Inspection·January 9, 2025

F 0565 Honor the resident's right to organize and participate in resident/family groups in the facility. Level of Harm - Minimal harm or potential for actual harm Based on record review and interview, the facility failed to act promptly to resolve and properly investigate grievances submitted for 2 out 2 residents sampled. (Resident #54 and #21) Residents Affected - Few The findings include: On 11/17/24 Resident #54 filed a grievance. The form stated that she was only getting grits, a slice of toast and a glass of tea. She included the meal card to show what she should be getting. Resident #54's meal card for 11/17/24 stated she should receive: a double protein at breakfast, bacon, hot cereal, biscuit, jelly, margarine, juice of choice, orange juice, coffee, creamer, sausage patty, English muffin, jelly, margarine, toast, jelly, margarine. This complaint was verbally communicated to the administrator and dietary. This section was signed by the business office manager (BOM) on 11/17/24. This investigation was assigned to dietary staff and the Kitchen Manager on 11/18/24. On the Findings portion of the form, all that was written was, On the menu we have a lot of no meat days. The Plan to Resolve Complaint/Grievance section was left blank. The Expected Results of Actions Taken section only stated, We are just following the menu. This section was not signed or dated. The third section was left blank. This section includes: Was the complaint/grievance resolved?, Is complainant satisfied?, and Who were the investigation findings reported to and how were the results communicated?. The signature and name of who completed that section are blank but Resident # 54 signed it on 11/22/24. Resident #21 filed a grievance on 11/18/24 with the Social Services Director (SSD) stating he has not received meat with his breakfast in the last 2 weeks. The grievance form stated it was assigned to dietary but no name was included. The findings of the investigation were, On the menu we have a lot of no meat days but we do have meat days to we are just following the menu. The Expected Results of Actions Taken section stated, We are just following the menu. The 3rd section was left blank and Resident #21 signed it on 11/22/24. During an interview held on 01/15/25 at 10:59 AM, Resident #54 stated she no longer gets meat with breakfast. When asked if she had filed a grievance, she stated, Not anymore, it does not make a difference. On 01/09/25 at 09:59 AM, an interview was held with the Regional Dietitian. When she was shown the grievances for Residents #54 and #21, she stated that those forms are not filled out correctly because it is unclear what staff did the investigation. She also stated, There is no actual investigation, saying the menu is being followed is not a resolution to a problem, this looks like they never even spoke to the residents. In my opinion those grievances are not acceptable. On 01/09/25 at 12:35 PM, during a meeting with the Facility Administrator (FA), she stated the (continued on next page) 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 7 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 01/09/2025 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)