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The next survey window likely opens around March 2027
Estimate from public CMS data, current as of June 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.
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 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.
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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.
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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 | — | 0 | 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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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.