Inspection·April 15, 2026

Office of Primary Care and Health Systems Management STATE FORM STATE FORM <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>(X3) DATE SURVEY COMPLETED 02/03/2026</td></tr><tr><td colspan="3">NAME OF PROVIDER OR SUPPLIER CORAL BAY AT PENSACOLA, LLC</td><td colspan="2">STREET ADDRESS, CITY, STATE, ZIP CODE 600 W GREGORY ST, PENSACOLA, Florida, 32502</td></tr><tr><td>(X4) IDprefixTAG</td><td>SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION)</td><td>IDprefixTAG</td><td>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>N0914 SS = G</td><td></td><td>N0914</td><td>Continued from page 2 will determine the need for auditing beyond three months:</td><td></td></tr><tr><td rowspan="3">N0110 SS = F</td><td>Physical Environment - Safe, Clean, Homelike CFR(s): 400.141(1)(h) FS; 59A-4.122(1) FAC 400.141(1)(h) FS</td><td>N0110</td><td>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></td></tr><tr><td>Maintain the facility premises and equipment and conduct its operations in a safe and sanitary manner. 59A-4.122(1) FAC</td><td>The sprinklers identified by facility&#x27;s vendor were replaced on 1/22/2026. The facility is working with vendors and the county utilities authority to correct the issue with the fire pump. The facility started a fire watch on 1/12/2026, and this remains ongoing. Staff who perform fire watch duties are educated first on their role and responsibilities. Fire watch staff have been educated on the use of a fire extinguisher and emergency response by the Director of Nursing. The Maintenance Supervisor monitors fire watch checks daily to ensure compliance. The wash basins, bedside commode basin, urinal, and toilet hat were removed and replaced from the bathroom in room 306/308 on 1/15/26. The trash bag in the bathroom of room 306/308 was brought to the soiled utility room. Items kept in the bathroom of room 306/308 were appropriately stored and labeled. A fire report was sent to the state agency by the Administrator on 1/18/26 for the incident that occurred on 12/24/2025.</td><td></td><td></td></tr><tr><td>Based upon record review and interview, it was determined that the immediacy of this citation has been removed. The findings include: A review of documentation verified that the facility has implemented a Fire Watch 24 hours a day that covers all areas. Review of training logs verified that the staff have received education on Fire Watch procedures, proper use of fire extinguishers, evacuation protocols and have participated in fire drills. The Fire Watch log and the invoice from the sprinkler heads replacement were reviewed. Additionally, all smoking materials have been removed from residents&#x27; rooms, and a new smoking policy has been implemented. Interviews were conducted with 5 staff members regarding fire watch protocol. The staff members were able to confirm they received training about the responsibilities of staff members performing fire watch duties. An observation of fire watch was conducted with 1 staff member. No concerns were identified at this time. Based upon these findings, it was determined that the immediacy had been abated and the severity/scope of this finding was reduced from an L to an F.</td><td>The Administrator reviewed reports from Life Safety vendors on 1/19/26 to ensure no other repairs were needed to Life Safety equipment. No other concerns were noted. The Administrator also reviewed physical plant incidents from the last three months on 2/18/26 to determine if any incidents needed to be reported to the state agency. No further physical plant incidents were identified. Unit Managers conducted rounds in resident rooms and bathrooms on 1/15/26 to ensure personal care items were stored properly. Issues were addressed as they were observed. Facility staff received education from the DON/Designee on fire watch procedures, individual roles and responsibilities during an emergency, use of a fire extinguisher, and emergency response for resident safety. This education was completed by 1/15/26. The Life Safety Consultant educated the Maintenance Supervisor and Administrator on 1/12/26 on fire incident reporting and maintaining</td><td></td><td></td></tr></table> STATE FORM STATE FORM <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 02/03/2026</td></tr><tr><td colspan="4">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) 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) COMPLETION DATE</td></tr><tr><td>N0204SS = F</td><td colspan="2">Continued from page 4 shall set forth in writing the circumstances requiring the use of restraint, and, in the case of use of a chemical restraint, a physician shall be consulted immediately thereafter. Restraints may not be used in lieu of staff supervision or merely for staff convenience, for punishment, or for reasons other than resident protection or safety. This LICENSURE REQUIREMENT IS NOT MET as evidenced by: Based on observations, interviews and record reviews, the facility implemented a facility-wide in-service and education on abuse and neglect, including a review of applicable policies. The process for reporting abuse was reviewed by the staff who demonstrated understanding during interviews. Staff members identified as alleged perpetrators were terminated or suspended in response to the allegations. Additionally, the facility conducted facility-wide interviews with all residents and completed skin assessments. Weekly resident council meetings were also held. 5 staff interviews were held. All staff were familiar with their duties in reporting any suspected abuse or neglect. Based upon these findings, it was determined that the immediacy had been abated and the severity/scope of this finding was reduced from an L to an F.</td><td>N0204</td><td>Continued from page 4psych services and receives supportive visits from Social Services.The Administrator reviewed reports from Life Safety vendors on 1/19/26 to ensure no other repairs were needed to Life Safety equipment. No other concerns were noted. Resident interviews were conducted on 1/21/26 to determine if any other residents had allegations of abuse or neglect. Allegations that rose to the level of abuse or neglect were reported.Facility staff received education from the DON/Designee on fire watch procedures, individual roles and responsibilities during an emergency, use of a form extinguisher, and emergency response for resident safety. This educator was compared by 1/15/26. The Life Safety Consultant educated the Maintenance Supervisor and Administrator on 1/12/26 on maintaining the facility&#x27;s sprinkler and fire pump systems. The Healthcare Risk Manager initiated education for facility staff including the Administrator, Director of Nursing, and the Governing Body on sprinkler system impairments that require reporting, as well as the abuse and neglect policy, protection requirements, and reporting requirements for abuse or neglect. This was completed on 1/20/2026. Facility staff were educated on the Abuse and Neglect policy, which included identifying types of abuse and reporting, including sexual abuse. This education was completed on 1/21/26. New employees will receive this education during orientation, and agency nurses will be educated prior to working their first shift. Fire drills will be held three times a month, one on each shift, to ensure staff respond appropriately. The Administrator will review reports from Life Safety vendors monthly as available to ensure repairs are performed as needed. The Risk Manager will review incidents and grievances weekly to determine if there are any allegations of abuse or neglect. If allegations are made, they will be investigated and reported per regulation. The Administrator will review reportable incidents weekly to ensure they are reported timely.The results of the fire drills and fire watches will be reported to the facility&#x27;s Q&amp;A Committee by the Maintenance Director monthly. The results of the reviews of Life Safety vendor reports will be reported to the facility&#x27;s Q&amp;A Committee monthly by the Administrator. The results of grievance and incident reviews will be reported to the Q&amp;A Committee monthly by the Risk Manager. The results of</td><td></td><td></td></tr></table> STATE FORM <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>(X3) DATE SURVEY COMPLETED 02/03/2026</td></tr><tr><td colspan="4">NAME OF PROVIDER OR SUPPLIER CORAL BAY AT PENSACOLA, LLC</td><td colspan="2">STREET ADDRESS, CITY, STATE, ZIP CODE 600 W GREGORY ST, PENSACOLA, Florida, 32502</td></tr><tr><td>(X4) IDprefix TAG</td><td colspan="2">SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION)</td><td>IDprefix TAG</td><td>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>N0204 SS = F</td><td colspan="2"></td><td>N0204</td><td>Continued from page 5 reportable incident review will be reported to the Q&amp;A Committee monthly by the Administrator. The Q&amp;A Committee will determine the need for auditing beyond three months.</td><td>04/15/2026</td></tr><tr><td>N0901 SS = F</td><td colspan="2">Risk Mgmt &amp; Q A Program Required CFR(s): 400.147(1), FS Every facility shall, as part of its administrative functions, establish an internal risk management and quality assurance program, the purpose of which is to assess resident care practices; review facility quality indicators, facility incident reports, deficiencies cited by the agency, and resident grievances; and develop plans of action to correct and respond quickly to identified quality deficiencies. The program must include: This LICENSURE REQUIREMENT is NOT MET as evidenced by: Based upon record reviews and interviews, the facility was able to abate the immediacy of the citation. The findings include: Based on interviews and records review, the facility incorporated data-driven Quality Assurance and Performance Improvement (QAPI) into their program that focuses of all areas of deficiencies to improve the outcome of care. The Committee and the Governing Body (GB) conduct weekly meetings to review facility processes and monitor compliance. Additionally, a Project Improvement Plan (PIP) was implemented titled: &quot;4 Points Action Plan&quot; Based upon these findings, it was determined that the immediacy had been abated and the severity/scope of this finding was reduced from an L to an F.</td><td>N0901</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. Ad-hoc QAPI meetings were held with the Q&amp;A Committee, including the medical director, on 1/13/26 and 1/19/26 to discuss all areas of alleged non-compliance. A QAPI plan was implemented on 1/19/26 that addressed a safe resident environment. The sprinklers identified by the facility&#x27;s vendor were replaced on 1/22/2026. The facility is working with vendors and the county utilities authority to correct the issue with the fire pump. The facility started a fire watch on 1/12/2026, and this remains ongoing. Staff who perform fire watch duties are educated first on their role and responsibilities. Fire watch staff have been educated on the use of a fire extinguisher and emergency response by the Director of Nursing. The Maintenance Supervisor monitors fire watch checks daily to ensure compliance. A fire report was sent to the state agency by the Administrator on 1/18/26 for the incident that occurred on 12/24/2025. The Administrator reviewed reports from Life Safety vendors on 1/19/26 to ensure no other repairs were needed to Life Safety equipment. No other concerns were noted. The Administrator also reviewed physical plant incidents from the last three months on 2/18/26 to determine if any incidents needed to be reported to the state agency. One physical plant incident was identified. The incident occurred on 2/5/26 and was reported to AHCA and Fire Dept. QAPI meetings are being held weekly to discuss the progress of the performance improvement plan. Governing Body members received education from the Healthcare Risk Management consultant on 1/20/2026 for incident reporting, sprinkler system impairments that require reporting, fire watch initiation, and QAPI oversight expectations. Facility staff received education from the DON/Designee on fire watch procedures, individual roles and responsibilities during an emergency, use of a fire extinguisher, and emergency response for resident</td></tr></table> STATE FORM STATE FORM STATE FORM STATE FORM STATE FORM STATE FORM STATE FORM <table><tr><td colspan="2">STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTIONS</td><td colspan="2">(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 108051</td><td>(X2) MULTIPLE CONSTRUCTION A. BUILDING B. WING</td><td colspan="2">(X3) DATE SURVEY COMPLETED 02/03/2026</td></tr><tr><td colspan="4">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 colspan="2">SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION)</td><td>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>F0584 SS = SQC-F</td><td colspan="2">Continued from page 1$483.10(i)(1)A safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belongings to the extent possible.(i) This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk.(ii) The facility shall exercise reasonable care for the protection of the resident&#x27;s property from loss or theft.$483.10(i)(2) Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior; $483.10(i)(3) Clean bed and bath linens that are in good condition; $483.10(i)(4) Private closet space in each resident room, as specified in $483.90 (e)(2)(iv); $483.10(i)(5) Adequate and comfortable lighting levels in all areas; $483.10(i)(6) Comfortable and safe temperature levels. Facilities initially certified after October 1, 1990 must maintain a temperature range of 71 to 81°F; and $483.10(i)(7) For the maintenance of comfortable sound levels. This REQUIREMENT is NOT MET as evidenced by: Based upon record review and interview, it was determined that the immediacy of this citation has been removed. The findings include: A review of documentation verified that the facility has implemented a Fire Watch 24 hours a day that covers all areas. Review of training logs verified that the staff have received education on Fire Watch procedures, proper use of fire extinguishers, evacuation protocols and have participated in fire drills. The Fire Watch log and the invoice from the sprinkler heads replacement were reviewed.</td><td>F0584</td><td>Continued from page 1Staff who perform fire duty duties are educated first on their role and responsibilities. Fire watch staff have been educated on the use of a fire extinguisher and emergency response by the Director of Nursing. The Maintenance Supervisor monitors fire watch checks daily to ensure compliance. The wash basins, bedside commode basin, urinal, and toilet hat were removed and replaced from the bathroom in room 306/308 on 1/15/26. The trash bag in the bathroom of room 306/308 was brought to the soiled utility room. Items kept in the bathroom of room 306/308 were appropriately stored and labeled. A fire report was sent to the state agency by the Administrator on 1/18/26 for the incident that occurred on 12/24/2025.The Administrator reviewed reports from Life Safety vendors on 1/19/26 to ensure no other repairs were needed to Life Safety equipment. No other concerns were noted. The Administrator also reviewed physical plant incidents from the last three months on 2/18/26 to determine if any incidents needed to be reported to the state agency. One physical plant incident was identified. The incident occurred on 2/5/26 and was reported to AHCA and Fire Dept. Unit Managers conducted rounds in resident rooms and bathrooms on 1/15/26 to ensure personal care items were stored properly. Issues were addressed as they were observed.Facility staff received education from the DON/Designee on fire watch procedures, individual roles and responsibilities during emergency, use of a fire extinguisher, and emergency response for resident safety. This education was completed by 1/15/26. The Life Safety Consultant educated the Maintenance Supervisor and Administrator on 1/12/26 on fire incident reporting and maintaining the facility&#x27;s sprinkler and fire pump systems. The Administrator and DON were educated by the Healthcare Risk Management Consultant on 1/19/26 on resident rights to a safe environment. Education was completed with nursing staff by 2/18/26 on proper storage of personal care items by the DON/Designee. New employees will receive this education during orientation, and agency nurses will be educated prior to working their first shift. Fire drills will be held three times a month, one on each shift, to ensure staff respond appropriately. The Administrator will review reports from Life Safety vendors monthly as available to ensure repairs are performed as needed. The Administrator will also review physical plant incidents monthly to ensure</td><td></td><td></td></tr></table> <table><tr><td colspan="2">STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTIONS</td><td colspan="2">(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 108051</td><td>(X2) MULTIPLE CONSTRUCTION A. BUILDING B. WING</td><td colspan="2">(X3) DATE SURVEY COMPLETED 02/03/2026</td></tr><tr><td colspan="4">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 PRIX TAG</td><td colspan="2">SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION)</td><td>ID PRIX 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>F0584 SS = SQC-F</td><td colspan="2">Continued from page 2 Additionally, all smoking materials have been removed from residents&#x27; rooms, and a new smoking policy has been implemented. Interviews were conducted with 5 staff members regarding fire watch protocol. The staff members were able to confirm they received training about the responsibilities of staff members performing fire watch duties. An observation of fire watch was conducted with 1 staff member. No concerns were identified at this time. Based upon these findings, it was determined that the immediacy had been abated and the severity/scope of this finding was reduced from an L to an F.</td><td>F0584</td><td colspan="2">Continued from page 2 reports are made to the state agency as required. Unit Managers will audit ten resident rooms/bathrooms weekly to ensure personal care items are stored properly. The results of the fire drills and fire watches will be reported to the facility&#x27;s QA&amp;A Committee by the Maintenance Director monthly. The results of the reviews of Life Safety vendor reports and physical plant incidents will be reported to the facility&#x27;s QA&amp;A Committee monthly by the Administrator. The results of the Unit Manager audits will be presented 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><td>04/15/2026</td></tr><tr><td>F0600 SS = SQC-F</td><td colspan="2">Free from Abuse and Neglect CFR(s): 483.12(a)(1) $483.12 Freedom from Abuse, Neglect, and Exploitation The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident&#x27;s medical symptoms. $483.12(a) The facility must- $483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion; This REQUIREMENT is NOT MET as evidenced by: Based on interviews, observations, and record reviews, the facility implemented corrective actions to abate the immediacy of this issue. The findings include: Based on observations, interviews and record reviews, the facility implemented a facility-wide in-service and education on abuse and neglect, including a review of applicable policies. The process for reporting abuse was reviewed by the staff who demonstrated understanding during</td><td>F0600</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. The sprinklers identified by facility&#x27;s vendor were replaced on 1/22/2026. The facility is working with vendors and the county utilities authority to correct the issue with the fire pump. The facility started a fire watch on 1/12/2026, and this remains ongoing. Staff who perform fire watch duties are educated first on their role and responsibilities. Fire watch staff have been educated on the use of a fire extinguisher and emergency response by the Director of Nursing. The Maintenance Supervisor monitors fire watch checks daily to ensure compliance. One and five-day federal abuse reports were submitted for Resident #205. The allegation of abuse was investigated, and the allegation was reported to the Department of Health, DCF, and the police department. Resident #205 is being seen by psych services and receives supportive visits from Social Services. The Administrator reviewed reports from Life Safety vendors on 1/19/26 to ensure no other repairs were needed to Life Safety equipment. No other concerns were noted. Resident interviews were conducted on 1/21/26 to determine if any other residents had allegations of abuse or neglect. Allegations that rose to the level of abuse or neglect were reported.</td><td>04/15/2026</td></tr></table> <table><tr><td colspan="2">STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTIONS</td><td colspan="2">(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 108051</td><td>(X2) MULTIPLE CONSTRUCTION A. BUILDING B. WING</td><td colspan="2">(X3) DATE SURVEY COMPLETED 02/03/2026</td></tr><tr><td colspan="4">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 colspan="2">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>F0600 SS = SQC-F</td><td>Continued from page 3 interviews. Staff members identified as alleged perpetrators were terminated or suspended in response to the allegations. Additionally, the facility conducted facility-wide interviews with all residents and completed skin assessments. Weekly resident council meetings were also held. 5 staff interviews were held. All staff were familiar with their duties in reporting any suspected abuse or neglect. Based upon these findings, it was determined that the immediacy had been abated and the severity/scope of this finding was reduced from an L to an F.</td><td>F0600</td><td colspan="2">Continued from page 3Facility staff received education from the DON/Designee on fire watch procedures, individual roles and responsibilities during an emergency, use of a fire extinguisher, and emergency response for resident safety. This education was completed by 1/15/26. The Life Safety Consultant educated the Maintenance Supervisor and Administrator on 1/12/26 on maintaining the facility&#x27;s sprinkler and fire pump systems. The Healthcare Risk Manager initiated education for facility staff including the Administrator, Director of Nursing, and the Governing Body on sprinkler system impairments that require reporting, as well as the abuse and neglect policy, protection requirements, and reporting requirements for abuse or neglect. This was completed on 1/20/2026. Facility staff were educated on the Abuse and Neglect policy, which included identifying types of abuse and reporting, including sexual abuse. This education was completed on 1/21/26. New employees will receive this education during orientation, and agency nurses will be educated prior to working their first shift. Fire drills will be held three times a month, one on each shift, to ensure staff respond appropriately. The Administrator will review reports from Life Safety vendors monthly as available to ensure repairs are performed as needed. The Risk Manager will review incidents and grievances weekly to determine if there are any allegations of abuse or neglect. If allegations are made, they will be investigated and reported per regulation. The Administrator will review reportable incidents weekly to ensure they are reported timely. The results of the fire drills and fire watches will be reported to the facility&#x27;s QA&amp;AA Committee by the Maintenance Director monthly. The results of the reviews of Life Safety vendor reports will be reported to the facility&#x27;s QA&amp;AA Committee monthly by the Administrator. The results of grievance and incident reviews will be reported to the QA&amp;AA Committee monthly by the Risk Manager. The results of reportable incident review will be reported to the QA&amp;AA Committee monthly by the Administrator. The QA&amp;AA Committee will determine the need for auditing beyond three months.</td><td>04/15/2026</td><td></td></tr><tr><td>F0835 SS = F</td><td>Administration CFR(s): 483.70 §483.70 Administration. A facility must be administered in a manner that enables it to use its resources effectively and</td><td>F0835</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.</td><td>04/15/2026</td><td></td></tr></table> <table><tr><td colspan="2">STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTIONS</td><td colspan="2">(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 108051</td><td>(X2) MULTIPLE CONSTRUCTION A. BUILDING B. WING</td><td colspan="2">(X3) DATE SURVEY COMPLETED 02/03/2026</td></tr><tr><td colspan="4">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) 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) COMPLETION DATE</td></tr><tr><td>F0835 SS = F</td><td colspan="2">Continued from page 4 efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. This REQUIREMENT is NOT MET as evidenced by: Based on observations, interviews, and record reviews, the facility removed the immediacy of the finding. The findings include: The facility retained a risk manager and a nurse consultant who provided education to the administration on risk management, patient&#x27;s rights, prevention of abuse and neglect. The Administration demonstrated appropriate and timely actions taken to ensure the well-being and safety of the residents. They have provided education to the staff conducted a facility-wide interviews with residents to assess their well-being. Based upon these findings, it was determined that the immediacy had been abated and the severity/scope of this finding was reduced from an L to an F.</td><td>F0835</td><td colspan="2">Continued from page 4 The sprinklers identified by facility&#x27;s vendor were replaced on 1/22/2026. The facility is working with vendors and the county utilities authority to correct the issue with the fire pump. The facility started a fire watch on 1/12/2026, and this remains ongoing. Staff who perform fire watch duties are educated first on their role and responsibilities. Fire watch staff have been educated on the use of a fire extinguisher and emergency response by the Director of Nursing. The Maintenance Supervisor monitors fire watch checks daily to ensure compliance. One and five-day federal abuse reports were submitted for Resident #205. The allegation of abuse was investigated, and the allegation was reported to the Department of Health, DCF, and the police department. Resident #205 is being seen by psych services and receives supportive visits from Social Services. A contract was signed with a consulting company on 2/14/20 to provide an Administrator Consultant for virtual and on-site support. The Administrator reviewed reports from Life Safety vendors on 1/19/26 to ensure no other repairs were needed to Life Safety equipment. No additional concerns were noted. Resident interviews were conducted on 2/17/26 to determine if any other residents had allegations of abuse or neglect. Allegations that rose to the level of abuse or neglect were reported. The Risk Manager Consultant provided training to the Administrator on 1/19/2026 on the following topics: QAPI requirements, the QAPI program and plan components including development of a Performance Improvement Plan, providing a safe resident environment, fire watch, abuse and neglect, sexual abuse allegations, and corrective action plans to implement and evaluate performance improvement efforts. The Administrator Consultant&#x27;s first onsite visit occurred on 1/19/26. Ad-hoc QAPI meetings were held with the Q&amp;A Committee, including the medical director, on 1/13/26 and 1/19/26 to discuss all areas of alleged non-compliance. A performance improvement plan was developed by the Q&amp;A Committee. The Administrator Consultant will continue to make routine visits to the facility for support and training. The performance improvement plans will be discussed by the Administrator during monthly Q&amp;A meetings. The results of the fire drills and fire watches will be reported to the facility&#x27;s Q&amp;A</td><td>04/15/2026</td></tr></table> <table><tr><td colspan="2">STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTIONS</td><td colspan="2">(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 106051</td><td>(X2) MULTIPLE CONSTRUCTION A. BUILDING B. WING</td><td>(X3) DATE SURVEY COMPLETED 02/03/2026</td><td></td></tr><tr><td colspan="4">NAME OF PROVIDER OR SUPPLIER CORAL BAY AT PENSACOLA, LLC</td><td colspan="2">STREET ADDRESS, CITY, STATE, ZIP CODE 600 W GREGORY ST, PENSACOLA, Florida, 32502</td><td></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) COMPLETION DATE</td></tr><tr><td>F0836SS = F</td><td>Continued from page 6The findings include:Based on interviews and record reviews, the facility took actions to bring deficiencies to compliance with safety State regulations by implementing a Fire Watch, reporting all issues to the appropriate state agencies, and starting repairs on the facility&#x27;s fire suppression system. Based upon these findings, it was determined that the immediacy had been abated and the severity/scope of this finding was reduced from an L to an F.</td><td>F0836</td><td>Continued from page 6vendors monthly as available to ensure repairs are performed as needed.The performance improvement plans will be discussed by the Administrator during monthly Q&amp;A meetings. The results of the fire drills and fire watches will be reported to the facility&#x27;s Q&amp;A Committee by the Maintenance Director monthly. The results of the reviews of Life Safety vendor reports will be reported to the facility&#x27;s Q&amp;A Committee monthly by the Administrator. The Q&amp;A Committee will determine the need for further reporting beyond three months.</td><td>04/15/2026</td><td></td><td></td></tr><tr><td>F0837SS = F</td><td>Governing BodyCFR(s): 483.70(d)(1)-(3)§483.70(d) Governing body.§483.70(d)(1) The facility must have a governing body, or designated persons functioning as a governing body, that is legally responsible for establishing and implementing policies regarding the management and operation of the facility; and§483.70(d)(2) The governing body appoints the administrator who is:(i) Licensed by the State, where licensing is required;(ii) Responsible for management of the facility; and(iii) Reports to and is accountableable to the governing body.§483.70(d)(3) The governing body is responsible and accountable for the QAPI program, in accordance with §483.75(f).This REQUIREMENT is NOT MET as evidenced by:Based upon interviews and record reviews, the facility was able to abate the immediacy of the issue.The findings include:Per record reviews and interviews, the facility&#x27;s Administrator reports to the Governing Body on a weekly basis to establish and implement actions and policies regarding the management of the facility and remain active and engage in the process.</td><td>F0837</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.The sprinklers identified by the facility&#x27;s vendor were replaced on 1/22/2026. The facility is working with vendors and the county utilities authority to correct the issue with the fire pump. The facility started a fire watch on 1/12/2026, and this remains ongoing. Staff who perform fire watch duties are educated first on their role and responsibilities. Fire watch staff have been educated on the use of a fire extinguisher and emergency response by the Director of Nursing. The Maintenance Supervisor monitors fire watch checks daily to ensure compliance. The Governing Body hired an outside consulting company to provide training and support to facility staff, including the Administrator.The Administrator reviewed reports from Life Safety vendors on 1/19/26 to ensure no other repairs were needed to Life Safety equipment. No additional concerns were noted.Governing Body members received education from the Healthcare Risk Management consultant on 1/20/2026 for incident reporting, sprinkler system impairments that require reporting, fire watch initiation, and QAPI oversight expectations. Facility staff received education from the DON/Designee on fire watch procedures, individual roles and responsibilities during an emergency, use of a fire extinguisher, and emergency response for resident safety. This education was completed by 1/15/26. The Life Safety Consultant educated the Maintenance</td><td>04/15/2026</td><td></td></tr></table> <table><tr><td colspan="2">STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTIONS</td><td>(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 106051</td><td>(X2) MULTIPLE CONSTRUCTION A. BUILDING B. WING</td><td colspan="2">(X3) DATE SURVEY COMPLETED 02/03/2026</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 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>F0837 SS = F</td><td>Continued from page 7 Based upon these findings, it was determined that the immediacy had been abated and the severity/scope of this finding was reduced from an L to an F.</td><td>F0837</td><td colspan="2">Continued from page 7 Supervisor and Administrator on 1/12/26 on maintaining the facility&#x27;s sprinkler and fire pump systems. New employees will receive this education during orientation, and agency nurses will be educated prior to working their first shift. A contract was signed with a consulting company on 1/14/26 to provide an Administrator Consultant for virtual and on-site support. The Administrator Consultant&#x27;s first onsite visit occurred on 1/19/26. The Administrator Consultant will continue to make routine visits to the facility for support and training. Fire drills will be held three times a month, one on each shift, to ensure staff respond appropriately. The Administrator will review reports from Life Safety vendors monthly as available to ensure repairs are performed as needed. The results of the fire drills and fire watches will be reported to the facility&#x27;s QA&amp;A Committee by the Maintenance Director monthly. The results of the reviews of Life Safety vendor reports will be reported to the facility&#x27;s QA&amp;A Committee monthly by the Administrator. The QA&amp;A Committee will determine the need for further reporting beyond three months.</td><td>04/15/2026</td></tr><tr><td>F0865 SS = F</td><td>QAPI Prgm/Plan, Disclosure/Good Faith Attempt CFR(s): 483.75(a)(1)-(4)(b)(1)-(4)(f)(1)-(6)(h)(i) $483.75(a) Quality assurance and performance improvement (QAPI) program. Each LTC facility, including a facility that is part of a multiunit chain, must develop, implement, and maintain an effective, comprehensive, data-driven QAPI program that focuses on indicators of the outcomes of care and quality of life. The facility must: $483.75(a)(1) Maintain documentation and demonstrate evidence of its ongoing QAPI program that meets the requirements of this section. This may include but is not limited to systems and reports demonstrating systematic identification, reporting, investigation, analysis, and prevention of adverse events; and documentation demonstrating the development, implementation, and evaluation of corrective actions or performance improvement activities; $483.75(a)(2) Present its QAPI plan to the State Survey Agency no later than 1 year after the promulgation of this regulation;</td><td>F0865</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. Ad-hoc QAPI meetings were held with the QA&amp;A Committee, including the medical director, on 1/13/26 and 1/19/26 to discuss all areas of alleged non-compliance. A QAPI plan was implemented on 1/19/26 that addressed a safe resident environment. The sprinklers identified by the facility&#x27;s vendor were replaced on 1/22/2026. The facility is working with vendors and the county utilities authority to correct the issue with the fire pump. The facility started a fire watch on 1/12/2026, and this remains ongoing. Staff who perform fire watch duties are educated first on their role and responsibilities. Fire watch staff have been educated on the use of a fire extinguisher and emergency response by the Director of Nursing. The Maintenance Supervisor monitors fire watch checks daily to ensure compliance. A fire report was sent to the state agency by the Administrator on 1/18/26 for the incident that occurred on 12/24/2025. The Administrator reviewed reports from Life Safety</td><td>04/15/2026</td></tr></table> <table><tr><td colspan="2">STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTIONS</td><td colspan="2">(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 106051</td><td>(X2) MULTIPLE CONSTRUCTION A. BUILDING B. WING</td><td colspan="2">(X3) DATE SURVEY COMPLETED 02/03/2026</td><td></td></tr><tr><td colspan="4">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><td></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) COMPLETION DATE</td><td></td></tr><tr><td>F0865SS = F</td><td colspan="3">Continued from page 9$483.75(f)(2) The QAPI program is sustained during transitions in leadership and staffing;$483.75(f)(3) The QAPI program is adequately resourced, including ensuring staff time, equipment, and technical training as needed;$483.75(f)(4) The QAPI program identifies and prioritizes problems and opportunities that reflect organizational process, functions, and services provided to residents based on performance indicator data, and resident and staff input, and other information;$483.75(f)(5) Corrective actions address gaps in systems, and are evaluated for effectiveness; and$483.75(f)(6) Clear expectations are set around safety, quality, rights, choice, and respect;$483.75(h) Disclosure of information.A State or the Secretary may not require disclosure of the records of such committee except in so far as such disclosure is related to the compliance of such committee with the requirements of this section;$483.75(i) Sanctions.Good faith attempts by the committee to identify and correct quality deficiencies will not be used as a basis for sanctions.This REQUIREMENT is NOT MET as evidenced by:Based upon record reviews and interviews, the facility was able to abate the immediacy of the citation.The findings include:Based on interviews and records review, the facility incorporated data-driven Quality Assurance and Performance Improvement (QAPI) into their program that focuses of all areas of deficiencies to improve the outcome of care. The Committee and the Governing Body (GB) conduct weekly meetings to review facility processes and monitor compliance.Additionally, a Project Improvement Plan (PIP) was implemented titled: &quot;4 Points Action Plan&quot;</td><td>F0865</td><td></td><td></td><td>04/15/2026</td></tr></table> <table><tr><td colspan="2">STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTIONS</td><td colspan="2">(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 108051</td><td>(X2) MULTIPLE CONSTRUCTION A. BUILDING B. WING</td><td>(X3) DATE SURVEY COMPLETED 02/03/2026</td></tr><tr><td colspan="4">NAME OF PROVIDER OR SUPPLIER CORAL BAY AT PENSACOLA, LLC</td><td colspan="2">STREET ADDRESS, CITY, STATE, ZIP CODE 600 W GREGORY ST, PENSACOLA, Florida, 32502</td></tr><tr><td>(X4) IDprefixTAG</td><td>SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION)</td><td>IDprefixTAG</td><td>PROVIDER&#x27;S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)</td><td>(X5) COMPLETION DATE</td><td></td></tr><tr><td>F0865SS = F</td><td>Continued from page 10Based upon these findings, it was determined that the immediacy had been abated and the severity/scope of this finding was reduced from an L to an F.</td><td>F0865</td><td>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>04/15/2026</td><td></td></tr><tr><td>F0908SS = F</td><td>Essential Equipment, Safe Operating Condition CFR(s): 483.90(d)(2)5483.90(d)(2) Maintain all mechanical, electrical, and patient care equipment in safe operating condition.This REQUIREMENT is NOT MET as evidenced by:Based upon record reviews and interview, the facility abated the immediacy of the immediate jeopardy.The findings include:Record reviews and interviews showed that the facility is in process of replacing the defective sprinkler heads. The water pump has been inspected, and the local utility was contacted regarding the water pressure. The Fire Marshal was notified of the implementation of the Fire Watch, and the red tags have been signed off. Based upon these findings, it was determined that the immediacy had been abated and the severity/scope of this finding was reduced from an L to an F.</td><td>F0908</td><td>The sprinklers identified by facility&#x27;s vendor were replaced on 1/22/2026. The facility is working with vendors and the county utilities authority to correct the issue with the fire pump. The facility started a fire watch on 1/12/2026, and this remains ongoing. Staff who perform fire watch duties are educated first on their role and responsibilities. Fire watch staff have been educated on the use of a fire extinguisher and emergency response by the Director of Nursing. The Maintenance Supervisor monitors fire watch checks daily to ensure compliance. A fire report was sent to the state agency by the Administrator on 1/18/2026 for the incident that occurred on 12/24/2026.The Administrator reviewed reports from Life Safety vendors on 1/19/26 to ensure no other repairs were needed to Life Safety equipment. No other concerns were noted. The Administrator also reviewed physical plant incidents from the last three months on 2/18/26 to determine if any incidents needed to be reported to the state agency. One physical plant incident was identified. The incident occurred on 2/5/26 and was reported to AHCA and Fire Dept.Facility staff received education from the DON/Designee on fire watch procedures, individual roles and responsibilities during an emergency, use of a fire extinguisher, and emergency response for resident safety. This education was completed by 1/15/26. The Life Safety Consultant educated the Maintenance Supervisor and Administrator on 1/12/26 on maintaining the facility&#x27;s sprinkler and fire pump systems. The Healthcare Risk Manager initiated education for facility staff including the Administrator, Director of Nursing, and the Governing Body on sprinkler system impairments that require reporting. Fire drills will be held three times a month, one on each shift, to ensure staff respond appropriately. The Administrator will review reports from Life Safety vendors monthly as</td><td></td><td></td></tr></table> <table><tr><td colspan="2">STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTIONS</td><td colspan="2">(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 108051</td><td>(X2) MULTIPLE CONSTRUCTION A. BUILDING B. WING</td><td colspan="2">(X3) DATE SURVEY COMPLETED 02/03/2026</td></tr><tr><td colspan="4">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) 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) COMPLETION DATE</td></tr><tr><td>F0585SS = D</td><td colspan="2">Continued from page 16 the contact information of the grievance official with whom a grievance can be filed, that is, his or her name, business address (mailing and email) and business phone number; a reasonable expected time frame for completing the review of the grievance; the right to obtain a written decision regarding his or her grievance; and the contact information of independent entities with whom grievances may be filed, that is, the pertinent State agency, Quality Improvement Organization, State Survey Agency and State Long-Term Care Ombudsman program or protection and advocacy system; (ii) Identifying a Grievance Official who is responsible for overseeing the grievance process, receiving and tracking grievances through to their conclusions; leading any necessary investigations by the facility; maintaining the confidentiality of all information associated with grievances, for example, the identity of the resident for those grievances submitted anonymously, issuing written grievance decisions to the resident; and coordinating with state and federal agencies as necessary in light of specific allegations; (iii) As necessary, taking immediate action to prevent further potential violations of any resident right while the alleged violation is being investigated; (iv) Consistent with §483.12(c)(1), immediately reporting all alleged violations involving neglect, abuse, including injuries of unknown source, and/or misappropriation of resident property, by anyone furnishing services on behalf of the provider, to the administrator of the provider; and as required by State law; (v) Ensuring that all written grievance decisions include the date the grievance was received, a summary statement of the resident&#x27;s grievance, the steps taken to investigate the grievance, a summary of the pertinent findings or conclusions regarding the resident&#x27;s concerns(s), a statement as to whether the grievance was confirmed or not confirmed, any corrective action taken or to be taken by the facility as a result of the grievance, and the date the written decision was issued; (vi) Taking appropriate corrective action in accordance with State law if the alleged violation of the residents&#x27; rights is confirmed by the facility or if an outside entity having jurisdiction, such as the State Survey Agency, Quality Improvement Organization, or local law enforcement agency confirms a violation for any of these residents&#x27; rights within its area of responsibility; and</td><td>F0585</td><td></td><td></td><td>04/15/2026</td></tr></table> <table><tr><td colspan="2">STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTIONS</td><td colspan="2">(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 106051</td><td>(X2) MULTIPLE CONSTRUCTION A. BUILDING B. WING</td><td>(X3) DATE SURVEY COMPLETED 02/03/2026</td><td></td></tr><tr><td colspan="4">NAME OF PROVIDER OR SUPPLIER CORAL BAY AT PENSACOLA, LLC</td><td colspan="2">STREET ADDRESS, CITY, STATE, ZIP CODE 600 W GREGORY ST, PENSACOLA, Florida, 32502</td><td></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>PROVIDER&#x27;S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)</td><td>(X5) COMPLETION DATE</td><td></td></tr><tr><td>F0656SS = D</td><td colspan="2">Continued from page 20psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following - (i) The services that are to be furnished to attain or maintain the resident&#x27;s highest practicable physical, mental, and psychosocial well-being as required under $483.24, $483.25 or $483.40; and (ii) Any services that would otherwise be required under $483.24, $483.25 or $483.40 but are not provided due to the resident&#x27;s exercise of rights under $483.10, including the right to refuse treatment under $483.10(c)(6). (iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident&#x27;s medical record. (iv)In consultation with the resident and the resident&#x27;s representative(s)- (A) The resident&#x27;s goals for admission and desired outcomes. (B) The resident&#x27;s preference and potential for future discharge. Facilities must document whether the resident&#x27;s desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose. (C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section. $483.21(b)(3) The services provided or arranged by the facility, as outlined by the comprehensive care plan, must- (iii) Be culturally-competent and trauma-informed. This REQUIREMENT is NOT MET as evidenced by: This citation was carried over from the previous survey and remains unchanged.</td><td>F0656</td><td colspan="2">Continued from page 20 feedings as allowed by resident. Resident #10 was discharged on 1/22/2026. Resident #17 was invited to his care plan meeting on 1/13/26 and will continue to be invited to future care plan meetings. If the resident does not want to get out of bed to attend the meeting, the care plan meeting will be held in his room upon request. Rounds were completed by Unit Managers on 2/16/26 to ensure residents receiving enteral feedings had the head of their beds elevated at least 30 degrees. Care plans were spot checked by MDS Coordinators on 2/17/26 to ensure interventions and goals were identified for those on Hospice and for code status. Residents were interviewed by Social Services on 1/27/26 to ensure they received their invitation to care plan meetings. No other residents were affected by this alleged deficient practice. Re-education by the DON/Designee was completed with nursing staff by 2/18/26 regarding the need to keep the head of residents&#x27; beds elevated to at least 30 degrees during enteral feedings. Re-education by the DON/Designee was completed with MDS Coordinators on 2/18/26 regarding developing comprehensive care plans. Re-education by the Administrator was completed with MDS Coordinators and Social Services staff on 1/15/26 regarding issuing invitations to residents for care plan meetings and holding these meetings in resident rooms if that is their preference. New employees will receive this education during orientation, and agency nurses will be educated prior to working their first shift. Unit Managers will perform rounds once a week to ensure the head of residents&#x27; beds are raised at least 30 degrees during enteral feedings. MDS Coordinators will review five care plans weekly to ensure they are accurate and comprehensive. The Social Services Director will review care plan attendance weekly to ensure residents are invited to their care plan meetings, and meetings are held in resident rooms if that is their preference. The results of the Unit Manager and MDS Coordinator audits will be presented to the facility&#x27;s Q&amp;A/Committee monthly by the DON. The results of the Social Services reviews will be presented to the facility&#x27;s Q&amp;A/Committee monthly by the Social Services Director. The results of grievance and incident reviews will be reported to the Q&amp;A/Committee monthly by the Risk Manager. The results of reportable incident review will be reported to the Q&amp;A/Committee monthly by the Administrator.</td><td>04/15/2026</td></tr></table> <table><tr><td colspan="2">STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTIONS</td><td colspan="2">(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 108051</td><td>(X2) MULTIPLE CONSTRUCTION A. BUILDING B. WING</td><td colspan="2">(X3) DATE SURVEY COMPLETED 02/03/2026</td></tr><tr><td colspan="4">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 colspan="2">SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION)</td><td>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>F0689 SS = D</td><td colspan="2"></td><td>F0689</td><td colspan="2">Continued from page 23 the DON/Designee on 2/18/26 with licensed nurses regarding smoking assessments and smoking care plans for all residents who smoke. New employees will receive this education during orientation, and agency nurses will be educated prior to working their first shift. The Administrator will review physical plant incidents monthly to ensure reports are made to the state agency as required. The Risk Manager will perform rounds in the resident smoking area twice a week to ensure all residents who are smoking have a smoking assessment and care plan completed. 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>04/15/2026</td></tr><tr><td>F0693 SS = D</td><td colspan="2">Tube Feeding Mgmt/Restore Eating Skills CFR(s): 483.25(g)(4)(5) $483.25(g)(4)-(5) Enteral Nutrition (Includes naso-gastric and gastrostomy tubes, both percutaneous endoscopic gastrostomy and percutaneous endoscopic jejunostomy, and enteral fluids). Based on a resident&#x27;s comprehensive assessment, the facility must ensure that a resident- $483.25(g)(4) A resident who has been able to eat enough alone or with assistance is not fed by enteral methods unless the resident&#x27;s clinical condition demonstrates that enteral feeding was clinically indicated and consented to by the resident; and $483.25(g)(5) A resident who is fed by enteral means receives the appropriate treatment and services to restore, if possible, oral eating skills and to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-phenyngeal ulcers. This REQUIREMENT IS NOT MET as evidenced by: This citation was carried over from the previous survey and remains unchanged.</td><td>F0693</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 #181 was evaluated by therapy on 1/26/26 and is currently receiving therapy services for passive range of motion and stretching. Wedge cushions are being utilized for proper positioning. Unit Managers completed rounds on 2/18/26 and observed residents receiving enteral feeding. No other residents appeared to be affected by the alleged deficient practice. Re-education by the DON/Designee was completed with nursing staff by 2/18/26 regarding the proper position of residents during enteral feedings. New employees will receive this education during orientation, and agency nurses will be educated prior to working their first shift. Unit Managers will observe five residents with enteral feedings weekly to ensure they are positioned properly. The results of these observations will be presented to the facility&#x27;s Q&amp;A Committee monthly by the Director of Nursing. The Q&amp;A Committee will determine the need for further observations beyond three months.</td><td>04/15/2026</td></tr></table>