Below average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Pensacola Nursing & Rehabilitation Center during CMS and state inspections, most recent first.
Failure to Knock and Announce Entry Before Entering Resident Rooms: Staff did not consistently knock or announce themselves before entering resident rooms. A CNA entered one resident’s room without first announcing herself, and a maintenance employee entered another resident’s room without knocking or explaining his purpose while working on an AC unit. The resident also reported multiple unannounced entries to the LTC Ombudsman, and the DON stated staff were expected to knock, announce entry, and explain their purpose before providing care or services.
Failure to Obtain Consent for Psychotropic Medications: The facility failed to obtain and document consent before starting psychotropic medications for two residents. One resident with depression, anxiety, bipolar disorder, and insomnia received multiple psychotropic meds, and another resident with anxiety and depression received Zolpidem, Xanax, and Fluoxetine. Surveyors found no psychotropic consent in either chart, and the DON stated admission documents and consents could not be located.
Missing advance directive documentation was identified for two residents. One resident was full code and had a care plan noting Full Code status, but the EMR lacked the advance directive education discussion sheet and admission consent. For another resident, the EMR contained no admission consent or advance directive documentation since admission, and the facility could not produce the records when requested by survey staff and the DON/Social Services Director.
Failure to maintain a clean resident shower and secure bathroom toilet. A resident’s shower had black grime on the tile walls and floors, with hair and a thick white substance in the drain, and the resident said he had asked staff multiple times to clean it and wanted it cleaned before showering. Another resident’s bathroom toilet had a thick brown and black substance around the base and was pulled away from the floor. Housekeeping staff said rooms, bathrooms, and showers were cleaned daily, but the HM observed the shower and said it did not look cleaned, and the monthly deep clean log showed the room was not cleaned.
Failure to follow up on a resident grievance: A resident’s sister reported missing clothing items and was told a grievance would be completed, but she did not receive a resolution after several weeks. Social Svcs and the DSW were unaware of the grievance, grievance logs showed no entry for the resident, and the grievance form could not be located. The facility’s policy required investigation and notification within set timeframes.
Care plans were incomplete or not followed for two residents with Foley catheters and one resident at risk for falls. Two residents had active Foley orders, but their care plans did not include catheter-related focus areas or interventions, and an MDS Coordinator stated the plans should have been developed within 48 hours of admission. A resident with a history of falls had an active order and care plan for fall mats, but repeated observations showed no mats at the bedside after the resident was moved to a new room; a CNA and UM confirmed the mats were not in place.
The facility failed to follow physician orders for two residents. One resident with bilateral hand contractures did not have ordered palm protectors in place during repeated observations, even though the care plan called for bilateral palm guards and the DON acknowledged the restorative process was broken. Another resident with a history of UTI reported burning with urination and tight briefs, but a urinalysis ordered for the resident was not sent, and there was no documentation that the resident refused to provide a sample.
A resident with CHF and edema had an active order for weights 3 times weekly, but the facility failed to obtain and document the ordered weights. The resident reported weight loss since admission, his care plan included weight monitoring for altered nutrition/hydration risk, and the regular weight list omitted his name. An LPN and the UM both stated they did not know why the ordered weights were not completed.
Dialysis Communication Not Maintained: A resident with ESRD, an AV fistula, and dependence on dialysis was observed returning from treatment tired but otherwise okay. He stated he did not always receive the paperwork to take to the dialysis center, and record review showed no documented collaboration of care in the chart or dialysis communication binder, despite binder instructions requiring facility nursing completion of dialysis paperwork before treatment.
Failure to obtain ordered pain medication for a resident with fractured tibia, cervicalgia, and chronic pain. The resident’s Tramadol was not given because it was unavailable in the cart or Pyxis, and the MAR documented missed doses. An LPN contacted the ARNP about reordering, but the medication never arrived from the pharmacy, and the LPN stated he did not know he needed to call the pharmacy.
Missing Infection Control Signage for Residents on Precautions: A resident on TBP for MRSA and two residents with indwelling urinary catheters on EBP were observed without the required room signage posted. Staff confirmed the signs were missing, and a CNA stated she did not know what PPE to wear for the two residents.
Broken Hallway Handrail: A handrail on the 200 hall outside a room was observed broken and displaced about 3 inches vertically when pressure was applied. The Administrator and Maintenance Director confirmed handrails should be secure to the wall and agreed the handrail needed repair. The facility policy stated maintenance is responsible for keeping buildings and equipment safe and operable.
A resident admitted with sepsis, peripheral vascular disease, a surgically debrided pressure-related hip wound, and additional wounds to the sacrum and great toe had physician orders for a wound vac to the right hip, daily wound care to the toe and sacrum, and heel protection. Although the wound vac and supplies were already in the facility and staff nurses were reported by the DON to be knowledgeable in wound vac application, the wound care nurse did not work weekends and the wound vac was not applied on admission, but instead was initiated several days later when she returned. The wound care nurse also reported she was unaware that the hip wound was a pressure area surgically debrided in the hospital, contributing to the delay in implementing the ordered pressure ulcer treatment.
A resident with documented swallowing difficulties had physician and speech therapy orders, as well as a care plan and in-room signage, requiring supervision for all meals, defined as staff remaining in sight for the entire meal and not leaving the tray unattended. During an observed mealtime, the resident was found eating alone in bed with no staff present. A CNA reported being unaware of the supervision requirement, while the UM and other staff indicated such needs should be communicated via orders, care plans, shift reports, and meal tickets, demonstrating a failure to implement the ordered and care-planned supervision during meals.
A resident with a physician-ordered regular diet with mechanical soft texture and thin liquids, and documented dysphagia precautions with mechanical soft/chopped textures, was observed at lunch feeding independently with no staff present while their tray contained potato chips and saltine crackers. Signage above the bed indicated a mechanical soft, chopped meats, thin liquids diet, and the meal ticket read “Regular-DYS ADV,” indicating avoidance of hard, sticky, or crunchy foods. A CNA, UM, Speech Pathologist, and CDM all confirmed that chips and crackers are not appropriate for a mechanical soft diet and should not have been placed on the tray, indicating the ordered therapeutic diet was not followed.
The facility failed to offer the 2024 influenza vaccine to a resident and did not document education on the benefits and side effects of influenza and pneumonia vaccines for five residents. An interview with the ADON confirmed these deficiencies, which were contrary to the facility's policy requiring annual vaccine offers and documented education.
The facility did not offer the 2024 COVID-19 vaccine to four residents, as revealed by a review of their medical records. The ADON admitted that the last vaccine offering was in November 2023, despite the facility's policy and CDC guidance recommending annual vaccination. This oversight affected the residents' compliance with the 2024-2025 COVID-19 vaccine recommendations.
Two residents filed grievances about not receiving the meals as indicated on their meal cards, specifically lacking meat at breakfast. The facility's investigation was inadequate, with findings merely stating that the menu was being followed, and the resolution sections were left blank. Interviews revealed that the grievances were not properly addressed.
A resident with muscular sclerosis did not receive the ordered methylprednisolone for a flare-up due to insurance coverage issues. The medication was ordered for IV administration but was not given until the order was changed to an oral form. LPNs were aware of the issue but did not contact the DON for a pharmacy override. The MAR indicated the medication was on order, but there was no documentation of provider notification. The DON confirmed the situation as a missed dose and noted the lack of a specific policy on missed doses.
The facility failed to follow infection control protocols during wound care for a resident, as a nurse used a soiled glove to handle a marker without sanitizing it. Additionally, the facility did not change a PICC line dressing for another resident as per physician orders, with the dressing remaining unchanged beyond the scheduled date. The DON confirmed these oversights, which were against facility policies.
Failure to Knock and Announce Entry Before Entering Resident Rooms
Penalty
Summary
Resident rights and dignity were not upheld when staff failed to knock and announce themselves before entering the rooms of two residents. During observation, a CNA entered one resident’s room, passed a partially pulled privacy curtain by the resident’s bed, and left, then re-entered a few seconds later after knocking and stating she had lunch. The resident also reported to the local LTC Ombudsman that staff had come into the room without knocking or announcing themselves on three occasions during a recent visit, and the Ombudsman said she had already raised the concern with the facility Administrator. A separate observation showed a maintenance employee entering another resident’s room without knocking or announcing his presence or purpose. He went directly to the window AC unit, removed the front cover, left the room, and returned about 5 minutes later without knocking or explaining why he was there. The DON stated that all staff were expected to knock, announce entry, and explain what they were there for before starting care or services. The maintenance employee stated he had become too comfortable with residents, admitted he did not knock, and said he could not promise it would not happen again.
Failure to Obtain Consent for Psychotropic Medications
Penalty
Summary
The facility failed to ensure residents were fully informed and understood their health status, care, and treatments before psychotropic medications were started for 2 of 5 residents reviewed for general consent to treat. Resident #12 was readmitted after a hospital stay with diagnoses including major depressive disorder, anxiety, bipolar disorder, and insomnia. Her record showed a brief interview for mental status score of 15, indicating she was cognitively intact, and physician orders included Paroxetine Mesylate daily, Trazodone nightly, Topiramate twice a day, and Hydroxyzine three times a day. Although her care plan referenced antidepressant medication use and a psychiatric consult, there was no consent for psychotropic medications in the chart when reviewed by surveyors. Resident #37 was admitted with diagnoses including polyneuropathy, lupus, cellulitis of the left lower extremity, heart attack, anxiety, pulmonary embolism, and depression. She was receiving Zolpidem for sleep, Xanax for anxiety, and Fluoxetine for depression, and her care plans addressed insomnia, depression, and anxiety with use of hypnotic, antidepressant, and anti-anxiety medications. Her MDS also showed use of antianxiety, antidepressant, and hypnotic medications. Surveyors found no consent for psychotropic medications in the chart, and the DON stated the facility was unable to locate the admission documents, including consents to treat and psychotropic medication consents, and that treatment should not have been initiated without consent first.
Missing Advance Directive Documentation
Penalty
Summary
The facility failed to maintain required advance directive documentation for 2 of 35 sampled residents. For Resident #37, the record showed full code status and a plan of care dated 2/10/26 indicating she requested Full Code status, but no advance directive education discussion sheet was available in the electronic medical record. The DON stated on 4/8/26 that the facility was unable to locate the admission documents, including the resident’s consent for advance directives. For Resident #114, the electronic medical record contained no admission consent or advance directive documentation since admission on [DATE]. Requests for these documents were made to the Administrator on 4/7/26 and again during an interview with the Social Services Director on 4/7/26, but the facility still could not produce the advance directives documentation to survey staff by 3:16 PM that day, and a subsequent request on 4/8/2026 also yielded no documentation.
Failure to Maintain Clean Resident Shower and Secure Bathroom Toilet
Penalty
Summary
The facility failed to maintain a clean and comfortable environment for 2 of 29 sampled occupied resident rooms, specifically rooms 201 and 206. In room 201, the shower was observed with black grime on the tile walls and floors, and the shower drain was covered with hair and a thick white substance. The resident stated he had been using the shower in his room and had asked staff multiple times to clean it. On a later observation, the shower still had black grime on the tile walls and floors, and the drain remained covered with hair and the thick white substance. The resident then stated he wanted to shower but wanted the shower cleaned first. Housekeeping staff stated the rooms, bathrooms, and showers were cleaned daily, and the Housekeeping Manager stated bedrooms, bathrooms, and showers were expected to be cleaned daily with monthly deep cleans. During the tour, the Housekeeping Manager observed the shower and stated he would not want to use it with grime and hair in the drain, and also stated it did not look like it had been cleaned. Review of the monthly deep cleaning schedule showed room 201 was not cleaned by staff. In room 206, the bathroom toilet was observed with a thick brown and black substance around the base, and there was approximately a half-inch gap where the toilet was pulled away from the floor. During a later tour with the Administrator and Maintenance Director, both observed the black substance at the toilet base and the toilet being pulled away from the floor. The Maintenance Director stated staff should report repairs by writing a ticket, calling, or entering the issue in the facility's Secura System, and both stated the toilet would be repaired. Review of the facility's Maintenance Service policy stated the maintenance department is responsible for maintaining the building, grounds, and equipment in a safe and operable manner and in compliance with applicable laws, regulations, and guidelines.
Failure to Follow Up on Resident Grievance
Penalty
Summary
The facility failed to follow up on a grievance for one resident after the resident’s sister reported that clothing items were missing. The sister stated she was told a grievance would be completed and the issue would be resolved, but about three weeks later she had not heard any resolution. During interviews, the Social Services Assistant and the Director of Social Work stated they were not aware of a grievance filed by the sister, and a review of the grievance logs from 01/28/2026 through 03/31/2026 showed no entries regarding the resident. There was no grievance log for April 2026 at the time of review, and the Social Services Assistant stated she still needed to make the April log. The Director of Admissions stated the resident’s sister informed her of the missing clothing items and that she completed a grievance form and turned it into the Social Services office. She stated she did not know the exact date, but it was not long after the resident was admitted to the facility, and she was unsure which Social Services staff member received it. On review of the facility’s grievance procedure, the grievance officer was required to review and investigate grievances and submit findings to the Administrator within five working days, and the resident or person filing the grievance was to be informed of the findings and actions taken within ten working days. The Director of Social Work stated they could not locate a grievance form regarding the resident.
Care Plans Missing or Not Implemented for Catheters and Falls
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for 2 residents with indwelling urinary catheters and 1 resident reviewed for falls. Resident #10 and Resident #122 each had an active physician order for a Foley catheter, but their Comprehensive Care Plans did not include a care plan focus area for the indwelling urinary catheter or catheter care interventions. The MDS Coordinator stated that the catheter care plans should have been developed within 48 hours of admission and acknowledged that they were omitted for both residents. Resident #11 had an active physician order for fall mats at the bedside due to a history of falls, and the care plan identified the resident as at risk for falls related to weakness and involuntary movements with fall mats listed as an intervention. However, observations on multiple occasions showed the resident lying and moving around in bed with no fall mats present at the bedside. The CNA confirmed the resident had not had any fall mats in place since being moved to the current room, and the Unit Manager stated the fall mats were not transferred with the resident but should have been.
Failure to Follow Physician Orders for Splints and Urinalysis
Penalty
Summary
The facility failed to carry out physician orders for two residents. One resident had bilateral hand contractures and multiple observations on 04/06/2026, 04/07/2026, and 04/08/2026 showed no splints or braces in place, despite a physician order for bilateral palm protectors to be applied at all times except during ADLs and skin assessment, with monitoring of skin surfaces under the device and notification of the physician for abnormal findings. The resident also had a care plan for skin impairment to the left palm and a goal to wear bilateral palm guards during the day because of debility, weakness, decreased strength, decreased cognition, and contractures. The DON stated the restorative nurse was out and the restorative aide worked only every other week, and acknowledged that the restorative process was broken and residents on the restorative program were not receiving consistent care to meet their needs. A second resident reported that incontinence briefs were too small and tight and that she had been experiencing burning with urination for several days. A CNA later reported to the Nurse Manager that the resident continued to complain of burning during urination. The record showed a urinalysis was ordered, and the resident had a history of UTI with a care plan indicating labs should be monitored as ordered. However, review of the outgoing lab binder showed no laboratory specimens had been sent after the urinalysis order was written, and the record contained no documentation that the resident refused to provide a sample, despite staff stating another order would be entered for a straight catheter urinalysis due to reported refusal.
Failure to Obtain Ordered Weights
Penalty
Summary
The facility failed to monitor weights for 1 of 3 residents reviewed for weights, involving a resident with an active physician order for weights 3 times a week on Mondays, Wednesdays, and Fridays. The resident stated he had lost some weight since admission. His comprehensive care plan identified him as at risk for altered nutrition/hydration related to a history of weight loss and weight fluctuations due to CHF and edema, with interventions for weights as ordered. However, review of the facility’s regular weight list dated 3/30/26 showed the resident’s name was omitted, and staff were unable to explain why the ordered weights were not obtained or documented. An LPN confirmed the active weight order and stated she did not know why the weights were not documented, and the UM stated the restorative aide was responsible for obtaining weights and the assigned nurse would follow up if weights were not obtained, but she also did not know why the weights were not obtained per the physician order.
Dialysis Communication Not Maintained
Penalty
Summary
The facility failed to ensure ongoing communication and collaboration was maintained with the dialysis facility for one resident who required dialysis services. Resident #52 was admitted and later re-admitted with diagnoses including end stage renal disease (ESRD), arteriovenous fistula, and dependence on dialysis, and was ordered to receive dialysis every Tuesday, Thursday, and Saturday. The resident also had a care plan addressing fluid imbalance related to kidney failure, fluid restrictions, and risk for complications related to hemodialysis, with a goal of being compliant with dialysis appointments, nursing interventions, and physician orders. On observation, Resident #52 was out of the facility for dialysis treatment and later returned after lunch, stating he was tired from treatment but was okay. During interview, he stated that he did not always get the paperwork to take with him to the dialysis center. The dialysis communication binder instructions indicated that dialysis sheets were to be filled out by the facility nurse before dialysis and that the dialysis clinic should be contacted if the sheet was not returned. Review of hemodialysis communication records dated 3/2/24, 2/5/26, and 3/14/26 showed no documentation of collaboration of care in the medical chart or in the dialysis communication binders on the unit.
Failure to Obtain Ordered Pain Medication
Penalty
Summary
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist was not met when the facility failed to obtain pain medication in a timely manner for Resident #103. The resident had diagnoses of fractured tibia, cervicalgia, and chronic pain, and had an order for Tramadol 50 mg by mouth every day at 9:00 AM and 11:00 PM. During interview, the resident stated he received Tramadol twice a day but did not receive any pain medication on 4/3/26, 4/4/26, or 4/5/26, and he continued participating in morning workouts despite not having the medication. The MAR confirmed Tramadol was not administered on those dates, with the documented reason that the medication was not available. Staff interviews showed the night shift nurse reported the medication was not in the cart or Pyxis, and the LPN contacted the ARNP, who said she was taking care of reordering the Tramadol. The LPN stated the medication never arrived from the pharmacy and he did not know he needed to call the pharmacy. The DON stated her expectation was that if a medication was not available in the cart or Pyxis, the nurse should contact the pharmacy, and if the pharmacy could not deliver or complete the order, the nurse should notify the doctor or ARNP for an alternative medication.
Missing Infection Control Signage for Residents on Precautions
Penalty
Summary
The facility failed to ensure appropriate infection control practices were followed for three residents reviewed for infection control. Resident #1 was observed eating lunch in a room where red biohazard bags were on the floor. Staff J, a CNA, stated that Resident #1 did not have a roommate because the resident was on Transmission Based Precautions (TBP) for MRSA in a wound. At the time of the observation, no TBP signage was posted on the door of the resident’s room. A later observation on 4/7/26 also found no TBP sign present, and the medical record showed TBP had been ordered on 4/6/26. On 4/8/26, an EBP sign was observed on the outside of the room, and the DON acknowledged the signs had not been present until that day. Resident #10 and Resident #122 each had indwelling urinary catheters, and observations on 4/6/26 found no Enhanced Barrier Precautions signage posted on either room door. Their clinical records showed active physician orders for EBP, and both care plans included EBP interventions. During follow-up observations and interviews, Staff A, an LPN, acknowledged the signage needed to be posted and said a sign would be posted. Staff E, the UM, confirmed that an EBP sign should have been placed on the resident room doors so staff would know what PPE to wear. Staff F, a CNA, stated she was unaware of what appropriate PPE to wear for the two residents.
Broken Hallway Handrail
Penalty
Summary
The facility failed to maintain the handrails in a safe, secure, and functional condition on the 200 hallway. During an initial tour, the handrail outside of a room on the 200 hall was observed to be broken, and when pressure was applied it displaced approximately 3 inches vertically. Photographic evidence was obtained. During a follow-up observation with the Administrator and Maintenance Director, both confirmed that handrails should be secure to the wall and agreed that this handrail needed to be repaired. Review of the facility's Maintenance Service policy stated that the maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner and in compliance with applicable laws, regulations, and guidelines.
Failure to Timely Initiate Ordered Wound Vac Therapy for Pressure-Related Hip Wound
Penalty
Summary
The facility failed to provide ordered pressure ulcer treatment and services for a resident with multiple wounds, including a surgically debrided pressure area on the right hip. The resident was admitted with diagnoses of sepsis due to E. coli, peripheral vascular disease, acquired absence of foot, and a wound to the right hip. Physician orders at admission included daily wound care to the right great toe, daily treatment to a sacral wound, application of a wound vac to the right hip at 125 mmHg three times weekly and as needed, and skin prep to bilateral heels every shift for 14 days. A care plan initiated shortly after admission identified a pressure ulcer to the hip with a goal for healing. Wound care evaluations documented a surgical wound to the right trochanter hip on 3/10/26 and a black-colored wound to the right great toe on 3/12/26, with corresponding treatment orders. Despite these orders and the presence of the wound vac equipment in the facility prior to admission, the wound vac was not applied to the resident’s right hip on the day of admission. The wound care nurse stated she did not work weekends and believed no one else at the facility would have been able to place the wound vac, so she did not initiate it until she saw the resident on 3/10/26. She also stated she was not aware that the right hip wound was a pressure area that had been surgically debrided in the hospital. The Admissions Coordinator confirmed that the wound vac and supplies had been ordered and delivered before the resident’s admission, and the DON stated that staff nurses were knowledgeable in applying wound vacs and that it was expected the wound vac be applied on the day of admission when needed. This sequence of events resulted in a failure to timely implement the ordered wound vac therapy for the resident’s pressure-related hip wound.
Failure to Implement Ordered Supervision During Meals
Penalty
Summary
The deficiency involves the facility’s failure to implement care plan interventions for supervision during meals for one resident. Observation on 2/19/26 showed signage above the resident’s bed stating “Supervised All meals,” and record review confirmed an order dated 2/1/26 for “Supervised all meals, monitor oral holding,” a diet order and communication from the speech pathologist with the same instruction, and a speech therapy evaluation indicating the patient requires supervision at mealtime. The resident’s care plan, initiated 2/4/26, also stated “Supervise for all meals.” The speech pathologist clarified that supervision with meals means staff must remain in sight of the resident for the entire meal and should not leave a meal tray with the resident alone. The Regional Nurse Consultant, acting as DON, stated her expectation that staff delivering the tray stay with the resident during the entire meal. Despite these documented requirements, on 2/19/26 at approximately 12:45 PM, the resident was observed sitting up in bed feeding himself with no staff present, while the room door was open and the privacy curtain pulled. A CNA interviewed shortly afterward stated she was unaware the resident required supervision with all meals and acknowledged that the sign in the room means staff are to be with the resident while he eats. The Unit Manager reported that if a resident requires assistance or supervision with meals, there is usually an order or it will be listed on the care plan, and that CNAs and staff are informed during daily shift reports. Another CNA stated that such requirements would be indicated on the resident’s meal ticket. These observations and interviews show that, although the need for supervised meals was ordered, documented, and posted, staff did not consistently implement the supervision intervention during the observed meal.
Failure to Follow Ordered Mechanical Soft Therapeutic Diet
Penalty
Summary
The facility failed to provide an ordered therapeutic diet to a resident who had a physician order dated 2/1/26 for a regular diet with mechanical soft texture and thin consistency, and speech therapy documentation for mechanical soft/chopped textures with dysphagia precautions. On the morning of 2/19/26, signage above the resident’s bed indicated a mechanical soft diet with chopped meats and thin liquids. At lunchtime the same day, the resident was observed feeding himself without staff present, and his meal tray contained approximately seven potato chips and two saltine crackers. The meal ticket on the tray read “Regular-DYS ADV,” indicating a regular diet avoiding hard, sticky, or crunchy foods, with foods to be bite-sized. During subsequent interviews, a CNA, the Unit Manager, the Speech Pathologist, and the Certified Dietary Manager each stated that chips and crackers are not appropriate for a mechanical soft texture diet and should not have been on the tray. The Certified Dietary Manager stated that dietary staff are expected to read each meal ticket and place food on the tray according to the therapeutic diet, and acknowledged that the chips and crackers should not have been included. The Regional Nurse Consultant, acting as DON, and the Administrator both stated their expectations that staff follow therapeutic diets according to meal tickets and physician orders, confirming that the observed tray contents did not align with the ordered mechanical soft diet and dysphagia-related precautions documented for the resident.
Failure to Offer and Document Vaccine Education
Penalty
Summary
The facility failed to offer the 2024 influenza vaccine to one resident and did not document the provision of education regarding the benefits and potential side effects of the influenza and pneumonia vaccines for five residents. Specifically, one resident had not been offered the influenza vaccine since November 2023, and no education had been documented for this resident since 2022. Another resident's medical record showed no documentation of education regarding the pneumonia vaccine. A third resident had no documented education about the influenza vaccine since 2021. Additionally, two other residents had no documented education regarding the pneumonia vaccine, and one of them also lacked documentation of influenza vaccine education since 2022. An interview with the Assistant Director of Nursing confirmed the lack of documented education for the five residents and the failure to offer the influenza vaccine to one resident in 2024. The facility's policy, revised in February 2024, requires that residents be offered the influenza vaccine annually and be provided with information and education about the vaccines, which should be documented in their medical records.
Failure to Offer 2024 COVID-19 Vaccine to Residents
Penalty
Summary
The facility failed to offer the 2024 COVID-19 vaccine to four out of five sampled residents, specifically Residents #37, #46, #54, and #73. A review of their medical records indicated that these residents had not been offered the COVID-19 vaccine in 2024. During an interview, the Assistant Director of Nursing (ADON) acknowledged that the last time the facility offered the COVID-19 vaccine to residents was in November 2023, and it should be offered annually. However, the facility had not done so for the year 2024. The facility's policy, revised in June 2024, states that COVID-19 vaccines should be offered to residents and staff in accordance with CDC guidance. The current CDC recommendations, accessed in January 2025, advise that everyone aged 6 months and older, including those in long-term care settings, should receive the 2024-2025 COVID-19 vaccine. The failure to offer the vaccine to the sampled residents indicates a deviation from both the facility's policy and CDC recommendations.
Failure to Investigate and Resolve Meal Service Grievances
Penalty
Summary
The facility failed to properly investigate and resolve grievances submitted by two residents regarding their meal service. Resident #54 filed a grievance stating that she was not receiving the meals as indicated on her meal card, which included a variety of breakfast items with double protein. Instead, she was only receiving grits, a slice of toast, and a glass of tea. The grievance was communicated to the administrator and dietary staff, but the investigation was inadequate, with the findings merely stating that the menu was being followed. The resolution section was left blank, and there was no indication that the resident's concerns were addressed or resolved. Similarly, Resident #21 filed a grievance about not receiving meat with breakfast for two weeks. The grievance was assigned to dietary staff, but no specific individual was named. The investigation findings were identical to those of Resident #54, stating that the menu was being followed, and the resolution section was again left blank. Interviews with the Regional Dietitian and Facility Administrator revealed that the grievances were not properly filled out or investigated, and the residents' concerns were not adequately addressed.
Failure to Administer Ordered Medication Due to Insurance Issues
Penalty
Summary
The facility failed to ensure that ordered medication was available for a resident diagnosed with muscular sclerosis, who required methylprednisolone to treat a flare-up. The medication was ordered by an ARNP on January 2, 2025, and confirmed by an LPN on January 3, 2025, to be administered intravenously for five days starting January 4, 2025. However, the medication was not administered as scheduled due to insurance coverage issues, and the order was discontinued on January 6, 2025. The resident did not receive the medication until January 8, 2025, after the order was changed to an oral form by the ARNP. During interviews, it was revealed that the LPNs were aware of the insurance issue but did not take steps to ensure the medication was administered, such as contacting the DON or obtaining a pharmacy override. The MAR indicated that the medication was on order, but there was no documentation of notification to the ordering provider. The DON confirmed that medication not covered by insurance is not a valid reason for non-administration and acknowledged the situation as a missed dose. The facility's policy on medication administration did not specifically address missed doses, and the incident was not communicated to the DON until January 7, 2025.
Infection Control Deficiencies in Wound and PICC Line Care
Penalty
Summary
The facility failed to ensure proper infection control processes during wound care for Resident #3. During an observation, the Wound Care Registered Nurse, Employee A, was seen placing her soiled, gloved hand into her pocket to retrieve a marker, which she used to date a dressing before applying it to the wound. Employee A did not sanitize the marker before returning it to her pocket. In an interview, Employee A admitted to not having received formal wound care training at the facility and acknowledged the mistake of not cleaning the marker, which was against the facility's policy of cleaning and disinfecting reusable items between residents. Additionally, the facility did not adhere to the physician's order and facility policy regarding the changing of a PICC line dressing for Resident #156. The PICC line dressing, observed on two separate occasions, was dated 12/31/24 and had not been changed by 1/7/25 as required. The Director of Nursing confirmed the oversight, noting that the dressing should have been changed weekly or as ordered by the physician. A review of the resident's medical record showed a physician order to change the dressing every 7 days, starting on 1/5/25, but the medication record was blank for the scheduled dressing change.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 78 citations issued within 25 miles in the last 12 months — including the 12 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Pensacola
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Rosewood Healthcare And Rehabilitation Center | 2.3 mi | ★★★★★ | 2 | 0 |
| Arabella Health & Wellness Of Pensacola | 3 mi | ★★★★★ | 12 | 3 |
| Havens At Pensacola, The | 3.2 mi | ★★★★★ | 4 | 0 |
| Specialty Health And Rehabilitation Center | 3.4 mi | ★★★★★ | 7 | 0 |
| Olive Branch Health And Rehabilitation Center | 3.5 mi | ★★★★★ | 1 | 0 |
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