Health inspection·February 19, 2026

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). Page 1 of 2 105935 105935 02/19/2026 Pensacola Nursing & Rehabilitation Center 235 West Airport Blvd Pensacola, FL 32505

F 0808 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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. 105935 Page 2 of 2