Inspection·February 25, 2026

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, interviews, and record reviews, the facility failed to implement and maintain accident?prevention interventions for 1 resident (Resident #1) who previously sustained a fall with major injury, resulting in the resident experiencing a second preventable injury. The facility did not follow the resident's updated care plan requiring two?person assistance for bed baths only and allowed the resident to be taken to the shower despite this restriction. This failure resulted in the resident sustaining a humerus fracture and placed the resident at continued risk for further avoidable harm. This deficient practice is cross?referenced to F0689 due to the facility's failure to provide adequate supervision and accident?prevention interventions. The findings include:A record review of Resident #1's chart on 02/25/2026 revealed that she had a right closed hip fracture and displaced hip following a fall from the bed on 09/29/2025. The facility reported the following corrective action after the incident: All bed baths for [Resident #1] are now conducted with two person assistAn interview and observation of Employee B, a Certified Nursing Assistant (CNA), on 02/25/2026 at 11:19 AM revealed that the facility uses a sticker system outside each resident's door to indicate the required level of assistance, with 1P meaning one?person assist and 2P meaning two?person assist. An observation of the sticker outside Resident #1's room indicated she requires a two?person assist.An interview with two of Resident #1's daughters on 02/25/2026 at 11:30 AM revealed that the resident had recently sustained an injury to her left shoulder, and an X?ray confirmed a humerus fracture. The resident's daughter stated that Resident #1 was able to describe the event, telling them, I was brought to the shower room, they pulled on my arm, and hurt me. They further explained that an investigator reviewed the incident and closed the case after determining the fracture was pathological and related to the resident's history of osteopenia. Following this event, the daughter reported attending a meeting where it was agreed that Resident #1 would receive bed baths only, with two staff assisting. A sign reading 2 person bed baths only was observed above Resident #1's bed, and the daughter confirmed it had been placed there after the September 2025 fall from the bed. The daughter stated that Resident #1 was complaining of shoulder pain 2 days before the x-ray and Employee D, a Licensed Practical Nurse (LPN), was made aware.A review of the Resident #1's Xray report for 01/05/2026 showed an acute left humeral fracture.An interview with Employee D on 02/25/2026 at 1:20 PM revealed that she notified the Nurse Practitioner in January about Resident #1's increased pain and subsequently received orders for an X?ray and additional pain medication. She further stated that after Resident #1's first injury, the facility revised its practice to require two?person assistance for bed baths for residents on hospice or those with limited mobility in bed.A review of Resident #1's revised care plan revealed that the following:09/30/2025 (After hip fracture)- The resident is dependent with staff of 2 persons for bathing/showering 3 times per week as tolerated and as necessary.10/02/2025- The resident is dependent with staff of 2 persons for bathing/showering 3 times per week as tolerated and as necessary. Cloth bed pad to be placed under the resident (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: 105552 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 105552 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/25/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sandy Ridge Center for Rehabilitation and Healing 5360 Glover Lane Milton, FL 32570 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)