Inspection·June 26, 2025

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record Review, the facility failed to provide maintenance services to maintain a clean, safe living environment for 2 of 4 bathrooms observed in Hallway 200. (rooms [ROOM NUMBERS]) The findings include: On 06/23/25 at approximately 8:45 AM, an environmental observation was made in room [ROOM NUMBER], where holes were noted in the wall adjacent to the television and scratches were noted behind the bed. (Photographic evidence obtained) On 06/23/25 at approximately 9:50 AM, an observation in room [ROOM NUMBER] revealed peeling paint and a hole in the bathroom wall near the sink, with visible plaster residue deposited on the sink surface. Additionally, the bathroom faucet exhibited a buildup of a greenish hard biofilm. (Photographic evidence obtained) On 06/25/25 at approximately 12:16 PM, an interview was conducted with the Maintenance Technician. He explained the current process for reporting and addressing maintenance concerns, noting that any staff member may submit a work order, which can be recorded in maintenance logbooks located at each nursing station and in the kitchen. The Maintenance Technician further explained that both he and the Maintenance Director conduct monthly inspections to proactively identify and address areas in need of repair. During the interview, he assessed the bathroom wall and faucet in room [ROOM NUMBER]'s bathroom. He acknowledged the crumbling wall and the greenish biofilm buildup on the faucet, stating that the accumulation appeared to have developed over an extended period. He concluded that the condition was not acceptable and in need of corrective action. On 06/26/25 at approximately 11:35 AM, an interview was conducted with the Maintenance Director. He reported that he is responsible for reviewing the facility's work order book daily and addressing repairs requests accordingly. He clarified that the maintenance department consists of only himself and one technician and that the facility is currently undergoing renovations. During the interview, he assessed the bathroom wall and sink faucet in room [ROOM NUMBER]'s bathroom. He acknowledged that the wall above the sink was in poor condition with the crumbling deposit around the sink and confirmed the presence of a greenish biofilm buildup on the faucet. He indicated awareness of the need to repair the wall and replace the faucet and recalled discussing the matter previously with the Administrator. He explained that the repair priorities are determined in consultation with the Administrator and emphasized that renovation efforts are ongoing but take time to complete in addition to the daily repairs. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 3 Event ID: 105295 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105295 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fort Walton Rehabilitation Center, LLC 1 Lbj Sr Drive Fort Walton Beach, FL 32547 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)