F 0812
Level of Harm - Minimal harm
or potential for actual harm
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve
food in accordance with professional standards.
Based on observations, interviews and policy reviews, the facility failed to store and prepare food in
accordance with professional standards for food service safety.
Residents Affected - Few
The findings include:
On 9/17/23 at approximately 10:15 AM, an initial tour of the kitchen was conducted. During the tour, Staff A,
a cook, was observed preparing food but was not wearing a hair net over his head or a beard net over his
beard.
On 9/17/23 at approximately 10:44 AM, the walk in cooler was observed to have a three compartment
container with egg salad, macaroni salad, and lettuce, none of which were dated. On top of the container,
there was an open package of peeled boiled eggs with no date on it (see photographic evidence). There
were 7 plates covered with aluminum foil with no dates on them (Photographic evidence was obtained).
On 9/17/23 at approximately 10:20 AM, an interview was condcuted with Staff A, who stated they ran out of
hair nets and beard nets that day. The staff member stated there were nets available, but he did not have
keys to get into the manager's office to get them.
On 9/17/23 at approximately 10:30 AM, an interview was conducted with Staff B, a dietary aide, who stated
everyone is responsible for ensuring dates are on the opened and prepared food in the walk in cooler. The
staff member stated she believed the food was from the night before and night shift should have labeled it
before putting them in the cooler.
On 9/18/23 at approximately 9:15 AM, an interview was conducted with the Kitchen Manager, who stated
she arrived on 9/17/23 shortly after this surveyor left and put the dates on the food items in the cooler and
educated the staff members who did not label them and she provided hair and beard nets to Staff A when
she arrived.
On 9/18/23, a review of the facility policy Receiving (revised 9/2017), item 5, stated, All food items will be
appropriately labeled and dated through manufactures packging or staff notation. In addition, the policy
labeled Staff Attire (revised 9/2017), item 1, states, All staff members will have thoeir hair off the shoulders,
confined in a hair net or cap, and facial hair properly restrained.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 2
Event ID:
105935
Printed: 05/28/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
105935
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
09/21/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Pensacola Nursing & Rehabilitation Center
235 West Airport Blvd
Pensacola, FL 32505
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0880
Provide and implement an infection prevention and control program.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation, interviews, record reviews, and policy reviews, the facility failed to provide infection
control measures for 1 of 2 residents sampled for respiratory care. (Resident #395)
Residents Affected - Few
The findings include:
On 9/17/23 an observation was made of the Resident #395's nebulizer machine (a machine that delivers
medications to the resident's lungs using a mouthpiece to help with breathing) sitting on the nightstand with
the mouthpiece not bagged, covered, or stored appropriately to prevent contamination. The date on
mouthpiece read 08/25/2023.
On 09/18/2023, an observation was made of Resident #395's nebulizer machine sitting on the nightstand
once again with the mouthpiece not bagged, covered, or stored appropriately. However, the tubing was
dated 09/18/2023.
On 09/19/2023 an observation was made of Resident #395's nebulizer machine sitting on the nightstand
with mouthpiece not bagged, covered, or stored appropriately.
(Photographic evidence obtained)
A record review was conducted of Resident #395, which revealed a diagnosis of Chronic Obstructive
Pulmonary Disease (COPD) and Asthma. A review of the physician orders revealed an order dated
09/16/2023 for DuoNeb Inhalation with Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3)
milligram/3milliliter 3 milliliter inhale orally every 4 hours as needed for shortness of breath/wheezing (a
medication used to help open the resident's airway and breathe better).
On 09/19/2023 at approximately 9:45 AM, an interview was conducted with Nurse D (a licensed practical
nurse) concerning the storage of the nebulizer equipment when not in use. Nurse D stated, tubing should
be dated and the mask or mouthpiece should be in a bag with a date. Nurse D confirmed that the
mouthpiece for the nebulizer was not properly stored and stated that she would change it out and have it
bagged appropriately.
On 09/19/2023 at approximately 3:41 PM, an interview was conducted with the interim Director of Nursing
(DON) concerning proper storage of resident's nebulizer equipment while not in use. The DON stated her
expectations of nebulizer equipment storage while not being used is, the mouthpiece and equipment should
be bagged and dated when not in use.
Review of facility policy titled Respiratory Therapy Equipment dated April 2022 revealed:
Purpose: The purpose of this procedure is to provide guidelines to help prevent nosocomial infections
(facility acquired infections) associated with respiratory therapy equipment, including ventilators, and to
prevent transmission of infections to residents and staff.
Procedure Guidelines: Medication Nebulizers/Continuous Aerosol: 5. Use caution not to contaminate
internal nebulizer tubes. 6. Wipe mouthpiece with paper towel. 7. Store circuit in plastic bag, marked with
date and resident's name, between uses. 8. Wash hands. 9. Discard administration set-up every 7 days.
Date new tubing.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105935
If continuation sheet
Page 2 of 2
