1/12/26 at 11:00am. The Area Office emailed the Facility on 1/14/26 at 1:20pm regarding the need to notify the Office of Plans and Constructions. The Administrator notified the Office of Plans and Constructions on 1/14/25 at 1:58pm. The survey staff was verbally notified of the Fire Watch on 1/12/26. The 24-hour Fire Watch staff assigned were educated by the facility Director of Nursing and Administrator on role and their responsibilities with a written policy. All staff who worked on January 12, January 13, and January 14 were educated, for a total of 216 of 227 staff members. Education included that this role removes them from any other assignment, provides facility-wide coverage and monitoring resident units every hour with an accountability log. All remaining 11 staff will not be allowed to start their shifts until completion of their education. The Director of Nursing/designee re-educated Fire Watch staff on the use of a fire extinguisher and emergency response initiated on 1/12/26. The Maintenance Supervisor/Designee has overseen and reviewed the documentation of the Fire Watch checks daily initiated on 1/12/26 and 1/13/26. The Director of Nursing/designee educated all staff on fire watch procedures, their individual roles and responsibilities, use of fire extinguisher and emergency response for resident safety, initiated on 1/12/26. 216 of 227 employees (including contracted employees) have been educated. All remaining 11 staff will not be allowed to start their shifts until completion of their education. On 1/12/26 the Facility engaged and signed a contract with the Vendor to replace the sprinkler heads with an anticipated replacement within 30 days. The Facility confirmed L. [NAME] (Fire Protection Service) will be inspecting and remediating the Fire Pump including the valve(s) and conduct effective functional testing post-remediation to verify it is operating at 100% on the week of 1/12/26. On 1/13/26 smoking materials were verified as removed from all 30 residents who were care planned to safely maintain their smoking materials independently. Residents were educated by the facility Risk Manager at 1:24pm. Family members and visitors were notified via robocall on 1/15/26 at 8:00am and 3:00pm that the facility is currently on a Fire Watch with signage posted 1/14/26 at 3:10pm. Communications included that materials were being removed for the safety of all residents. Care plans were updated for the 30 residents that were assessed to safely hold their smoking materials. The Healthcare Risk Management Consultant/designee, initiated education for all facility staff including the Administrator, Director of Nursing, and the Facility's governing body on incident reporting on 1/20/26. The Healthcare Risk Management Consultant/designee, initiated education for all facility staff including the Administrator, Director of Nursing, and the Facility's governing body on sprinkler system impairments that require reporting and Fire watch initiation which began on 1/20/26. The Healthcare Risk Management Consultant/designee, initiated education for all facility staff on resident neglect on 1/20/26. Part B: Sexual Abuse Allegation – The alleged perpetrator's (Physical Therapy Assistant) last day of employment was 4/29/2025. The Facility Administration initiated an investigation upon resident allegation of sexual abuse on 1/13/26. The resident alleged the incident occurred sometime between 2/25/25 -4/29/25. The facility investigation included determining if other residents on the alleged perpetrator's assigned caseload were affected including interviewing cognitively intact residents on his assignment and no other residents had concerns of abuse regarding the alleged perpetrator of any other staff. The alleged perpetrator's personnel file was reviewed on 1/13/26 including the pre-employment background check, and there were no adverse findings, allegations, or performance concerns. The certification for PTA was verified to be in good standing. The alleged victim/resident was seen by Psychiatry on 1/12/26, and the resident did not address the allegation with psychiatry. The resident was medically evaluated by a medical provider on 1/14/26, and resident's plan of care was updated to address the allegation on 1/13/2026. The facility reported the allegation on 1/15/26, though the investigated started on 1/13/26. The Risk Management Consultant educated Administrator, Director of Nursing and Facility leadership on the facility abuse and neglect policy and procedure, protection requirements and reporting requirements for abuse and neglect initiated 1/15/26. The Administrator/Designee re-initiated all staff education on the Abuse and Neglect Policy which includes identifying types of abuse and reporting, including sexual abuse, which began on 1/15/26. 177 of 226 employees have been educated on ANE so far. Admin, DON, and Leadership were initially educated on 1/15/26 and then were educated again on 1/19/26. 131 of 226 employees were educated on ANE on 1/15/26 Verification of the facility's removal plan was conducted by the survey staff on 02/02/2026 and 02/03/2026. The surveyors verified in-services were conducted regarding abuse and neglect education on 01/14/25, 01/15/26, 01/20/26 and 01/21/26. The surveyors verified the facility submitted incident reports regarding the sexual abuse allegation and verified the facility conducted a thorough investigation of the allegation, including witness statements. The surveyors verified the facility had updated the resident's care plan. The surveyors verified the facility provided a psychiatric consultation for the resident. Interviews with the facility Administrator and Risk Manager were conducted on 02/03/26 to confirm the above information. Interviews were conducted with 6 staff members to confirm their education about abuse and neglect. During the survey, the survey staff verified the implementation of the facility's immediate actions to remove the Immediate Jeopardy.

Based on record reviews and interviews, the facility administrative staff failed to use all available resources effectively and efficiently to maintain the facility in a safe manner and ensure the facility's fire suppression system was repaired in a timely manner. The facility Administrator also failed to ensure residents were kept safe from sexual abuse by failing to address a resident's report of staff to resident sexual advances for 1 of 3 resident sampled for abuse. (Resident #205) The findings include:A tour of the facility was conducted on 1/12/2026 by the Life Safety surveyor at 12:00 PM. During this tour, the surveyor noted the Automatic Fire Sprinkler System (AFSS) and fire pump were red tagged and had been since 5/5/2025, indicating that the fire suppression system would not function as expected in the event of a fire. As of this annual survey, the facility failed to make the repairs to the automatic fire sprinkler system. Additionally, there were two subsequent red tags on each system, dated from August 2025 and November 2025.An interview was conducted with the facility Administrator on 01/12/2026 about what interim safety measures were put in place to ensure the safety of the residents while the sprinkler system and fire pump were red tagged. The Administrator could not produce documentation until October 2025 from the local fire marshal confirming the problem. The Administrator was unable to provide reason for repair delay aside from emails from various vendors showing that additional opinions were sought. A secondary interview was conducted with the facility Administrator on 01/13/2026 at 10:00 AM. The Administrator was unable to provide interim fire safety plan measures. The Administrator was also unable to provide training to staff regarding fire and evacuation protocols.2. During record review of Resident #205's medical record, a note was discovered, written on 01/13/26 at 9:00 AM by the facility Risk Manager. it stated This nurse was notified of resident making an allegation of inappropriate conduct r/t a prior employee. Resident then began to state that this allegation was against a former therapist who worked here last year and would provide her with exercises and stretches. Resident stated that this alleged staff member wanted her to do 'things'. When asked for clarification, resident stated 'Oral'. I asked resident if she meant 'oral sex' and she stated yes. I asked if alleged staff member requested anything else and she stated 'No, but he would have his crotch in my face when he would roll me on my side to stretch my arm out for exercise. It felt good. Resident stated that she didn't want to report this, that it was said in confidence. When asked why she didn't report at the time of the allegation, resident stated Because he quit. He was dating a worker here and I didn't want retaliation. When asked if she had ever had any interactions with the named staff member, she stated, No, but I know she can be authoritative. When asked how she knew that, resident confirmed it was via rumor. Resident was asked if she wanted me to the call the police and she stated 'no'. When asked if she felt like this was abuse, she stated, No.On 1/15/26 at approximately 10:30 AM and approximately 1:15 PM, the Risk Manager (RM) was interviewed about the sexual abuse allegation involving Resident #205. During these interviews, the RM confirmed she had not filed an abuse report. She stated her reasoning for not reporting was because Resident #205 was alert and oriented with a Brief Interview for Mental Status (BIMS) (BIMS is a standardized tool used assess cognitive function) of 15, indicating normal cognitive function. The RM further stated that reporting the incident against Resident #205's wishes would violate her rights. The RM acknowledged that sexual misconduct was a form of abuse, however, she stated she believed that Resident #205 had the right to refuse contacting law enforcement regarding the allegation.On 1/17/2026 at approximately 12:45 PM, an interview was conducted with Resident #205. Resident #205 said she told Staff GG, Physical Therapy Assistant (PTA) in confidence that she was afraid of retaliation and said, They (indicating the facility) talk about a no retaliation policy, but the Certified Nursing Assistants will find a way. Resident #205 explained that she was sexually abused as a child, and when her father found out about the abuse, he was upset and almost went to jail. She stated she did not want anyone to get in trouble, and she was afraid of retaliation from the facility staff.On 1/15/2026 at approximately 10:30 AM, an interview conducted with the RM. She acknowledged that she did not file a report based upon Resident #205's accusation. She stated she discussed this with the Administrator, and they decide not to file a report. She stated that she and the Director of Nursing interviewed the resident, but the resident did not want law enforcement notified and did not think it was abuse. She further stated it the resident's right to decline the law enforcement being called. Review of the Administrator Job Description dated 01/01/15 revealed Page 3, section Equipment and Supply Function, bullet 3 states Ensure that the facility is maintained in a clean and safe manner for resident comfort and convenience by ensuring that necessary equipment and supplies are maintained to perform such duties and services. Page 4 section Resident Rights, bullet 9 states report all allegations of abuse and/or misappropriation of resident property. (Photographic evidence obtained)On 01/19/2026, the facility submitted an acceptable Immediate Jeopardy removal plan which included the following measures:The governing body actively engaged RB Health Partners for an Administrator Consultant on 1/14/26 with virtual support and a first on-site visit scheduled for 1/19/26. The Risk Management Consultant provided the Facility's Administrator with training on the QAPI requirements, the QAPI program and plan components including development of a Performance Improvement Program (PIP), safe resident environment, Fire Watch, abuse and neglect, sexual abuse allegations, and corrective action plan(s) to implement and evaluate performance improvement efforts on 1/15/26.An Ad-Hoc QAPI meeting was held with the QAA committee to include the Medical Director to discuss all areas of alleged non-compliance 1/19/26.A Performance Improve Plan was developed by the QAA CommitteeThe initial AD-Hoc QAPI meeting was held on 1/13/26. An additional Ad-Hoc QAPI meeting was held on 1/19/26.Verification of the facility's removal plan was conducted by the survey staff on 02/02/2026 and 02/03/2026.The surveyors interviewed the consultant QAPI personnel to confirm her role and how she is helping the facility ensure they are maintaining the safe resident environment, Fire Watch, abuse and neglect, sexual abuse allegations, and corrective action plans.The surveyors verified the education that was given to the administration (including the Administrator, Director of Nursing, Assistant Director of Nursing, CEO, Social Services, and MDS Coordinator).The surveyors reviewed the QAPI agendas (dated 01/13/26, 01/16/26, 01/28/26) to ensure the committee was discussing all areas of non-compliance.The surveyors reviewed the 4-point action plan to ensure it included information of the fire watch initiative.During the survey, the survey staff verified the implementation of the facility's immediate actions to remove the Immediate Jeopardy.

Based on review of the Florida Administrative Code, National Fire Protection Association (NFPA) 101 and interview, the facility failed to comply with Federal, State, and Local Laws and Professional Standards by failing to have a functional fire suppression system since May 5, 2025. The facility must operate and provide services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards and principles that apply to professionals providing services in such a facility. The findings include:A tour of the facility was conducted on 1/12/2026 by the Life Safety surveyor at 12:00 PM. During this tour, the surveyor noted the Automatic Fire Sprinkler System (AFSS) and fire pump were red tagged and had been since 5/5/2025, indicating that the fire suppression system would not function as expected in the event of a fire. As of this annual survey, the facility failed to make the repairs to the AFSS. Additionally, there were two subsequent red tags on each system, dated from August 2025 and November 2025.Failure to provide a working fire sprinkler is a direct violation of Florida Administrative Code 69A-53.0053- Fire Sprinkler Requirements for Nursing Homes. Failure to have a fire sprinkler system also violates fire protection standards mandated for all nursing homes as outlined in the professional standards of National Fire Protection Association (NFPA) 101 (2012 Edition). Additionally, the facility failed to contact the State Survey Agency about the failure of the fire sprinklers, which is a violation of Florida Administrative Code 59a-4.130, which requires notification within one business day after the occurrence. An interview was conducted with the facility Maintenance Director on 01/12/2026 concurrent with the above observations. The Maintenance Director confirmed he was aware of the tags on the systems and stated he had requested repairs from the facility ownership but the repairs had not been completed.An interview was conducted with the facility Administrator on 01/12/2026 about what interim safety measures were put in place to ensure the safety of the residents while the sprinkler system and fire pump were red tagged. The Administrator could not produce documentation until October 2025 from the local fire marshal confirming the problem. The Administrator was unable to provide reason for repair delay aside from emails from various vendors showing that additional opinions were sought. An interview was conducted with the local Fire Marshal on 01/13/2026. He stated he was aware of the red tags on the sprinkler and fire pump systems and that he was under the understanding that the facility was under contract with an engineer for the repairs to be completed. A secondary interview was conducted with the facility Administrator on 01/13/2026 at 10:00 AM. The Administrator was unable to provide interim fire safety plan measures. The Administrator was also unable to provide training to staff regarding fire and evacuation protocols.An interview was conducted with the local Fire Inspector on 01/14/2026. He stated his staff failed to note the red tags in their report written in August 2025. He further stated he was under the understanding that the facility had the system repaired in October 2025.On 01/19/2026, the facility submitted an acceptable Immediate Jeopardy removal plan which included the following measures:The Healthcare Risk Management Consultant and Facility's Administrator immediately re-reviewed the local, state, and federal laws pertaining to a safe resident environment, notification and inspection requirements including inspection tagging, and sprinkler system and fire pump requirements.The Facility initiated Fire [NAME] on 1/12/26 at 11:00am. The facility notified the local Fire Marshall on 1/12/26 that a fire watch was initiated.The Life Safety Consultant re-educated the Maintenance Supervisor and Administrator on Fire Incident Reporting and Systems Failure Fire Incident Reporting Requirement for Agency for Health Care Administration- Florida and Regulatory requirement K353 and K354 initiated on 1/12/26.The Administrator and Maintenance Director were educated on regulations and laws regarding the sprinkler system and fire pump on 1/12/26.Verification of the facility's removal plan was conducted by the survey staff on 02/02/2026 and 02/03/2026.The surveyors interviewed the consultant QAPI personnel to confirm her role and how she is helping the facility ensure they are maintaining the safe resident environment, Fire Watch, abuse and neglect, sexual abuse allegations, and corrective action plans.The surveyors verified the education that was given to the administration (including the Administrator, Director of Nursing, Assistant Director of Nursing, CEO, Social Services, and MDS Coordinator).The surveyors reviewed the QAPI agendas (dated 01/13/26, 01/16/26, 01/28/26) to ensure the committee was discussing all areas of non-compliance.The surveyors reviewed the 4-point action plan to ensure it included information of the fire watch initiative.During the survey, the survey staff verified the implementation of the facility's immediate actions to remove the Immediate Jeopardy.

Based on record reviews and electronic mail correspondence (email), the governing body failed to assume responsibility for the protection of all 187 residents by failing to act in a timely manner in regard to the failing fire suppression system.The findings include:A tour of the facility was conducted on 1/12/2026 by the Life Safety surveyor at 12:00 PM. During this tour, the surveyor noted the automatic fire sprinkler system (AFSS) and fire pump were red tagged and had been since 5/5/2025, indicating that the fire suppression system would not function as expected in the event of a fire. As of this annual survey, the facility failed to make the repairs to the automatic fire sprinkler system. Additionally, there were two subsequent red tags on each system, dated from August 2025 and November 2025.On 1/17/26 at approximately 4:49 PM an email was sent to the Chief Executive Officer (CEO) who responded on 1/17/26 at 7:30 PM. The following questions and responses were communicated in the email: Were you notified by the facility regarding the fire pump and the sprinkler heads not passing inspection? YesWhen were you notified of these issues? On or about May 9, 2025When and what were your instructions to the facility regarding these issues? I maintained ongoing communication with the facility regarding the inspection findings. Following review of the report, we agreed to engage additional vendors for further evaluation. In July, another company conducted an independent inspection of the sprinkler system and fire pump and downgraded the red tag to yellow. We also retained the contractor that installed the fire pump in 2022, to perform an additional inspection.The three companies were unable to identify a cause for the reduced water output but confirmed that the pump was operating and not at risk of failure. We then pursued testing of the city water pressure through emerald Coast Utilities Authority (ECUA), as this was the only remaining plausible explanation for the change in performance. Although ECUA verbally confirmed that pressure levels were within normal parameters, we have not received written documentation to date. Without this documentation, we have been unable to retain an engineer to conduct a formal water flow study, which would have been the next step.There was no additional information or documentation to show implementation of an effective plan to ensure the residents were protected against the dangers of a fire.On 01/19/2026, the facility submitted an acceptable Immediate Jeopardy removal plan which included the following measures:The governing body actively engaged RB Health Partners for an Administrator Consultant on 1/14/26 with virtual support and a first on-site visit scheduled for 1/19/26. The governing body engaged with the Risk Management Consultant who provided the Facility's Administrator with training on maintaining a safe resident environment, reporting and investigating abuse and neglect, sexual abuse allegations, and corrective action plan(s) to implement and evaluate performance improvement efforts on 1/15/26.The governing body participated in the development of the Fire Watch protocols and the scheduling of repairs initiated on 1/12/26.The governing body members received targeted education by Healthcare Risk Management Consultant/designee on 1/20/2026 regarding roles and responsibilities.The governing body members received education by Healthcare Risk Management Consultant/designee on 1/20/2026 for incident reporting, sprinkler system impairments that require reporting, Fire watch initiation and QAPI oversight expectations.The Administrator immediately increased monitoring of the full facility by initiating a Fire Watch on 1/12/26 at 11:00am continuously 24 hours a day, 7 days a week. All residents in the facility were monitored for resident safety, and there was no adverse outcome to any residents in the building.The Administrator verbally notified the state agency of the Fire Watch on 1/12/26 at 11:00am. The Area Office emailed the Facility on 1/14/26 at 1:20pm regarding the need to notify the Office of Plans and Constructions. The Administrator notified the Office of Plans and Constructions on 1/14/25 at 1:58pm. The survey staff was verbally notified of the Fire Watch on 1/12/26.The 24-hour Fire Watch staff assigned were educated by the facility Director of Nursing and Administrator on role and their responsibilities with a written policy. All staff who worked on January 12, January 13, and January 14 were educated, for a total of 216 of 227 staff members. Education included that this role removes them from any other assignment, provides facility-wide coverage and monitoring resident units every hour with an accountability log. All remaining 11 staff will not be allowed to start their shifts until completion of their education.The Director of Nursing/designee re-educated Fire Watch staff on the use of a fire extinguisher and emergency response initiated on 1/12/26.The Maintenance Supervisor/Designee has overseen and reviewed the documentation of the Fire Watch checks daily initiated on 1/12/26 and 1/13/26.The Director of Nursing/designee educated all staff on fire watch procedures, their individual roles and responsibilities, use of fire extinguisher and emergency response for resident safety, initiated on 1/12/26. 216 of 227 employees (including contracted employees) have been educated. All remaining 11 staff will not be allowed to start their shifts until completion of their education. On 1/12/26 the Facility engaged and signed a contract with the Vendor to replace the sprinkler heads with an anticipated replacement within 30 days.The Facility confirmed the Fire Protection Service company will be inspecting and remediating the Fire Pump including the valve(s) and conduct effective functional testing post-remediation to verify it is operating at 100% on the week of 1/12/26.The Life Safety Consultant re-educated the Maintenance Supervisor and Administrator on Fire Incident Reporting and Systems Failure Fire Incident Reporting Requirement for Agency for Health Care Administration- Florida and Regulatory requirement K353 and K354 initiated on 1/12/26.On 1/13/26 smoking materials were verified as removed from all 30 residents who were care planned to safely maintain their smoking materials independently. Residents were educated by the facility Risk Manager at 1:24pm. Family members and visitors were notified via robocall on 1/15/26 at 8:00am and 3:00pm that the facility is currently on a Fire Watch with signage posted 1/14/26 at 3:10pm. Communications included that materials were being removed for the safety of all residents. Care plans were updated for the 30 residents that were assessed to safely hold their smoking materials.The CEO and another member of the Governing Body were educated on Governing body responsibilities, accountability of QAPI program, incident reporting, the facility sprinkler system and fire pump, fire watch initiation, abuse and neglect including maintaining a safe environment, and QAPI requirements on 1/19/26.Verification of the facility's removal plan was conducted by the survey staff on 02/02/2026 and 02/03/2026.The surveyors observed fire watches with 2 staff members on 02/02/26.The surveyors interviewed 10 staff members (including the Administrator and Maintenance Director) and 4 residents regarding the fire watches and removal of smoking materials. The surveyors verified signage was present throughout the facility regarding the fire watches. The surveyors verified education provided to staff from 01/12/26 to 01/14/26 regarding fire watch roles/responsibilities and policies, fire extinguishers, and emergency response. Fire Drills were conducted on 01/21/26, 01/28/26, and 01/29/26 (one on each shift).The surveyors verified the robocalls that took place on 01/15/26 and 01/18/26 regarding fire watch and smoking policies.The surveyors confirmed communication between the facility and the Fire Protection Service company, the Fire Safety and Protection company, the sprinkler vendor company, and the local Fire Marshal.The surveyors interviewed the consultant QAPI personnel to confirm her role and how she is helping the facility ensure they are maintaining the safe resident environment, Fire Watch, abuse and neglect, sexual abuse allegations, and corrective action plans.The surveyors verified the education that was given to the administration (including the Administrator, Director of Nursing, Assistant Director of Nursing, CEO, Social Services, and MDS Coordinator).The surveyors reviewed the QAPI agendas (dated 01/13/26, 01/16/26, 01/28/26) to ensure the committee was discussing all areas of non-compliance.The surveyors reviewed the 4-point action plan to ensure it included information of the fire watch initiative.During the survey, the survey staff verified the implementation of the facility's immediate actions to remove the Immediate Jeopardy.

Based on record review, interview, and facility policy review, the facility failed to utilize its Quality Assurance and Performance Improvement (QAPI) process to identify and correct quality deficiencies that posed a likelihood of immediate jeopardy to the health and safety of its residents. The facility failed to report and appropriately respond to a fire event, with prior knowledge that the sprinkler system was not functioning at full operational capacity, placing residents at increased risk for serious harm during an emergency. The findings include:A tour of the facility was conducted on 1/12/2026 by the Life Safety surveyor at 12:00 PM. During this tour, the surveyor noted the automatic fire sprinkler system (AFSS) and Fire Pump were red tagged and had been since 5/5/2025, indicating that the fire suppression system would not function as expected in the event of a fire. As of this annual survey, the facility failed to make the repairs to the automatic fire sprinkler system. Additionally, there were two subsequent red tags on each system, dated from August 2025 and November 2025. An interview was conducted with the facility Administrator on 01/12/2026 by the Life Safety surveyor about what interim safety measures were put in place and fire watch protocol. The Administrator confirmed they were not actively conducting fire watches and had not done any fire watches following the receipt of the red tags on May 5, 2025. During an interview with the Administrator on 01/19/2026, this incident was discussed as part of the facility's QAPI review. The Administrator stated they had discussed the issue in monthly QAPI meetings but had not done a formal Performance Improvement Project (PIP). No reason as to this failure in developing a PIP was given. The facility's QAPI Plan for 2025, under the Maintenance and Engineering section stated, We provide comprehensive building safety, repairs, and inspections to ensure all aspects of safety are enforced, assuring the safety and well-being for each resident, visitor and staff who enter the building. Under the Performance Improvement Projects (PIP) section, it stated, Quality improvement activities are also developed in collaboration with the support of providers, residents, families, and staff. PIPs are implemented in accordance with CMS' protocol including: Measurement of performance using objective quality indicators, Implementation of system interventions to achieve improvement in quality, Evaluation of the effectiveness of the interventions, and Plan and initiation of activities for increasing or sustaining improvement. (Photographic evidence obtained) On 01/19/2026, the facility submitted an acceptable Immediate Jeopardy removal plan which included the following measures: The governing body actively engaged RB Health Partners for an Administrator Consultant on 1/14/26 with virtual support and a first on-site visit scheduled for 1/19/26. The Risk Management Consultant provided the Facility's Administrator with training on maintaining a safe resident environment, reporting and investigating abuse and neglect, sexual abuse allegations, and corrective action plan(s) to implement and evaluate performance improvement efforts on 1/15/26. The facility's QAPI committee convened and implemented a QAPI plan that addresses a safe resident environment initiated on 1/19/26. The QAPI plan includes a continuous, facility-wide Fire Watch with documentation of hourly house-wide rounding, daily compliance auditing of the accountability log, notifications, staff education, Fire Safety rounds, sprinkler system and fire pump repair monitoring, including documentation verifying passing inspections, resident monitoring and an audit verification of removal of safe-smoking materials with appropriate care plan updates. A second AD-HOC QAPI meeting was conducted on 1/19/26 to discuss the removal plan. The CEO and another member of the Governing Body were educated on oversight of the QAPI process on 1/19/26. Verification of the facility's removal plan was conducted by the survey staff on 02/02/2026 and 02/03/2026. The surveyors interviewed the consultant QAPI personnel to confirm her role and how she is helping the facility ensure they are maintaining the safe resident environment, Fire Watch, abuse and neglect, sexual abuse allegations, and corrective action plans. The surveyors verified the education that was given to the administration (including the Administrator, Director of Nursing, Assistant Director of Nursing, CEO, Social Services, and MDS Coordinator). The surveyors reviewed the QAPI agendas (dated 01/13/26, 01/16/26, 01/28/26) to ensure the committee was discussing all areas of non-compliance. The surveyors reviewed the 4-point action plan to ensure it included information of the fire watch initiative. During the survey, the survey staff verified the implementation of the facility's immediate actions to remove the Immediate Jeopardy.

Based on observations, record reviews, and interviews, the facility failed to provide a safe living environment for all residents by failing to maintain the Automatic Fire Sprinkler System (AFSS). This can result in the system not activating as designed and has the potential to affect all 187 residents.Additionally, the facility failed to ensure the environment remained free of potential hazards for 1 of 1 resident reviewed for accidents (Resident #160).The findings included:A tour of the facility was conducted on 1/12/2026 by the Life Safety surveyor at 12:00 PM. During this tour, the surveyor noted the automatic fire sprinkler system (AFSS) and fire pump were red tagged and had been since 5/5/2025, indicating that the fire suppression system would not function as expected in the event of a fire. As of this annual survey, the facility failed to make the repairs to the automatic fire sprinkler system. Additionally, there were two subsequent red tags on each system, dated from August 2025 and November 2025.An interview was conducted with the facility Maintenance Director on 01/12/2026 concurrent with the above observations. The Maintenance Director confirmed he was aware of the tags on the systems and stated he had requested repairs from the facility ownership but the repairs had not been completed.An interview was conducted with the facility Administrator on 01/12/2026 about what interim safety measures were put in place to ensure the safety of the residents while the sprinkler system and fire pump were red tagged. The Administrator confirmed she was aware the red tags were present since May 2025. The Administrator stated they did not receive confirming documentation from the local fire marshal until October 2025 confirming the problem. The Administrator was unable to provide reason for repair delay aside from emails from various vendors showing that additional opinions were sought. An interview was conducted with the local Fire Marshal on 01/13/2026. He stated he was aware of the red tags on the sprinkler and fire pump systems and that he was under the understanding that the facility was under contract with an engineer for the repairs to be completed. A secondary interview was conducted with the facility Administrator on 01/13/2026 at 10:00 AM. The Administrator was unable to provide interim fire safety plan measures. The Administrator was also unable to provide training to staff regarding fire and evacuation protocols.An interview was conducted with the local Fire Inspector on 01/14/2026. He stated his staff failed to note the red tags in their report written in August 2025. He further stated he was under the understanding that the facility had the system repaired in October 2025.2. During an interview with Resident #160 at approximately 11:23 AM, the resident reported that her cell phone caught fire while it was charging on the window sill on 12/24/2025 at approximately 11:15 PM. She stated the fire alarms were sounding, and she observed the phone actively in flames. The resident extinguished the fire herself using her shoe. She reported that the fire department responded, checked the electrical outlets, and maintenance scraped melted plastic from the window area the next day (Photographic evidence obtained) The windowsill in Resident #160's room was noted to have residual smoke damage and burned plastic consistent with the resident's report of a phone fire on 12/24/2025. Burn marks and soot residue were also visible on the window blinds and window. A staff member provided an account of the fire event that occurred on 12/24/2025. Employee Y, Licensed Practical Nurse (LPN), reported that while staff were walking past Resident #160's room, they observed smoke coming from the doorway. When staff opened the door, the room's smoke detector was activated, but the building fire alarm did not activate. Staff observed a cell phone on the window sill actively on fire while plugged in and charging. The resident extinguished the fire using her shoe. Two residents were evacuated to the dining room for safety. Following the incident, staff reported eye irritation due to smoke exposure. Both residents were assessed and found safe, with no injuries documented.During an interview on 01/18/2026 at 1:43 PM, the Maintenance Director was asked to describe the events of 12/24/2025 regarding the fire in Resident #160's room. He stated that Resident #160's cell phone was plugged into the wall and charging on the window sill. He reported that smoke from the phone activated the room smoke alarms. He stated that there was no fire. He confirmed that the sprinklers did not activate. The Maintenance Director stated that the fire department did not respond to the incident. He reported that, after the event, he checked electrical outlets in all rooms and traced the circuits to the breakers, stating that everything was good. No further follow up was made. The Administrator, who was present during the interview, stated that the fire department did respond. The Administrator acknowledged that the incident was not reported to the state agency, despite reporting requirements. The Administrator and Maintenance Director confirmed there was no 2nd floor corridor evacuation conducted and only two residents were moved from the immediate area.On 01/19/2026, the facility submitted an acceptable Immediate Jeopardy removal plan which included the following measures:The Administrator immediately increased monitoring of the full facility by initiating a Fire Watch on 1/12/26 at 11:00am continuously 24 hours a day, 7 days a week. All residents in the facility were monitored for resident safety, and there was no adverse outcome to any residents in the building.The Administrator verbally notified the state agency of the Fire Watch on 1/12/26 at 11:00am. The Area Office emailed the Facility on 1/14/26 at 1:20pm regarding the need to notify the Office of Plans and Constructions. The Administrator notified the Office of Plans and Constructions on 1/14/25 at 1:58pm. The survey staff was verbally notified of the Fire Watch on 1/12/26.The 24-hour Fire Watch staff assigned were educated by the facility Director of Nursing and Administrator on role and their responsibilities with a written policy. All staff who worked on January 12, January 13, and January 14 were educated. To date, a total of 216 of 227 staff members were in-serviced. All remaining 11 staff will not be allowed to start their shifts until completion of their education. Education included that this role removes them from any other assignment, provides facility-wide coverage and monitoring resident units every hour with an accountability log.The Director of Nursing/designee re-educated Fire Watch staff on the use of a fire extinguisher and emergency response initiated on 1/12/26.The Maintenance Supervisor/Designee has overseen and reviewed the documentation of the Fire Watch checks daily initiated on 1/12/26 and 1/13/26.The Director of Nursing/designee educated all staff on fire watch procedures, their individual roles and responsibilities, use of fire extinguisher and emergency response for resident safety, initiated on 1/12/26. 216 of 227 employees (including contracted employees) have been educated. All remaining 11 staff will not be allowed to start their shifts until completion of their education. On 1/12/26 the Facility engaged and signed a contract with the Vendor to replace the sprinkler heads with an anticipated replacement within 30 days.The Facility confirmed the Fire Protection Service company will be inspecting and remediating the Fire Pump including the valve(s) and conduct effective functional testing post-remediation to verify it is operating at 100% on the week of 1/12/26.The Life Safety Consultant re-educated the Maintenance Supervisor and Administrator on Fire Incident Reporting and Systems Failure Fire Incident Reporting Requirement for Agency for Health Care Administration- Florida and Regulatory requirement K353 and K354 initiated on 1/12/26.On 1/13/26 smoking materials were verified as removed from all 30 residents who were care planned to safely maintain their smoking materials independently. Residents were educated by the facility Risk Manager at 1:24pm. Family members and visitors were notified via robocall on 1/15/26 at 8:00am and 3:00pm that the facility is currently on a Fire Watch with signage posted 1/14/26 at 3:10pm. Communications included that materials were being removed for the safety of all residents. Care plans were updated for the 30 residents that were assessed to safely hold their smoking materials.Verification of the facility's removal plan was conducted by the survey staff on 02/02/2026 and 02/03/2026.The surveyors observed fire watches with 2 staff members on 02/02/26.The surveyors interviewed 10 staff members (including the Administrator and Maintenance Director) and 4 residents regarding the fire watches and removal of smoking materials. The surveyors verified signage was present throughout the facility regarding the fire watches. The surveyors verified education provided to staff from 01/12/26 to 01/14/26 regarding fire watch roles/responsibilities and policies, fire extinguishers, and emergency response. Fire Drills were conducted on 01/21/26, 01/28/26, and 01/29/26 (one on each shift).The surveyors verified the robocalls that took place on 01/15/26 and 01/18/26 regarding fire watch and smoking policies.The surveyors confirmed communication between the facility and the Fire Protection Service company, the Fire Safety and Protection company, the sprinkler vendor company, and the local Fire Marshal.During the survey, the survey staff verified the implementation of the facility's immediate actions to remove the Immediate Jeopardy.

Based upon observations, interviews, and facility policy review the facility failed to prevent the spread of infections by not performing hand hygiene during wound care for 5 of 5 residents observed for proper infection control. (Residents #32, #53, #15, #17, #144)The findings include: On 01/13/26 at 12:00 PM, a wound care observation for Resident #53 was conducted with Staff B, Registered Nurse (RN). Staff B did not provide a barrier for clean dressing supplies; she placed clean dressing supplies on his bed. She did not remove her gloves or wash her hands after removing the soiled dressing and prior to applying the clean dressing to cover the resident's wound. 2. On 01/13/26 at 12:20 PM, an observation conducted of Resident #32 revealed a wound to his left heel. He was noted to be on contact isolation for infection of the wound. Staff B did not place a barrier prior to placing clean dressing supplies on Resident #32's bed. After removing the soiled dressing from his left heel, Staff B placed the soiled dressing on the bed next to the clean supplies. Staff B cleaned the wound and applied a clean dressing to left heel without performing hand hygiene and donning clean gloves. Upon exiting Resident #32's room, an interview was conducted with Staff B. Staff B stated the process for wound care was as follows: apply protective equipment, gather supplies, wash hands, place a barrier to prevent soiling of linens and contamination, remove dirty dressing, discard, wash hands, put on clean gloves, clean wound, wash hands, apply clean gloves and then apply clean dressing to wound site. When told about the observations of her wound care, she confirmed, I didn't change my gloves or wash my hands after removing a dirty dressing and before applying a new clean dressing or use a barrier during care. 3. During an observation on 01/13/2026 at 10:34 AM, a tube feeding bottle for Resident #15 was noted to be hanging from an IV pole, not attached to the resident. The end of the tube feeding tubing was uncapped and open to air, leaving the line exposed to potential contamination. An interview was conducted at this time with Staff X, Licensed Practical Nurse (LPN). Staff X stated she did not know where to obtain a cap for the end of the tube feeding tubing. On 01/14/2026 at 1:09 PM, the surveyor observed Staff K, LPN, performing percutaneous endoscopic gastrostomy (PEG) tube care for Resident #15. (A PEG tube is a feeding tube inserted through the abdominal wall to provide nutrition directly to the stomach.) During this observation, Staff K did not use Enhanced Barrier Precautions (EBP). (Enhanced Barrier Precautions are an infection control strategy used in nursing homes which requires staff to wear personal protective equipment like gowns and gloves during resident care to reduce the spread of drug-resistant organisms) It was noted that EBP signage was posted on Resident #15's room door and a Personal Protective Equipment (PPE) cart was available in the hallway outside the room. Review of Resident #15's clinical record revealed an active provider order requiring EBP for PEG tube related care every shift. 4. On 01/13/2026 at 9:30 AM, Staff L, Certified Nursing Assistant (CNA) and Staff M, CNA were observed providing perineal care and indwelling urinary catheter care to Resident #17. Neither CNA performed hand hygiene before beginning care, between perineal care and catheter care, or after completing care. Both CNAs performed perineal care and catheter care using the same pair of gloves without removing them or performing hand hygiene between contaminated and clean tasks. After completing care, both CNAs were observed moving between residents without performing hand hygiene after glove removal. An Enhanced Barrier Precautions sign was visible on Resident #17's door. A review of the resident's orders confirmed EBP related to catheter care, and the Treatment Administration Record showed EBP documented every shift. 5. On 01/13/2026 at 9:45 AM, Staff L and Staff M were observed providing perineal care and indwelling urinary catheter care on Resident #144. Neither CNA performed hand hygiene before beginning care, between perineal and catheter care, or after completing care. Both CNAs used the same pair of gloves throughout the care tasks without removing them or performing hand hygiene between contaminated and clean procedures. Employee M was also observed using the same pair of contaminated gloves to open Resident #144's closet and retrieve clean clothing. An Enhanced Barrier Precautions sign was visible on Resident #144's door. A review of the Resident #144's care plan confirmed EBP requirements related to catheter care. An interview was conducted following the observations of Resident #17's and Resident #144's perineal and catheter care. Staff L and Staff M both stated handwashing was not required when wearing gloves. Both CNAs also stated they did not know what Enhanced Barrier Precautions were and incorrectly reported that EBP is the cream used on the bottom after pericare. A review of the facility's policy titled Handwashing/Hand Hygiene, dated August 2019, revealed that the policy states that all personnel must receive ongoing training on hand hygiene, and that staff are required to follow all established handwashing and hand hygiene procedures. The policy further states that hand hygiene supplies, including soap, sinks, towels, and alcohol based hand rubs, must be easily accessible to staff at all times. The policy outlines the circumstances in which alcohol based hand rub or soap and water must be used. According to the policy, hand hygiene is required before and after shifts, before and after direct resident contact, before handling clean or soiled dressings, when moving from contaminated to clean body sites, after contact with intact skin, blood, body fluids, contaminated equipment, or resident surroundings, and after removing gloves. Additional provisions in the policy specify that hand hygiene must occur after removing personal protective equipment, and that the use of gloves does not replace the need for hand hygiene. The policy states that disposable gloves are required for aseptic procedures, anticipated exposure to body fluids, and when providing care under contact precautions. The section of the policy addressing glove application and removal instructs staff to perform hand hygiene before applying gloves, to remove gloves using proper technique to avoid contamination, and to perform hand hygiene immediately after glove removal. (Photographic evidence obtained) Interviews with Staff DD, CNA, Staff EE, CNA and Staff W, LPN were conducted on 01/14/2026 at 4:35 PM. Staff DD stated they had been employed at the facility since July 2025. Staff DD stated that Enhanced Barrier Precautions (EBP) meant wearing gloves, gown, and mask in rooms that have an EBP sign posted. Staff EE stated they had been employed at the facility for approximately 4 months. Staff EE stated that EBP involved wearing gloves and a gown when taking care of catheters. Staff W stated they had been employed at the facility for approximately 5 years. Staff W stated that all rooms with EBP signage should have a cart outside the door, and that staff should be wearing PPE when doing personal care or wound care. Review of Catheter Care Policy A review of the facility's policy titled Catheter Care, Urinary, dated September 2014, revealed that the policy instructs staff to use standard precautions and to maintain clean technique when handling the catheter or drainage system. (Photographic evidence obtained). The procedural steps outlined in the Perineal Care policy (dated February 2018) direct staff to prepare supplies and wash their hands before beginning care, position the resident appropriately and provide privacy, and perform perineal care with soap and water. The policy instructs staff to clean the catheter from the insertion site outward, secure the catheter, check drainage, ensure the resident's comfort, clean equipment after use, and wash their hands again upon completion of the procedure. (Photographic evidence obtained) An interview was conducted on 01/16/2026 at 8:24 AM with the facility's Infection Prevention Nurse. When asked to describe the facility's hand hygiene education, the nurse reported that staff are taught standard handwashing steps, but she was unable to provide specific details regarding the content or method of instruction. She stated that hand hygiene audits are conducted and that a log is maintained. Regarding Enhanced Barrier Precautions (EBP), the nurse reported that EBP education is provided during staff orientation and includes instruction related to catheter care, wound care, colostomy care, and dressing changes. When asked about supply availability, the nurse stated that supplies are kept at the door for residents requiring EBP, and that each hallway has one EBP cart, with unit staff responsible for stocking the carts

Based on observation and interview, the facility failed to ensure a resident's dignity was maintained by failing to provide appropriate clothing 1 of 6 resident reviewed for dignity (Resident #106).The findings included:A review of Resident #106 Quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #106 had Brief Interview for Mental Status (BIMS) (BIMS is a standardized tool used assess cognitive function) of 03, indicating Resident #106 has severe cognitive impairment. Review of this MDS revealed Resident #106 was dependent on staff for her Activities of Daily Living (ADL)On 1/12/2026 at approximately 12:45 PM, Resident #106 was observed sitting in her room in a wheelchair. The resident was dressed in a cardigan with only one middle button secured, with her upper chest and lower abdomen exposed, wearing an adult brief, eating her lunch. Resident #106 stated, I don't have any clothes. The door of Resident #106's closet had a sign indicating her family was responsible for doing her laundry. An observation was conducted of Resident #106's closet. There were no clothes hanging and sheets and a plastic bag of clothes were observed sitting on the bottom of the closet.On 1/13/2026 at approximately 8:30 AM, and 3:00 PM, observations were conducted of Resident #106 lying in her bed. Resident #106 indicated she did not get out of bed because she was not wearing pants and only clothed in a shirt and an adult brief.An interview was conducted on 1/13/26 at approximately 3:05 PM with Staff HH, Certified Nursing Assistant (CNA). Staff HH confirmed Resident #106 did not have clean clothes but she would go to the laundry room to find clothing for her. She confirmed she did not notify the nurse that Resident #106 had no clothes. Staff HH opened Resident #106's closet, and noted there was one pair of pants hanging in the closet.An interview was conducted on 1/13/26, at approximately 3:15 PM with Staff P, Unit Manager (UM.) She confirmed she had observed Resident #106 wearing only a shirt and an adult brief. Staff P inspected Resident #106's closet and noted the jeans. Staff P stated, this should never happen, Staff HH should have dressed [the resident].

Based on observations, interviews, and record reviews, the facility failed to ensure residents were able to exercise their rights for care and services regarding scheduled daily routines and failed to provide appropriate therapy or restorative services to improve mobility and strength for 1 of 14 resident reviewed for right to self determination. (Resident #123)The findings included:Review of the facility policy for Activities of Daily Living (ADLs), dated March 2018, revealed residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living. Residents who are unable to carry out ADLs independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. Policy interpretation and implementation stated: appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with hygiene (bathing dressing grooming) and mobility (transfer and ambulation). Interviews were conducted on 1/13/26 at 11:45 AM and 1/15/26 at 08:15 AM with Resident #123 who revealed she was unable to get a shower per her preference. She stated, the CNAs [Certified Nursing Assistants] will not get me up out of bed to get in the shower. I prefer to have a shower, but they give me a bed bath instead. I feel cleaner when I have a shower. The CNAs like to fuss at you if you ask for anything and they always say they don't have time to get me up, because it takes a lot of time. On 1/18/26 at 09:00 AM, an additional interview was conducted with Resident #123 who expressed her desire to receive therapy services to gain strength and improve her mobility with transfers. She stated, I have asked multiple times, and they keep telling me that I can't have any therapy or Restorative services because I don't have Medicaid, but once I get Medicaid, they told me that they will see about it then. I'm tired of asking for things because it doesn't do any good. On 01/15/26 at 11:30 AM, a follow up interview was conducted with Resident #123 who stated that Staff R, CNA told her she didn't have time to deal with getting her up on days she is to get a shower and would only give her a bed bath. Review of Resident #123's Minimum Data Set (MDS) dated [DATE] revealed Resident #123's Preferences for Routine and Activities for How important is to you to choose between a tub bath, shower, bed bath, or sponge bath documented her response as very important. Review of Resident #123's Therapy Notes revealed dates of service were 10/7/25 and 10/08/25 and then Resident #123 was discharged from therapy services on 10/08/25 due to benefits exhausted. The Therapy Discharge Note documented Resident #123 required partial to moderate assistance with bed mobility and required substantial maximal assistance with transfers. Skilled interventions for physical therapy evaluation included direct hands-on care with patient. Patient had limited sessions to demonstrate any progressions. Skilled interventions for Occupational Therapy included patient was seen for eval [evaluation] only focusing on establishing baseline, setting goals, and educating patient on use of call light and bed control. A Quarterly Therapy Screen Referral completed on 12/15/26 stated, patient would benefit from continued skilled for ADLs and functional mobility. Recommendations: no skilled therapy intervention indicated. An Interview was conducted with Staff A, Licensed Practical Nurse on 1/15/26 at 11:00 AM revealed Resident #123 asked multiple times to get out of bed for a shower, but the staff did not give her a shower. Staff A stated, I have discussed this with the Unit Manager and the CNAs several times, but the CNAs continue to refuse to abide by [Resident #123] wishes and they will mark 'refused' on shower sheets if they don't feel like giving showers.

Based on observations and interviews, the facility failed to provide appropriate privacy while personal care was being administered by a staff member for 1 of 7 resident reviewed for personal privacy (Resident #62).The findings included:An observation conducted on 1/12/2026 at 1:45 PM revealed Resident #62's room door was fully open, and the privacy curtain was not pulled closed. Continued observation revealed Staff Q, Certified Nursing Assistant was standing at Resident #62's bedside, performing incontinent care. Resident #62 was wearing a facility gown. The gown was pulled up to her upper torso, revealing she was not wearing an incontinent brief. No bed covers were covering Resident #62 during this care. Resident #62's body was exposed and visible from the hallway while other residents were observed passing in front of her room. When Staff Q completed her task, she stated to the surveyor, you can come in, I am just wiping her face now.An interview was conducted with Staff Q at this time. When asked why she had not provided privacy for Resident #62, Staff Q stated, Oh, my bad. Yes, I should have shut her door and pulled the privacy curtain while I was giving her care.Review of Resident 62's medical record revealed she was alert and oriented to self only. She required total assistance from staff with all activities of daily living, including bathing, personal cares, toileting, and dressing. She was incontinent of bowel and bladder and was noted to be dependent on staff for those care and services.

Based on record review and interviews, the facility failed to maintain a grievance protocol to properly identify, investigate, and resolve grievances for 1 of 6 resident reviewed for grievances (Resident #123).The findings included:Review of the facility's grievance log was conducted with the Social Worker (SW) and Grievance Official. They both independently reviewed the paper grievance log and compared it with the facility's electronic grievance system.A grievance dated 10/08/25 for Resident #123 was reviewed. The grievance stated, staff refused to dry her after providing incontinence care. The documented Actions stated, It appears to be lunch time when staff cannot toilet residents. The SW acknowledged this was not an appropriate resolution and stated he did not know what actions the unit manager took to address this concern.A grievance dated 11/08/25 for Resident #123 was reviewed. The grievance stated, the resident waited 30 minutes after activating the call light before being changed. The documented Actions stated, some sort of confabulation,. There was no evidence showing how the facility determined the resident was confabulating nor did the grievance have a resolution documented.An interview was conducted on 01/16/26 at 10:39 AM with the Grievance Official. The Grievance Official declined to provide access to notes documenting grievance resolutions.An interview was conducted on 01/16/26 at 12:15 PM with the facility's Administrator during which the grievance process was discussed. The Administrator confirmed the Social Worker (SW) and Grievance Official were not following proper grievance protocol and stated she educated them regarding the protocol. A copy of the facility's policy titled Grievance Policy and Procedure (undated) was obtained. The policy states that the facility will ensure, all written grievance decisions include the date the grievance was received, a summary statement of the resident's grievance, the steps taken to investigate the grievance, a summary of the pertinent findings or conclusions regarding the resident's concerns, a statement as to whether the grievance was confirmed or not confirmed, any corrective action taken or to be taken by the facility as a result of the grievance, and the date the written decision was issued.

Based on record review and interviews, the facility failed to immediately identify and timely report an allegation of sexual abuse for 1 of 3 residents sampled for abuse. (Resident #205) The findings include:A record review was conducted for Resident #205 revealed a note written by the facility Risk Manager (RM) dated 1/13/26 at 9:00 AM. The note indicated that on 1/13/26, Resident #205 confided in an employee an allegation of inappropriate sexual conduct by a former employee who worked at the facility in the previous year. During interviews on 1/13/26, Resident #205 revealed that a former therapy aide (who no longer works at the facility at the time of the survey) would ask to be her boyfriend and would ask inappropriate things, such as asking for oral sex. On 1/15/26 at approximately 10:30 AM, an interview was conducted with the RM. The RM stated she did not report the abuse to the state agency, citing the resident had the right to decline law enforcement, and that Resident #205 claimed that it was not abuse. On 1/15/26 at approximately 1:15 PM, an additional interview was conducted with the Risk Manager. The RM stated she was not mandated to report the allegation, citing #205's rights, and that Resident #205 had a high cognitive score. On 1/15/26 at approximately 2:00 PM, an interview was conducted with the facility Administrator. She stated she had been informed of the allegation that day and had read the RM's note in Resident #205's chart. She stated she had instructed the RM to investigate further and submit a report. She confirmed the report should have been filed on 1/13/26, when the allegation was brought to the staff's attention.A review of Facility's Abuse policy (dated April 2021) reveals: all reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft / misappropriation of residents property are reported to local, state, and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. Under the section policy interpretation and implementation 1) if resident abuse, neglect, exploitation, misappropriation, is suspected, the suspicion must be reported immediately to the administrator and to other officials according to the state law. 2) the administrator or the individual making the allegation immediately reports his or her suspicion to the following agencies, 3) immediately is defined as within two hours of an allegation involving abuse or result in serious bodily injury or within 24 hours of an allegation that does not involve abuse or result in serious bodily injury. #6) Upon receiving any allegations of abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source, the administrator is responsible for determining what actions are needed for the protection of residents. #11) The administrator ensures that the resident and the person(s) reporting the suspected violation are protected from retaliation or reprisal by the alleged perpetrator, or by anyone associated with the facility. (Photographic evidence obtained)

Based on observation, interview and record review it was determined the facility failed to follow the plan of care to provide pain medication prior to wound care for 1 of 3 sampled residents. (#212) resulting in the resident screaming in pain during wound assessment/care. The findings are: 1. Review of the plan of care for resident #212 dated 5/13/11 indicates to pre-medicate the resident with pain medication prior to wound care or dressing changes as ordered. Review of the Minimum data set (MD'S) dated 5/13/11 indicates a [DIAGNOSES REDACTED]. The resident was assessed for having pain almost constantly. The resident was ordered [MEDICATION NAME] 5/325 milligrams every 4 hours as needed for pain. Observation of wound care on 6/6/11 at 3:34 pm to residents left foot noted the foot to be swollen and red. Interview with the wound nurse stated we have been treating the area on top of the left foot which is almost healed. He stated the resident has some macerated areas that are new today to the bottom of his left foot. Observation noted several areas that were macerated with thick white wrinkled looking tissue and drainage noted. While the wound nurse was cleaning the area at 3:24 pm on the bottom of the foot the resident screamed in pain. The wound nurse paused and then continued with asking the resident if he needed anything for pain. Review of the 6/6/11 MAR indicated [REDACTED]. and did not have a dose prior to wound treatment. Interview with wound care nurse and director of nursing on 6/9/11 in 4:15 pm indicated the wound nurse had not done the wound treatment but was assessing a new area. The wound nurse did not stop treatment and or assessment when the resident screamed in pain.

Based on observation, record review and staff interview it was determined the facility failed to medicate for pain prior to staff intervention for wound assessment/care causing the resident to scream in pain for 1 (# 212) of 2 sampled residents. The findings are: Review of the Minimum data set ((MDS) dated [DATE] indicates a [DIAGNOSES REDACTED]. The resident was assessed for having pain almost constantly. The resident was ordered [MEDICATION NAME] 300 milligrams three times a day for Depression and [MEDICATION NAME] 5/325 milligrams every 4 hours as needed for pain. Observation of wound care on 6/6/11 at 3:34 pm to residents left foot noted the foot to be swollen and red. Interview with the wound nurse stated we have been treating the area on top of the left foot which is almost healed. He stated the resident has some macerated areas that are new today to the bottom of his left foot. Observation noted several areas that were macerated with thick white wrinkled looking tissue and drainage noted. While the wound nurse was cleaning the area at 3:24 pm on the bottom of the foot the resident screamed in pain. The wound nurse paused and then continued without asking the resident if he needed anything for pain Review of the 6/6/11 MAR indicated [REDACTED]. and did not have a dose prior to wound treatment. Interview with wound care nurse and director of nursing on 6/9/11 in 4:15 pm indicated the wound nurse had not done the wound treatment but was assessing a new area. The wound nurse did not stop treatment or assessment when the resident screamed in pain.