Health inspection·February 24, 2026

F 0676 Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon observations, interviews, and record reviews, the facility failed to provide Activities of Daily Living (ADLs) to maintain or improve abilities and choices for 5 out of 10 residents reviewed. (Resident #1, #6, #8, #9, #10)The findings include:On 2/23/26 at 10:15 AM, a tour of the facility was conducted. The following observations were made:Resident #6's room door was open and no privacy curtain was in use. The resident was lying in bed awake screaming I'm hurting. Resident #6 appeared unshaven and his hair was unkempt. He appeared to be restless moving in bed from side to side while rubbing his right and left lower legs. He did not have any clothes on except for an incontinence brief. He did not have any sheets or blankets over him. His room had a notable strong smell of urine.Resident #9 was lying in bed with the head of the bed elevated at a 45-degree angle. His eyes were closed, he appeared unshaven with notable facial hair, and his hair appeared unkempt and ungroomed.Resident #8's room has a notable strong smell of urine. She stated, I have been waiting on someone to come change me, someone came in and stated they will get someone, but no one has come yet. Resident #10's room had a strong smell of urine upon entering. She stated, I have been waiting to get changed, they haven't come yet, I pressed my call light, they are shorthanded, it depends on the time of day on how long it takes them to answer the call light, usually more than 30-45 minutes. An interview was conducted with Resident #1 on 2/23/26 at 02:00 pm. Resident #1 stated, I have to go to the bathroom now, and that's why I have been sitting at the nurses desk waiting for someone to help me. It takes the staff a while to answer my call light, it's been over 30 minutes and a couple of times an hour.On 2/24/26 at 09:00 am, follow up observations and interviews were conducted throughout the facility.Resident #6 was lying in bed. A hospital gown was covering him, facial hair was noted, and his hair was unkempt and ungroomed.Resident #9 appeared to have facial hair and the hair on his head was unkempt. During an interview, he stated, I have not had a shower since I have been here. I have been here 2 weeks now, and they haven't let me shave. They gave me a sponge bath, but I prefer to get up and get a shower. A record review was conducted for Resident #1 on 2/23/26 at 1:00 pm. She was admitted to the facility on [DATE] with the following diagnoses: Cerebral vascular Incident with hemiplegia to the right side, urinary tract infection, Chronic obstructive pulmonary disease, and hypertensive heart disease. A minimum data set (MDS) was completed with assessment reference date on 1/12/26 revealed she requires partial to maximal assistance with activities of daily living (ADLs).A record review of was conducted on 2/24/26 at 03:15 pm for Resident #6. He was admitted to facility on 2/19/26 with the following diagnoses: displaced fracture of left femur, unspecified dementia, hypertensive heart disease, hyperlipidemia, need for assistance with personal care, Post-traumatic stress disorder, and anxiety disorder. Review of hygiene documentation revealed that, since his admission, Resident #6 had not received a bath. A skilled nurses note dated 2/20/26 demonstrated that Resident #6 is dependent on staff for all ADLs and is incontinent of bowel and bladder function. A review of therapy notes Residents Affected - Some Page 1 of 6 105543 105543 02/24/2026 St Andrews Bay Skilled Nursing and Rehabilitation 2100 Jenks Ave Panama City, FL 32405

F 0676 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some indicates, dated 2/20/26, Resident #6 presents with severe cognitive-communication impairment impacting comprehension, expressive reliability, safety awareness, and functional task completion. Occupational Therapy states that the patient currently demonstrates behaviors, severe cognitive impairment and mobility due to left lower extremity fracture and pain. Physical therapy evaluation states he is alert and disoriented, high risk of falls, weakness to bilateral lower extremities. A record review of Resident #8 reveals she was admitted to facility on 11/4/25 with the following diagnoses: Type 2 diabetes, Fracture of left patella and left toes, Multiple Myeloma, Hypertensive heart disease, and Cirrhosis of the liver. A minimum data set (MDS) assessment with the assessment reference date of 2/19/26 revealed an impairment to one side lower extremity, requiring a wheelchair for mobility, limited to moderate assistance neededfor ADLs and is frequently incontinent of bowel and bladder function. A plan of care was initiated for ADL self - care deficit related to impaired mobility and is at risk for complications due to incontinence of urine and bowel.A record review of Resident #9 revealed he was admitted to the facility on [DATE] with diagnoses of non-displaced fracture of lateral malleolus of left Fibula, urinary tract infection, metabolic encephalopathy, heart disease, and need for assistance with personal care. A MDS assessment was completed on 1/31/26, indicating moderate to dependent assistance from staff to perform ADLs. A plan of care was initiated for ADL self-care deficit related to left ankle fracture and that he is at risk for complications due to incontinent episodes of urine and bowel. Upon reviewing CNA documentation of bathing task, Resident 9 received a bed bath on 2/21/26, 2/18/26, 2/14/26, 2/10/26, 2/7/26, 2/3/26, and 1/31/26, but has not received a shower as requested.A record review of Resident #10 revealed she was admitted to facility on 4/4/22 with the following diagnoses: hypertensive heart disease, personal history of transient ischemic attack (TIA) and cerebral infarction. A MDS assessment from 12/31/25 revealed that she utilizes a wheelchair for mobility due to impairment to one side of lower extremities and requires maximal assistance from staff to perform ADLs and is always incontinent of bowel and bladder function. A plan of care was initiated for decreased ability to perform ADLs, prefers not to be woken up at night for incontinent care.On 2/24/26 at 11:15 AM, an interview was conducted with Staff D, a Registered Nurse (RN), who states, [Resident #1] got changed on a regular basis during my shift, I can't say about the other shift. I work, day shift 7 am - 3 pm. But I will tell you this, the CNAs do not provide proper care, they don't make their rounds like they are supposed to. I have written several CNAs up on a disciplinary form, but nothing happens and nothing changes. The staff needs to provide better care to the residents. I have voiced my concerns and complaints to management but like I said nothing changes. Yes, sometimes we do work short staff.A interview with the Director of Nursing (DON) was conducted on 2/24/26 at 02:00 pm. She stated, Yes there have been several grievances filed in regard to call lights and care not being given in a timely manner. But we have done training with the staff. We have done call light audits to ensure that they are being answered and interviewed residents to ensure that call lights were being answered. As far as the education and training for care not being done, I have spoken to the staff but did not do any formal training. I can't give you anything on paper to confirm that. When asked to explain what her expectations are of her staff and she stated,Care should be done every two hours and as needed, more often if residents require it and call lights should be answered in a timely manner with 5-10 minutes.A review of facility policy for Incontinence was completed on 2/24/26 at 10:15 AM demonstrates, it is the policy of the facility to ensure that residents receive care and services to promote urinary continence of it residents. 105543 Page 2 of 6 105543 02/24/2026 St Andrews Bay Skilled Nursing and Rehabilitation 2100 Jenks Ave Panama City, FL 32405

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon interviews and record reviews, the facility failed to ensure 1 of 3 residents reviewed for wound care received ongoing monitoring and treatment for wound care to prevent worsening and new pressure ulcers from occurring, initiate treatment orders on admission, and monitor bruising to left lower abdomen, left groin and thigh that resulted in worsening of wounds and bruising. (Resident #1)The findings include:On 2/23/26 at 2:00 pm, an interview was conducted with Resident #1 who revealed upon admission on [DATE] that she did not have any wounds except on her sacral area but now she has a wound on her heel.A record review was conducted on 2/23/26 for Resident #1. She was admitted to the facility on [DATE] with one unstageable pressure ulcer injury presenting as SDTI (suspected deep tissue injury).A progress note dated 1/6/26 titled Skin Note revealed Resident #1 had extensive bruising to her left abdomen that was deep purple in color extending to her back shoulder blade, bruising to her right lower abdomen, left thigh from her groin to knee, dark purple in color, and an old area on her sacrum that was not opened at this time, her right and left arm swelling, and a callous to the bottom of her right foot near her great toe. Upon further review, progress notes dated 1/7/26, 1/8/26, 1/10/26, 1/12/26, 1/13/26, 1/14/26, and 1/15/26 revealed Resident #1 having skin that is warm, dry, and intact with no wounds present. A weekly skin evaluation was completed on 1/12/26 revealed Resident #1's skin was intact. (photographic evidence obtained)An interview was conducted with Staff Member D, Registered Nurse (RN), on 2/24/26 at 11:15 AM. She confirmed that she completed the admission on Resident #1 and that, when admitted , Resident #1 only had an old site from a wound on sacrum that was not opened.A review of Resident #1's wound care notes from the physician dated 1/13/26 revealed that Resident #1 presented with wounds to her right heel and sacral area. An unstageable DTI (deep tissue injury) of the right heel measuring 1.3 cm x 2.1 cm with an undetermined depth; skin intact with purple, maroon discoloration. A new order was initiated to skin prep area once a day and as needed. An unstageable DTI to the sacrum measures 5.1 cm x 4.7 x 0.1 cm with an order for hydrocolloid sheet apply three times a week and as needed was also noted.The medication administration record and treatment sheet showed orders were initiated on 1/14/26 to apply skin prep to right heel every day and to cleanse the sacral wound with normal saline (NS), skin prep area and apply hydrocolloid dressing three times a week every day shift. A plan of care was revised on 1/14/26 indicating Resident #1 is at risk for skin breakdown related to her right heel and sacral area.On 1/17/26, progress notes and change of condition assessments were initiated for Resident #1 due to complaints of pain to the abdominal area. Hospital medical records revealed Resident #1 was admitted to the hospital for abdominal pain for 3 days and a hematoma PSOAS muscle abscess (PSOAS muscle is a long ribbon shaped muscle, starting at the lower back and extending through the pelvis to the top of the femur. A hematoma PSOAS is a collection of blood within the muscle compartment often associated with trauma, bleeding disorders, or anticoagulant therapy.)Upon further review of the medication administration record on 02/23/26, Resident #1 was receiving anticoagulant medication. The medical record revealed that Resident #1 was re-admitted to facility on 1/23/26 with skin issues noted as follows: midline present to left upper arm, bruising to left hip and abdomen area, scattered bruising to right forearm, an open area to sacrum and DTI (deep tissue injury) to right heel. A revision of Resident #1's plan of care was initiated for being at risk for skin breakdown related to right heel and sacral wound. Physician orders were initiated on 1/24/26 for wound care to apply skin prep to right heel every day shift and as needed; sacral wound, cleanse with NS (normal saline), skin prep area, apply hydrocolloid dressing every day shift and as needed for wound healing. Resident 1 was seen by wound care physician on 02/17/26 indicating a unstageable Residents Affected - Few 105543 Page 3 of 6 105543 02/24/2026 St Andrews Bay Skilled Nursing and Rehabilitation 2100 Jenks Ave Panama City, FL 32405

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few wound to the right heel measuring 2.4cm x 2.7 cm x undetermined depth skin intact with purple, maroon discoloration. Sacral wound resolved, healed. On 2/24/26 at 10:15 am a review of facility's policy and procedures for wound management demonstrates the purpose of this policy is to assist the facility in the care, services, and documentation related to the occurrence, treatment, and prevention of pressure as well as non-pressure related wounds. In the absence of treatment orders, the licensed nurse will notify physician to obtain treatment orders. The effectiveness of treatments will be monitored through ongoing assessment . 105543 Page 4 of 6 105543 02/24/2026 St Andrews Bay Skilled Nursing and Rehabilitation 2100 Jenks Ave Panama City, FL 32405

F 0919 Make sure that a working call system is available in each resident's bathroom and bathing area. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon observations, interviews, and record reviews, the facility failed to ensure call lights were placed within reach of dependent residents while in their rooms for 12 out of 116 resident beds observed. (Rooms 115, 207, 208 (both A and B beds), 212, 213, 215, 302, 303, 308, 402, and 409)The findings include:A tour of the facility was conducted on 02/23/26 at 10:15 AM and revealed the following call light issues:In room [ROOM NUMBER], the call light was fastened with a red plastic clip hanging in between the bed and bedside dresser, out of reach of the resident lying in bed. In room [ROOM NUMBER], the call light was wrapped around a wheelchair handle hanging near the floor, out of reach of the resident lying in bed.In room [ROOM NUMBER], the call light for the A bed was hanging on the wall, out of reach of the resident. The call light for the B bed was lying on the floor at the head of the bed, out of reach of the resident lying in bed.In room [ROOM NUMBER], the call light was lying on the floor out of the reach of the resident lying in bed.In room [ROOM NUMBER], the call light was hanging from the wall, out of reach of the resident lying in bed.In room [ROOM NUMBER], the call light was observed lying on the floor out of reach of the resident lying in bed.In room [ROOM NUMBER] , the resident was sitting up in the wheelchair between his bed and window, the call light was clipped to the privacy curtain out of reach of him. (photographic evidence obtained of all call lights)An interview was conducted with Resident #1 on 02/23/26 at 02;00 PM. The resident stated, I will press the call light button for assistance, sometimes no one comes, and there are times when they will come in turn off the light, then states I'll be right back. But they never come back. A lot of the times I will sit out in the hallway or at the nursing station to get someone to help me as they walk by. I see staff on their phones playing games. It takes the staff a while to answer my call light, it's been over 30 minutes and a couple of times an hour.An interview was conducted with Resident #7 on 2/23/26 at 11:00 AM. The resident stated, sometimes the staff doesn't even come when you turn your call light on, if they do come, it's too late and I have already soiled myself.An interview was then conducted with Resident #10, who stated, I have been waiting to get changed, they haven't come yet, I pressed my call light, they are shorthanded, it depends on the time of day on how long it takes them to answer the call light, usually more than 30-45 minutes. During the tour on 300 hallway on 2/23/26 at 11:27 AM, it was observed that a call light was turned on and making a beeping noise. Several staff members were observed sitting at the nurses' station desk, a nurse was standing at the end of the hallway next to the medication cart, and several staff members passed by the room with the call light on at 11:40 AM. At 11:45 AM, the nurse standing at the end of 300 hallway approached and stated, I don't want you to think I am ignoring the light, but I am trying to finish up some stuff before I go in the room, the resident wants her phone plugged in to charge.On 02/24/26 at 09:00 AM, a tour was completed and the rooms were monitored and observed for call lights in reach of residents. It was observed that the call lights from rooms 212, 215, 207, 208, 302, 303, 308, and 409 were lying on the floor out of the residents' reach while the residents were lying in bed.A record review was conducted of facility grievances on 2/23/26 at 1:30 pm. A resident council meeting was held on 11/28/25 with eight grievances filed by residents consisting of concerns including staff on their phones in the hallway and call lights not being answered in a timely manner. A resident council meeting was held on 12/31/25 had twelve grievances filed by residents with concerns with call lights not being answered in a timely manner and residents not being changed in a timely manner after incontinent episodes. A resident council meeting was conducted by facility on 1/31/26, with seven grievances filed by residents with concerns of call lights not being answered in a timely manner and residents are not being changed in a Residents Affected - Some 105543 Page 5 of 6 105543 02/24/2026 St Andrews Bay Skilled Nursing and Rehabilitation 2100 Jenks Ave Panama City, FL 32405

F 0919 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some timely manner after incontinent episodes. (photographic evidence obtained)An interview with the Social Services Director was performed on 02/24/2026 at 01:30 PM by phone. She stated there have been several grievances filed in regard to call lights not being answered in a timely manner, residents not being changed in a timely manner, and some staff issues. All of those have been addressed with education and audits for call lights. If it involved a staff member in particular nursing, the Director of Nursing (DON) handled that on a 1:1 interaction.An interview with the Director of Nurses (DON) was conducted on 2/24/26 at 02:00 PM. She stated yes there have been several grievances filed in regard to call lights and care not being given in a timely manner. But we have done training with the staff. We have done call light audits to ensure that they are being answered and interviewed residents to ensure that call lights were being answered. As far as the education and training for care not being done, I have spoken to the staff but did not do any formal training. I can't give you anything on paper to confirm that. Asked DON to explain what her expectations are of her staff and she stated, care should be done every two hours and as needed, more often if residents require it and call lights should be answered in a timely manner with 5-10 minutes. I have done education and training in the town hall meetings in regard to call lights. I also expect if the CNAs are tied up in a resident's room, I expect my managers and nurses to assist with answering call lights.On 2/24/26 at 10:15 AM, a review of facility policy titled Call Lights: Accessibility and Timely response date implemented 11/2020 date revised 7/19/22 reveals the purpose of this policy is to assure the facility is adequately equipped with a call at each residents bedside, toilet, and bathing facility to allow residents to call for assistance. All staff will be educated on the proper use of the resident call system, including how the system works and ensuring resident access to the call light. Staff will ensure the call light is within reach of resident and secured, as needed. The call system will be accessible to residents while in their bed, or other sleeping accommodations within the residents' room. 105543 Page 6 of 6