Pensacola Nursing: Missing Advance Directives - FL

That admission came during a federal inspection at Pensacola Nursing & Rehabilitation Center on West Airport Boulevard, where staff failed to maintain required advance directive documentation for residents. The missing paperwork governs critical decisions about medical treatment when residents can no longer speak for themselves.

Resident #37 had clearly stated her preferences. Her care plan from February showed she wanted full medical intervention — what staff call "full code" status. But when inspectors asked to see the advance directive education discussion sheet that should have been in her electronic medical record, it wasn't there.

The Director of Nurses interviewed on April 8 at 5:15 PM couldn't explain where the documents went. She acknowledged the facility was "unable to locate the admission documents, including consent for advance directives" for Resident #37.

The problem extended beyond one resident. Inspectors reviewing Resident #114's electronic medical record found no admission consent or advance directive documentation since the person's admission. The file was completely empty of the paperwork that federal law requires nursing homes to maintain.

Staff had multiple opportunities to produce the missing documents. Inspectors first requested them from the Administrator on April 7 at 10:44 AM. When those weren't provided, they asked again during an interview with the Social Services Director that same day at 12:57 PM.

By 3:16 PM on April 7, the facility still couldn't produce any advance directive documentation. Inspectors made one more request the following day at 12:29 PM. Again, no documents materialized.

The missing paperwork represents more than administrative oversight. Advance directives document residents' wishes about life-sustaining treatment, resuscitation, and other critical medical decisions. Federal regulations require nursing homes to inform residents about their right to make these choices and to maintain proper documentation of their decisions.

Without these documents, medical staff face uncertainty during emergencies. They may not know whether a resident wants aggressive medical intervention or comfort care. Family members may disagree about treatment decisions, leaving healthcare providers without clear guidance about the resident's actual wishes.

The facility's electronic medical record system should have contained scanned copies of all admission documents, including advance directive paperwork. The absence of these files suggests either a failure to collect the documents during admission or problems with the facility's record-keeping systems.

Pensacola Nursing & Rehabilitation Center operates as a 120-bed facility providing skilled nursing and rehabilitation services. The missing advance directive documentation affected at least two of the 35 residents whose records inspectors reviewed during the April survey.

The violation carries minimal harm classification, meaning inspectors determined it created potential for harm rather than actual injury to residents. However, the missing documentation could create serious problems if residents require emergency medical decisions.

Federal law requires nursing homes to inform residents about advance directives within specific timeframes after admission. Facilities must document these discussions and maintain copies of any advance directive documents residents complete. The requirements ensure residents' end-of-life wishes are known and respected.

The inspection found that staff at Pensacola Nursing & Rehabilitation Center failed to meet these basic documentation requirements. When pressed by federal surveyors over two days, administrators and nursing leadership couldn't locate critical paperwork that should have been readily available in residents' medical records.

For families placing loved ones in nursing home care, the missing documents raise questions about the facility's admission procedures and record-keeping practices. The paperwork that disappeared contained residents' most personal medical wishes — decisions about how they wanted to be treated if they became unable to communicate their preferences.

Full Inspection Report

The details above represent a summary of key findings. View the complete inspection report for Pensacola Nursing & Rehabilitation Center from 2026-04-09 including all violations, facility responses, and corrective action plans.

Additional Resources

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