Health inspection·September 25, 2025

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Based on observations, staff interviews, and record review, the facility failed to honor residents right to dignity for 1 of 1 sampled residents sampled. (Resident #59) The findings include:On 9/22/2025 at approximately 10:32 AM, Resident #59 was observed lying in bed with a suprapubic catheter bag attached to the bed rail uncovered and visible to roommates.On 9/22/2025 at approximately 12:25 PM, Resident #59 was observed in the dining room with her catheter bag attached to the back of the wheelchair uncovered and visible to other residents in dining room.On 9/22/2025 at approximately 2:30 PM, Resident #59 was observed in her wheelchair in the smoking area with the catheter bag attached to the wheelchair uncovered and visible to other residents in smoking area.On 9/22/2025 at approximately 3:00 PM, an interview was conducted with Nurse D. He confirmed that the bag was visible to other residents and indicated that it should be covered for dignity with a dignity bag. Nurse D (Registered Nurse) indicated that he would get a cover for the bag right away.On 9/22/2025 at approximately 3:15 PM, interview was conducted with resident #59. The resident stated my bag is never covered and I don't like everyone seeing my pee. Record review of the resident's care plan revealed the resident has a suprapubic catheter with risk for infection and/or complications due to neurogenic bladder and/or bladder spasms. The goal is to minimize the risk of complications associated with catheter usage with an intervention to use catheter bag that promotes privacy and dignity. The Minimum Data Set (MDS) revealed the resident had an indwelling catheter with diagnosis of Obstructive Uropathy and Neurogenic Bladder. Page 1 of 3 105265 105265 09/25/2025 Emerald Coast Center 114 Third Street SE Fort Walton Beach, FL 32548

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Based on observations, record review, and interviews, the facility failed to develop and implement a comprehensive person-centered care plan for 1 of 1 resident sampled for pain. (Resident #3)The findings include:A review of the Quarterly Minimum Data Set (MDS) (a standardized assessment tool that measures health status in nursing home resident) dated 9/1/2025, revealed a diagnosis of Aphasia (a language disorder that affects a person's ability to communicate effectively) following Cerebral infarction.A review of the physician's orders revealed an order dated 1/04/2025 for Tramadol HCL oral tablet 50 milligrams every six hours as needed for non-acute pain. Further review revealed an order also dated 1/04/2025 to monitor pain every shift and record the pain number on a 0-10 scale. A review of the comprehensive care plan dated 9/11/2025 does not include a care plan for pain. On 9/24/25 at approximately 9:40 AM, an interview was conducted with Staff B, Certified Nursing Assistant (CNA). Staff B was asked how she assesses Resident #3 for pain. She replied that she just asks the resident if she is in pain. Resident #3 was observed to be alert and sitting in her wheelchair. Staff B asked resident # 3 If she was in pain twice and then asked if her foot was hurting. Resident # 3 did not respond by any observable means. Staff B was asked what other ways she would assess for pain if the resident does not communicate. Staff B replied, You just have to know them.On 9/24/25 at approximately 9:50 AM, an interview was conducted with the MDS coordinator. The MDS Coordinator confirmed Resident # 3 has aphasia and cannot communicate. She stated Resident # 3 should have a care plan for pain and interventions which should indicate how to monitor for pain with a non-verbal resident. On 9/25/2025 at approximately 9:35 AM, an interview with the Director of Nursing (DON) was conducted. She confirmed Resident #3 should have a care plan for pain and stated she reviewed the non-verbal cues for pain with Staff B, CNA. 105265 Page 2 of 3 105265 09/25/2025 Emerald Coast Center 114 Third Street SE Fort Walton Beach, FL 32548

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, and record reviews, the facility failed to complete an assessment of the residents' capabilities and deficits to determine whether or not supervision and/or assistance was needed for 1 of 3 sampled residents sampled for smoking. (Resident #80)The findings include: On 9/22/2025 at 10:30 AM, 9/22/2025 at 2:30 PM, and 9/23/2025 at 10:35 AM, Resident #80 was observed smoking in the designated smoking area with staff supervision. An interview was conducted with Nurse D (Registered Nurse) on 9/22/25 at approximately 10:50 AM. Nurse D indicated the resident enjoys sitting in the sun and smoking daily. An interview was conducted with Employee E (Certified Nursing Assistant) on 9/22/2025 at approximately 11:15 AM. Employee E confirmed resident #80 had a current smoker agreement that was signed by the resident on 6/30/25.A record review of the resident's record revealed she was admitted to the facility on [DATE] with active diagnoses of muscle wasting and atrophy, need for assistance with personal care and generalized Muscle Weakness. The facility supplied smoker list on 9/22/2025 had Resident #80 on active list. However, the resident evaluations only revealed one smoking evaluation completed on 09/22/2025 at 9:10 PM. 105265 Page 3 of 3