F 0656
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Develop and implement a complete care plan that meets all the resident's needs, with timetables and
actions that can be measured.
Based on observation, interview, and record review, the facility failed to implement care plan interventions
for supervision during meals for 1 of 4 residents sampled. (Resident #6)The findings include: On 2/19/26 at
approximately 9:00 AM, an observation made in Resident #6's room revealed signage above the head of
bed that reads, 1. Supervised All meals. (Photographic evidence obtained).On 2/19/26 at approximately
11:10 AM, an interview was conducted with Staff A, Unit Manager (UM), who stated if a resident requires
assistance or supervision with meals there is usually an order, or it will be listed on the resident's care plan.
Staff A went on to state the certified nursing assistants and staff are made aware during daily shift
reports.On 2/19/26 at approximately 11:45 AM, an interview was conducted with Staff B, Certified Nursing
Assistant (CNA), who stated if a resident requires assistance or supervision with meals, it will be located on
the meal ticket for that resident. On 2/19/26 at approximately 12:45 PM, an observation was made of
Resident #6's room. The door was open with the privacy curtain pulled. Resident #6 was observed sitting
up in bed feeding himself with no staff present. On 2/19/26 at approximately 12:47 PM, an interview was
conducted with Staff B (CNA) who stated she was unaware that Resident #6 required supervision with all
meals. Staff B went on to state the sign in Resident #6's room means staff are to be with the resident while
he eats and she will stay with him.On 2/19/26 at approximately 12:55 PM, an interview was conducted with
the Speech Pathologist, who stated Resident #6 has a history with difficulty swallowing and he
recommended supervision with all meals on 02/01/26. The Speech Pathologist stated supervision with
meals means staff are to be in sight of the resident during the entire meal and staff should not leave a meal
tray with Resident #6 alone.On 2/19/26 at approximately 1:00 PM, an interview was conducted with the
Regional Nurse Consultant (who is currently acting as the Director of Nursing). She stated her expectations
for staff when a resident requires supervision during meals is, when the staff delivers the tray to the
resident, that staff is to stay with the resident during the entire meal.A record review of Resident #6'
revealed the following: An order dated 2/1/26 reading, Supervised all meals, monitor oral holding. A Diet
Order and Communication by the Speech Pathologist dated 2/1/26 reading, Supervised all meals, monitor
oral holding. A Speech Therapy Evaluation, with certification period dates 2/1/26 through 3/2/26, stating,
Patient requires supervision at mealtime prior to onset. Resident #6's care plan date initiated 2/4/26 states,
Supervise for all meals. (Photographic evidence obtained).
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
02/19/2026
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 0808
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or
licensed dietitian, to the extent allowed by State law.
Based on observation, interview, and record review, the facility failed to provide an ordered therapeutic diet
for 1 of 4 residents sampled. (Resident #6)The findings include: On 2/19/26 at approximately 9:00 AM, an
observation made in Resident #6's room revealed signage above the head of bed that read, 3. Mech soft,
chopped meats, thin liquids. (Photographic evidence obtained)On 2/19/26 at approximately 12:45 PM, an
observation was made of Resident #6 feeding himself with no staff present. The meal tray was observed to
have approximately 7 potato chips and approximately 2 saltine crackers with his meal. The meal ticket read,
Regular-DYS ADV (DYS ADV is short for Dysphagia Advanced, which means a regular diet, but avoiding
hard, sticky, or crunchy foods. Foods should be bite-size). (Photographic evidence obtained).On 2/19/26 at
approximately 12:47 PM, an interview was conducted with Staff B, Certified Nursing Assistant (CNA), who
stated chips and crackers are not part of a mechanical soft texture diet. Staff B entered Resident #6's room
and removed the chips and crackers from his meal tray. Staff B stated the Regular-DYS ADV on the meal
ticket means the diet is regular with mechanical soft texture.On 2/19/26 at approximately 12:50 PM, an
interview was conducted with Staff A, Unit Manager (UM), who stated chips and crackers are not part of a
mechanical soft texture diet and would notify dietary.On 2/19/26 at approximately 12:55 PM, an interview
was conducted with the Speech Pathologist, who stated a resident with a mechanical soft and chopped
meat diet would not have chips and crackers on a meal tray.On 2/19/26 at approximately 1:00 PM, an
interview was conducted with the Regional Nurse Consultant (who is acting Director of Nursing). She stated
her expectations are for staff to follow therapeutic diets according to the meal tickets and physician
orders.On 2/19/26 at approximately 1:05 PM, an interview was conducted with the Administrator, who
stated his expectation for the dietary department is to accurately place meals on trays according to the
meal tickets.On 2/19/26 at approximately 1:10 PM, an interview was conducted with the Certified Dietary
Manager (CDM), who stated dietary staff are to read each meal ticket and place food on the meal tray
according to the therapeutic diet on the ticket. The CDM stated the chips and saltine crackers should not
have been placed on Resident #6's tray.Resident #6's diet order dated 2/1/26 reads, Regular diet,
mechanical soft texture, thin consistency. Resident #6's Speech encounter date of service 2/1/26 reads,
Dysphagia Precautions: aspiration, malnutrition, voice, cognition, exercises to improve mastication with
solids, reduce oral holding, swallow strategy, staff education. Mechanical soft/chopped textures.A review of
the facility's Diet Consistency policy (revised: 7/2024) reveals, Texture modified diets will be prepared to the
appropriate consistency for ease of chewing/swallowing. Follow the diet manual instructions for texture
modified diets. Texture modified diets are: Mechanical/Ground Soft Diet and Puree Diet. A therapeutic diet
is considered a diet ordered by a physician, practitioner or dietician as part of treatment for a disease or
clinical condition, to modify specific nutrients in the diet, or to alter the texture of a diet, for example: The
Diet order should have: Diet Type, Texture, and fluid consistency.
Event ID:
Facility ID:
105935
If continuation sheet
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