Pensacola Nursing & Rehabilitation Center

Review of Resident #12's physician orders revealed that Resident #12 was taking Paroxetine Mesylate daily for depression, Trazodone nightly for insomnia (psychotropic), Topiramate twice a day for bipolar disorder, and Hydroxyzine three times a day for anxiety. A review of Resident #12's Minimum Data Set, dated [DATE] indicated the use of antidepressant medications being used.

The care plan, with the review date of 2/26/26, indicated that Resident #12 took antidepressant medication related to depression and had a psychiatric consult.

Further review of Resident #12's medical record revealed there was no consent for psychotropic medications present in the chart.

An interview was conducted on 4/8/26 at approximately 1:30 PM with the Director of Nursing (DON), requesting the consent for Paroxetine, Trazodone, Topiramate and Hydroxyzine as there was no evidence that informed consent specific to the use of psychotropic medications was obtained prior to administration of the medications. On 4/9/26 at approximately 11:45 PM, the DON supplied a consent dated 5/16/25 that was signed by Resident #12 and a Licensed Practical Nurse.

Closer review of this document revealed there were no medications listed on the consent form.

A record review was completed for Resident #37. Resident #37 was admitted to the facility on [DATE] with the diagnoses of Polyneuropathy, Lupus, Cellulitis of left lower extremity, heart attack, Anxiety, Pulmonary embolism, and Depression.

She was receiving the following medications since admission to facility: Zolpidem for sleep, Xanax for anxiety, and Fluoxetine for depression. Resident #37 had plans of care for Insomnia including use of hypnotic medication for sleep initiated on 4/7/26, depression including use of an anti-depressant medication related to depression disorder initiated on 4/8/2026, and for anxiety including use of anti-anxiety medication due to anxiety disorder with date of 04/06/2026.

Review of Resident #37's MDS showed use of antianxiety, antidepressant, and hypnotic medications.

Further review of Resident #37's medical record revealed there was no consent for psychotropic medications present in the chart.

An interview was conducted with the DON on 4/8/2026 at 5:15 PM.

She stated that they were unable to locate the admission documents, including consents to treat, consent for advance directives, and psychotropic medication consents.

She further explained that treatment should not have been initiated without consent first.

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Pensacola Nursing & Rehabilitation Center 235 West Airport Blvd Pensacola, FL 32505

During a record review of 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 at 10:44 AM and again during an interview with the Social Services Director on 4/7/26 at 12:57 PM. By 3:16 PM on 4/7/26, the facility still could not produce the advance directives documentation to the survey staff. A subsequent request on 4/8/2026 at 12:29 PM also yielded no documentation.

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Pensacola Nursing & Rehabilitation Center 235 West Airport Blvd Pensacola, FL 32505

limited to receiving treatment and supports for daily living safely.

observation, interview, and record review, the facility failed to maintain a clean and comfortable

include: On 4/6/26 at approximately 12:30 PM, during the initial tour, occupied room [ROOM NUMBER]'s shower was observed with black grime on the tile walls and floors.

The shower drain was covered with hair and a thick white substance. (Photographic evidence obtained)An interview conducted with room [ROOM NUMBER]'s occupant, who stated he had been using the shower in his room.

The resident further stated he had asked the staff multiple times to clean it. On 4/7/26 at approximately 10:30 AM, an additional observation was made.

The shower still had black grime on the tile walls and floors.

The shower drain was still covered with hair and thick white substance.A follow up interview was conducted with the room's occupant, who stated he wanted to take a shower but wanted it cleaned first.On 4/7/26 at approximately 12:45 PM, an interview conducted with Staff B, Housekeeping, who stated the rooms, bathrooms, and showers get cleaned daily.On 4/7/26 at approximately 12:55 PM, an interview conducted with Staff C, Housekeeping Manager (HM), who stated his expectations were for staff to clean bedrooms, bathrooms, and showers daily and deep cleans are conducted monthly.

The HM stated there were logs for the deep cleaning schedule and rooms were assigned per month. A tour was conducted with the HM, who observed room [ROOM NUMBER]'s shower and stated he would not want to use the shower with grime and hair in the drain.

The HM went on to state the shower did not look like it had been cleaned.

The HM reviewed the monthly deep cleaning schedule, which revealed room [ROOM NUMBER] was not cleaned by the staff.Review of Facility's Deep Clean Verification form for room [ROOM NUMBER] (dated 3/20/26) page 1 of 1 revealed: unsatisfactory for resident bathroom shower sanitized & shower curtain checked. (Photographic evidence obtained.) On 4/6/26 at approximately 9:00 AM, during the initial tour, room [ROOM NUMBER]'s bathroom was observed. An observation of the toilet revealed a thick brown and black substance around the base of toilet.

There was also approximately a half inch gap where the toilet was pulled away from the floor. (Photographic evidence obtained) On 4/8/26 at approximately 12:05 PM, a tour was conducted with the Administrator and Maintenance Director.

They both observed the base of the toilet with the black substance and that the toilet was pulled away from the floor. An interview was conducted with the Maintenance Director. He stated the staff should report repairs by writing a ticket, calling, or entering in the facility's Secura System.

They both stated the toilet would be repaired. A review of Facility's Maintenance Service policy (dated 12/2009) page #1 of 2 revealed: The maintenance department is responsible for maintaining the buildings, ground, and equipment in a safe and operable manner.

Maintaining the building in compliance with current federal, state, and local laws, regulations, and guidelines. (Photographic evidence obtained.)

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Pensacola Nursing & Rehabilitation Center 235 West Airport Blvd Pensacola, FL 32505

establish a grievance policy and make prompt efforts to resolve grievances.

residents reviewed (Resident #40)The findings include: On 04/06/2026 at 12:13pm, an interview with

March and, when she reported it, she was informed a grievance would be completed and the facility would resolve the issue.

She stated it had been about three weeks, and she has not heard the resolution.On 04/08/2026 at 2:07pm, an interview with the Social Services Assistant and the Director of Social Work was conducted. A review of the facility grievance logs from 01/28/2026 through 03/31/2026 was also conducted.

There were no entries in the grievances logs regarding Resident #40.

The Social Services Assistant stated she was not aware of a grievance filed by the sister of Resident #40.

There was no grievance log for April 2026.

The Social Services Assistant stated she still needs to make the April log.

The Director of Social Work stated they could not locate a grievance form regarding Resident #40.On 04/09/2026 at 9:36am, an interview was conducted with the Director of Admissions.

She stated Resident #40's sister informed her of missing clothing items, and she completed the grievance form and turned it into the Social Services office.

The Director of Admissions stated she did not know the exact date but stated it was not long after Resident #40 was admitted to the facility.

She also stated she is unsure of the specific person she handed the grievance form to, but she stated it was one of the two people who work in Social Services. On 04/09/2026 at 11:50am a review of the facility procedure titled, Standards and Guidelines: Grievance - Resident Rights was conducted.

The procedure revealed in Step #8, upon receipt of a grievance and/or complaint, the Grievance officer will review and investigate the allegations and submit a report of such findings to the Administrator within five (5) working days and Step #12 reveals, The resident or person filing the grievance and/or complaint on behalf of the resident, will be informed (verbally and/or in writing as per request) of the findings of the investigation and the actions that will be taken to correct any identified problems, and Step 12a., The Administrator, or his or her designee, will make such reports orally within ten (10) working days of the filings of the grievance or complaint with the facility.

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Pensacola Nursing & Rehabilitation Center 235 West Airport Blvd Pensacola, FL 32505

Review of Resident #122's clinical record revealed they were admitted to the facility on [DATE].

Further review revealed Resident #122 had an active physician's order for a Foley catheter.

The Comprehensive Care Plan failed to include a care plan focus area for the indwelling urinary catheter or catheter care interventions.

On 4/8/26 at approximately 1:10 PM, an interview was conducted with the Minimum Data Set (MDS) Coordinator.

The MDS Coordinator stated the indwelling urinary catheter care plan for Resident #10 and Resident #122 should have been developed within 48 hours of their admission and admitted that it had been omitted for both residents.

Observations were conducted of Resident #11 on 4/6/26 at 11:57 AM, 4/7/26 at 10:02 AM, 12:25 PM, 3:26 PM and 4/8/26 at 9:11 AM.

During each of these observations, Resident #11 was seen lying and moving around in their bed.

During each of these observations, it was noted that there was no fall mats present at the bedside.

A review of Resident #11's physician's orders revealed an active order for fall mats to be placed at the bedside due to Resident #11 having a history of falls. A review of the care plan revealed Resident #11 was identified as being at risk for falls related to weakness and involuntary movements and included the use of fall mats as an intervention.

Despite the physician order and care plan interventions, fall mats were not in place for Resident #11.

On 4/8/26 at approximately 9:00 AM, an interview with Staff X, Certified Nursing Assistant (CNA) confirmed Resident #11 had not had any fall mats in place since they were moved into their current room.

On 4/8/26 at approximately 1:49 PM, an interview with Staff E, Unit Manager (UM) revealed Resident #11 was recently moved to their current room and the fall mats were not transferred with the resident but that they should have been.

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Pensacola Nursing & Rehabilitation Center 235 West Airport Blvd Pensacola, FL 32505

During an interview on 04/06/2026 at 2:45 PM, Resident #108 reported that her incontinence briefs were too small and tight and stated she had been experiencing burning with urination for several days.

On 04/06/2026 at 4:12 PM, Staff T, Certified Nursing Assistant (CNA), reported to Staff E, Nurse Manager that Resident #108 continued to complain of burning during urination while Staff T was providing care.

A record review for Resident #108 showed that a urinalysis was ordered on 03/31/2026 at 5:00 PM.

The record also showed that Resident #108 had a history of urinary tract infections (UTI).

The care plan, updated on 02/09/2026, indicated Resident #108 was at risk for UTIs and that labs should be monitored as ordered.

During an interview on 04/08/2026 at 2:40 PM, Staff G, Licensed Practical Nurse (LPN), reviewed the outgoing lab binder and confirmed that no laboratory specimens had been sent for Resident #108 since the urinalysis order was written on 03/31/2026.

Staff E was notified and stated another order would be entered for a straightˆcatheter urinalysis due to reported resident refusal to provide a sample.

However, a review of the resident's record contained no documentation indicating Resident #108 had refused to provide a sample.

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Pensacola Nursing & Rehabilitation Center 235 West Airport Blvd Pensacola, FL 32505

#9 on 4/6/26 at approximately 2:06 PM, he stated he had lost some weight since being admitted to

2/6/26, for weights 3 times a week every Monday, Wednesday, and Friday.

The Comprehensive Care Plan included a care plan focus area for at risk for alteration nutrition/hydration related to history of weight loss/weight fluctuations due to Congestive Heart Failure (a chronic condition where the heart does not pump blood efficiently enough to meet the body's needs) and Edema (swelling caused by excess fluid trapped in the body's tissues) with interventions for weights as ordered. (Photographic evidence obtained.)

Review of the facility's list for obtaining regular weights (dated 3/30/26) revealed Resident #9's name was omitted. (Photographic evidence obtained.)On 4/7/26 at approximately 12:30 PM, Staff A, Licensed Practical Nurse (LPN) independently reviewed Resident #9's weight input on the Medication Administration Record and stated Resident #9 did have an active order to obtain weights 3 times a week on Mondays, Wednesdays, and Fridays.

Staff A stated she was unaware why the weights were not documented in the computer. On 4/7/26 at approximately 1:15 PM an interview conducted with Staff E, Unit Manager (UM).

She stated the restorative aide was responsible for obtaining weights on residents and the assigned nurse would follow up if no weights were obtained.

Staff E reviewed the clinical record for Resident #9 and stated she did not know why the weights were not obtained per the physician order.

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Pensacola Nursing & Rehabilitation Center 235 West Airport Blvd Pensacola, FL 32505

collaboration was maintained with the dialysis facility for 1 of 1 resident reviewed for dialysis

facility for dialysis treatment. Resident #52 returned to the facility after lunch, around 2:00 PM. An observation was conducted at 4:15 PM with Resident #52. He voiced being tired due to his treatment but was okay. On 4/8/26 at 11:30 AM, during an interview with Resident #52, he stated, I don't always get the paperwork to take with me to the dialysis center.A record review revealed that Resident #52 was initially admitted to the facility on [DATE] and re-admitted to facility on 8/7/25 post hospitalization with diagnoses including end stage renal disease (ESRD), arteriovenous fistula, and dependence of dialysis. He was ordered for dialysis every Tuesday, Thursday and Saturday for his ESRD. Resident #52 had a plan of care for being at risk for fluid imbalance related to kidney failure, fluid restrictions. Resident #52 was at risk for complications related to hemodialysis with goal that he will be compliant with dialysis appointments, nursing interventions and physician orders.The dialysis communication binder with instruction sheet present in front of binder revealed contains tabs of patients who has dialysis for your unit, dialysis sheets will need to be filled out by our nurse prior to dialysis clinic nurse, and then vital signs once patient arrives at facility, if patient does not have sheet filled out and back to facility, contact the dialysis clinic to retrieve the portion where the dialysis clinic.A review of the Long-term care facility outpatient dialysis services care coordination agreement: section B information sharing: for the purposes of care coordination, in advance of each resident's dialysis treatment, long term care facility shall furnish all information and documentation necessary for dialysis facility to provide safe and appropriate care, including any and all information reasonably requested by dialysis facility.

Further review of hemodialysis communication records dated 3/2/24, 2/5/26, and 3/14/26 revealed no documentation of collaboration of care is observed in the medical chart or in dialysis communication binders on the unit.

105935 04/09/2026

Pensacola Nursing & Rehabilitation Center 235 West Airport Blvd Pensacola, FL 32505

Review of the facility policy, Standards and Guidelines: Medication Administration, (issued 10/2020 and revised 1/2024) stated, If a Drug is withheld, refuse, or given at a time other than the scheduled time, The individual administering the medication shall document the rationale in the residence medical record and notify the physician.

And responsible party if indicated.

Medications will be reordered as needed with practitioner approval unless otherwise indicated. (ie auto-refill from pharmacy, emergency medication supply use, etc)

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Pensacola Nursing & Rehabilitation Center 235 West Airport Blvd Pensacola, FL 32505

During this observation, it was noted that red biohazard bags were on the floor of Resident #1's room.

An interview was conducted at the time of the observation with Staff J, Certified Nursing Assistant.

Staff J stated that Resident #1 did not have a roommate because Resident #1 was on Transmission Based Precautions (TBP) for Methicillinˆresistant Staphylococcus aureus (MRSA) in a wound (MRSA is a drug-resistant bacteria). It was noted that no TBP signage was posted on the door of Resident #1's room.

An additional observation of Resident #1's room was conducted on 4/7/26 revealed that no TBP sign was present. A review of the medical record showed that TBP had been ordered on 4/6/26.

On 4/8/26, it was observed that an Enhanced Barrier Precaution (EBP) sign was posted on the outside of Resident #1's room.

On 4/8/26, an interview with the Director of Nursing was performed.

She acknowledged these signs had not been present until that day.

On 4/6/26 at approximately 1:14 PM, observations were made of indwelling urinary catheters for Resident #10 and Resident #122.

During these observations, it was noted that there was no signage posted for Enhanced Barrier Precautions (an infection control measure requiring staff to wear gowns and gloves during high-contact care) on the doors of either resident.

A review of Resident #10's clinical record, admitted [DATE], revealed an active physician's order for Enhanced Barrier Precautions.

The Comprehensive Care Plan, reviewed on 4/7/26, included a care plan focus area for Enhanced Barrier Precautions with interventions. (Photographic evidence obtained.) Review of Resident #122's clinical record, admitted [DATE], revealed an active physician's order for Enhanced Barrier Precautions.

The Comprehensive Care Plan, reviewed on 4/7/26, included a care plan focus area for Enhanced Barrier Precautions with interventions. (Photographic evidence obtained.) On 4/7/26 at approximately 9:00 AM a follow up observation was conducted with Staff A, Licensed Practical Nurse (LPN), who acknowledged signage for Enhanced Barrier Precautions needed to be posted for Resident #10 and Resident #122.

Staff A stated a sign would be posted.

On 4/7/26 at approximately 12:55 PM, an interview was conducted with Staff E, Unit Manager (UM).

Staff E confirmed that an Enhanced Barrier Precautions sign should have been placed on the door of the resident's rooms for the staff to know what Personal Protective Equipment (PPE) to wear.

On 4/7/26 at approximately 1:30 PM, an interview was conducted with Staff F, Certified Nursing Assistant (CNA).

Staff F stated she was unaware of what appropriate PPE to wear for Resident's #10 and #122.

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Pensacola Nursing & Rehabilitation Center 235 West Airport Blvd Pensacola, FL 32505

and functional condition for the 200 hallway.The findings include:On 4/6/26 at approximately 11:35

be broken.

When pressure was applied to the handrail, the handrail displaced approximately 3 inches vertically. (Photographic evidence obtained)On 4/8/26 at approximately 12:05 PM, a follow-up observation on the broken handrail was conducted with facility's Administrator and Maintenance Director.

They both confirmed handrails should be secure to the wall and they confirmed this handrail needed to be repaired. A review of Facility's Maintenance Service policy (dated 12/2009) page #1 of 2 revealed: The maintenance department is responsible for maintaining the buildings, ground, and equipment in a safe and operable manner.

Maintaining the building in compliance with current federal, state, and local laws, regulations, and guidelines. (Photographic evidence obtained.)