Pensacola Nursing & Rehab: Doctor Orders Ignored - FL

Federal inspectors found Pensacola Nursing & Rehabilitation Center failed to carry out physician orders for two residents during an April inspection, documenting how broken systems left vulnerable patients without prescribed medical care.

Resident 69 had bilateral hand contractures that required protective splints around the clock. A physician ordered "Bilateral palm protectors to be used at all times except for ADLs and skin assessment" on March 31. The resident also had an active skin wound on her left palm.

Inspectors observed the resident six times over three days in April. During every observation, no splints or braces were in place.

The facility's care plan acknowledged the resident needed bilateral palm guards "due to debility/weakness, decrease in strength, decreased cognition, presence of contractures." That plan had been in effect since May 2024 and was revised in March 2026, just days before the physician's order.

The Director of Nursing told inspectors on April 9 that "the restorative nurse was out and the restorative aide only worked every other week." She admitted she knew "the restorative process was broken, and the residents who were on the restorative program were not receiving consistent care to meet their needs."

Resident 108 faced a different but equally troubling breakdown in medical care.

The resident told inspectors on April 6 that her incontinence briefs were too small and tight. She said she had been experiencing burning with urination for several days.

That same afternoon, a certified nursing assistant reported to the nurse manager that Resident 108 "continued to complain of burning during urination" while receiving care.

A physician had ordered a urinalysis for the resident on March 31 at 5:00 PM. The resident had a documented history of urinary tract infections, and her care plan specifically noted she was at risk for UTIs and that "labs should be monitored as ordered."

Eight days later, no urine sample had been collected.

A licensed practical nurse reviewed the facility's outgoing lab records on April 8 and confirmed "no laboratory specimens had been sent for Resident #108 since the urinalysis order was written on 03/31/2026."

When the nurse manager was notified, she said another order would be entered for a straight-catheter urinalysis "due to reported resident refusal to provide a sample."

But inspectors found no documentation in the resident's record indicating she had ever refused to provide a urine sample.

The facility's care plan for Resident 108, updated in February, specifically identified her UTI risk and the need to monitor ordered laboratory work. Despite this acknowledgment and the resident's complaints of burning urination, staff failed to collect the specimen for more than a week after the physician's order.

The inspection revealed systemic problems with following physician orders at the 235 West Airport Boulevard facility. In one case, a resident went without prescribed protective equipment despite documented skin breakdown and contractures. In another, a resident with a history of infections experienced symptoms for days while staff ignored a diagnostic order.

Both cases demonstrated what the Director of Nursing herself acknowledged: care systems were "broken" and residents weren't receiving consistent care to meet their medical needs.

The April inspection found these failures affected few residents overall and caused minimal harm. But for Resident 69, whose hands remained unprotected despite active skin wounds, and Resident 108, whose potential infection went undiagnosed for over a week, the impact was immediate and personal.

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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