Inspection·February 12, 2026

Florida State Department of Health <table><tr><td colspan="2">STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTIONS</td><td>(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 15506095</td><td>(X2) MULTIPLE CONSTRUCTION A. BUILDING B. WING</td><td colspan="2">(X3) DATE SURVEY COMPLETED 02/12/2026</td></tr><tr><td colspan="3">NAME OF PROVIDER OR SUPPLIER CORAL BAY AT PENSACOLA, LLC</td><td colspan="3">STREET ADDRESS, CITY, STATE, ZIP CODE 600 W GREGORY ST , PENSACOLA, Florida, 32502</td></tr><tr><td>(X4) ID PREFERRED TAG</td><td>SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION)</td><td>ID PREFERRED TAG</td><td>PROVIDER&#x27;S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)</td><td colspan="2">(X5) COMPLETION DATE</td></tr><tr><td>N0000</td><td>INITIAL COMMENTS</td><td>N0000</td><td></td><td colspan="2">03/12/2026</td></tr><tr><td rowspan="9">N0072 SS = E</td><td>An unannounced complaint survey for complaint numbers 2026001816, 2026001913, 2026001560, 2026001496, and 2026002075 at Coral Bay at Pensacola, a nursing home in Pensacola, FL. There were deficiencies noted during the survey.</td><td rowspan="4">N0072</td><td rowspan="4">This plan of correction does not constitute an admission or agreement by the provider of the truth or conclusions set forth in this statement of deficiencies. This plan of correction is prepared solely because it is required by state and federal law.</td><td rowspan="4" colspan="2">04/06/2026</td></tr><tr><td>Comprehensive Care Plans</td></tr><tr><td>CFR(s): 59A-4.109(2), FAC;</td></tr><tr><td>59A-4.109 FAC</td></tr><tr><td>(2) The nursing home licensee develop a comprehensive care plan for each resident that includes measurable objectives and timetables to meet a resident&#x27;s medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment. The care plan must describe the services that are to be furnished to attain or maintain the resident&#x27;s highest practicable physical, mental and social well-being. The care plan must be completed within 7 days after completion of the resident assessment.</td><td rowspan="4">N0072</td><td>Confabulation care plans for residents #9, 11,12, and 13 were revised between 2/13/26 and 3/9/26. Care plans were spot checked to ensure that they are accurate and documented in a resident-centered manner by MDS Coordinators and Social Services on 3/9/26. Any care plans found to affected by this alleged deficient practice were corrected.</td><td colspan="2">04/06/2026</td></tr><tr><td>This LICENSURE REQUIREMENT is NOT MET as evidenced by:</td><td rowspan="4">Re-education by the DON/Designee was completed with MDS Coordinators on 2/18/26 regarding developing comprehensive care plans. MDS Coordinators will review five care plans weekly to ensure they are accurate and comprehensive.</td><td rowspan="4" colspan="2">The results of the MDS Coordinator audits will be presented to the facility&#x27;s QA&amp;A Committee monthly by the DON. The results of the Social Services reviews will be presented to the facility&#x27;s QA&amp;A Committee monthly by the Social Services Director. The QA&amp;A Committee will determine the need for auditing beyond three months.</td></tr><tr><td>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)</td></tr><tr><td>The findings include:</td></tr><tr><td colspan="2">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 &quot;confabulation&quot; on the care plans (Confabulation is a neuropsychiatric symptom, often referred to as &quot;honest lying,&quot; where a person generates false or distorted memories without the intent to deceive. It is not a standalone medical</td></tr></table> Office of Primary Care and Health Systems Management STATE FORM Florida State Department of Health STATE FORM Florida State Department of Health <table><tr><td colspan="2">STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTIONS</td><td colspan="2">(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 15506095</td><td>(X2) MULTIPLE CONSTRUCTION A. BUILDING B. WING</td><td colspan="2">(X3) DATE SURVEY COMPLETED 02/12/2026</td></tr><tr><td colspan="3">NAME OF PROVIDER OR SUPPLIER CORAL BAY AT PENSACOLA, LLC</td><td colspan="4">STREET ADDRESS, CITY, STATE, ZIP CODE 600 W GREGORY ST , PENSACOLA, Florida, 32502</td></tr><tr><td>(X4) ID PREFERRED TAG</td><td>SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION)</td><td colspan="2">ID PREFERRED TAG</td><td colspan="2">PROVIDER&#x27;S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)</td><td>(X5) COMPLETION DATE</td></tr><tr><td>N0101 SS = E</td><td colspan="2">Continued from page 2 the resident; and individual resident care plans, including, but not limited to, prescribed services, service frequency and duration, and service goals. The records must be open to agency inspection. The licensee shall maintain clinical records on each resident in accordance with accepted professional standards and practices, which must be complete, accurately documented, readily accessible, and systematically organized. 59A-4.118(2) FAC Each medical record must contain sufficient information to clearly identify the resident, his or her diagnosis and treatment, and results. This LICENSURE REQUIREMENT is NOT MET as evidenced by: Based on observations, interviews, and record reviews, the facility failed to ensure a resident&#x27;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 =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</td><td>N0101</td><td colspan="2">Continued from page 2 Unit Managers also spot-checked ADL documentation on 2/20/26 to review for accuracy. Concerns were addressed as identified. Re-education was conducted by the DON/Designee with CNAs and was completed by 2/18/26 on accurate ADL documentation. Unit Managers will audit ADL documentation for five residents weekly to ensure medical records are accurate. The results of these audits will be presented to the facility&#x27;s QA&amp; Committee monthly by the Director of Nursing. The QA&amp; Committee will determine the need for further auditing beyond three months.</td><td></td></tr></table> STATE FORM Florida State Department of Health STATE FORM Florida State Department of Health <table><tr><td colspan="2">STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTIONS</td><td colspan="2">(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 15506095</td><td>(X2) MULTIPLE CONSTRUCTION A. BUILDING B. WING</td><td colspan="2">(X3) DATE SURVEY COMPLETED 02/12/2026</td></tr><tr><td colspan="3">NAME OF PROVIDER OR SUPPLIER CORAL BAY AT PENSACOLA, LLC</td><td colspan="4">STREET ADDRESS, CITY, STATE, ZIP CODE 600 W GREGORY ST , PENSACOLA, Florida, 32502</td></tr><tr><td>(X4) ID PREFERRED TAG</td><td>SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION)</td><td>ID PREFERRED TAG</td><td colspan="3">PROVIDER&#x27;S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)</td><td>(X5) COMPLETION DATE</td></tr><tr><td>N0202 SS = D</td><td colspan="2">Continued from page 4 (m) The right to have privacy in treatment and in caring for personal needs; to close room doors and to have facility personnel knock before entering the room, except in the case of an emergency or unless medically contraindicated; and to security in storing and using personal possessions. Privacy of the resident&#x27;s body shall be maintained during, but not limited to, toileting, bathing, and other activities of personal hygiene, except as needed for resident safety or assistance. Residents&#x27; personal and medical records shall be confidential and exempt from the provisions of s. 119.07(1). This LICENSURE REQUIREMENT is NOT MET as evidenced by: Based on interviews and record review, the facility failed to ensure the protection of residents&#x27; 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&#x27;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&#x27;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&#x27;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&#x27;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</td><td>N0202</td><td colspan="3">Continued from page 4 solely because it is required by state and federal law. Images of Resident #2 was deleted from personal devices on 1/20/26. Staff A and Staff L received education on 2/18/26 regarding videotaping, photographing, and other imaging of residents. Unit Managers conducted staff interviews on 2/18/26 to regarding facility&#x27;s videotaping and photography policy and to ensure no staff were taking photographs or videos of residents. No concerns were noted. Re-education was completed with staff on 2/18/26 regarding videotaping or photographing residents during care by the DON/Designee. New staff will receive this education during orientation. Unit Managers/designee will conduct 3 random staff interviews weekly to ensure privacy is being provided to residents with regard to videotaping and photography. The results of these audits will be reported to the QA&amp;A Committee monthly by the Director of Nursing. The QA&amp;A Committee will determine the need for auditing beyond three months.</td></tr></table> STATE FORM Florida State Department of Health STATE FORM Florida State Department of Health <table><tr><td colspan="2">STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTIONS</td><td colspan="2">(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 15506095</td><td>(X2) MULTIPLE CONSTRUCTION A. BUILDING B. WING</td><td colspan="2">(X3) DATE SURVEY COMPLETED 02/12/2026</td></tr><tr><td colspan="3">NAME OF PROVIDER OR SUPPLIER CORAL BAY AT PENSACOLA, LLC</td><td colspan="4">STREET ADDRESS, CITY, STATE, ZIP CODE 600 W GREGORY ST, PENSACOLA, Florida, 32502</td></tr><tr><td>(X4) ID PREFERRED TAG</td><td>SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION)</td><td>ID PREFERRED TAG</td><td colspan="3">PROVIDER&#x27;S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)</td><td>(X5) COMPLETION DATE</td></tr><tr><td>N0202 N0241B SS = G</td><td colspan="2">Health and Safety of Resident CFR(s): 400.102(1), FS In addition to the grounds listed in part II of chapter 408, any of the following conditions shall be grounds for action by the agency against a licensee: (1) An intentional or negligent act materially affecting the health or safety of residents of the facility: This LICENSURE REQUIREMENT is NOT MET as evidenced by: 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 witnesses 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&#x27;s room on 12/23/2025. A review of Resident #6&#x27;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&#x27;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</td><td>N0202 N0216</td><td colspan="2">This plan of correction does not constitute an admission or agreement by the provider of the truth or conclusions set forth in this statement of deficiencies. This plan of correction is prepared solely because it is required by state and federal law. Resident #1 expired 2/15/26. Resident #6 had a room changed completed on 2/6/26. There have been no issues reported. The IDT team reviewed roommate compatibility on 2/17/26. Any resident or staff expressing issues with/between roommates were addressed immediately. Facility&#x27;s monitoring of roommate compatibility will be on-going. Re-education was completed by the Administrator/Designee on 3/8/26 with licensed nurses regarding reporting concerns with roommate compatibility. The Administrator and IDT team will review room changes weekly ensure room changes are appropriate. The results of these reviews and audits will be presented to the facility&#x27;s Q&amp;A Committee monthly by the Administrator. The Q&amp;A Committee will determine the need for further auditing beyond three months.</td><td>04/06/2026</td></tr></table> STATE FORM Florida State Department of Health <table><tr><td colspan="2">STATEMENT OF DEFICIENCIESAND PLAN OF CORRECTIONS</td><td colspan="2">(X1) PROVIDER/SUPPLIER/CLIAIDENTIFICATION NUMBER:15506095</td><td>(X2) MULTIPLE CONSTRUCTIONA. BUILDINGB. WING</td><td colspan="2">(X3) DATE SURVEY COMPLETED02/12/2026</td></tr><tr><td colspan="3">NAME OF PROVIDER OR SUPPLIERCORAL BAY AT PENSACOLA, LLC</td><td colspan="4">STREET ADDRESS, CITY, STATE, ZIP CODE600 W GREGORY ST , PENSACOLA, Florida, 32502</td></tr><tr><td>(X4) IDPREFIXTAG</td><td colspan="2">SUMMARY STATEMENT OF DEFICIENCIES(EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION)</td><td>IDPREFIXTAG</td><td colspan="2">PROVIDER&#x27;S PLAN OF CORRECTION(EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)</td><td>(X5) COMPLETIONDATE</td></tr><tr><td>NO216SS = G</td><td colspan="2">Continued from page 7mouth, 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 alterations 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&#x27;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&#x27;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&#x27;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&#x27;s room change was initiated by the facility after Resident #1 sustained unanticipated 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&#x27;s assessment, it was believed that the injuries were consistent with contact from the bed side rails and that the injury</td><td>N0216</td><td></td><td></td><td></td></tr></table> STATE FORM Florida State Department of Health STATE FORM