F 0880
Provide and implement an infection prevention and control program.
Level of Harm - Minimal harm
or potential for actual harm
Based on observations, interviews, and record reviews, the facility failed to implement Enhanced Barrier
Precautions (EBP) as an infection control intervention designed to reduce transmission of organisms that
employs targeted gown and glove use during high contact resident care activities for 1 of 1 residents
observed for transmission based precautions. (Resident #131)The findings include: Observations
performed on 09/07/25 at approximately 12:58 PM and 4:25 PM and 9/08/25 at 8:19 AM discovered that
there was no EBP signage posted and no Personnel Protective Equipment (PPE) access outside of the
room for Resident #131. (Photographic Evidence Obtained). On 09/07/25 at approximately 12:58 PM, an
interview was conducted with Resident #131. She explained that she has been newly admitted to the facility
status post colostomy and requires wound care to her surgical scar. On 09/08/25 at approximately 8:19 AM,
an additional interview was conducted with Resident #131. She explained that the staff do not wear
additional gowns or protective equipment during wound care. On 09/09/25 at approximately 11:25 AM, an
interview was conducted with the Director of Nursing (DON) and the Infection Preventionist. They explained
that Resident #131 was admitted with a small dehiscence to her surgical scar on 09/02/25. They further
indicated that EBP was initiated in her care plan on 09/05/25, however they forgot to place the signage that
includes instructions for use of specific PPE to be used and make PPE readily available near the entrance
of the room for Resident #131. They acknowledged that between 09/05/25 and 09/08/25, EBP were not
followed during high-contact resident care activities, providing opportunities for transfer of organisms.The
physician's orders initiated on 09/03/25 for Resident #131 include cleanse area of dehiscence to proximal
end of midline abdominal with wash, loosely pack wound with calcium alginate, cover with small foam
dressing.The Care Plan initiated on 09/05/25 for Resident #131 has a focus for break in skin integrity with
open area to proximal end of surgical wound, including a goal to minimize risk for symptoms of infection
with an intervention that includes Enhanced Barrier Precautions. The weekly Wound Care progress note
dated 09/09/25 reveals proximal end of midline abdominal surgical scar dehiscence present on admission.
The Treatment Administration Record (TAR) for September 2005 reveals wound care to the proximal end of
midline abdominal surgical scar dehiscence was provided on 09/03/25, 09/06/25 and 09/08/25.A facility
policy titled Enhanced Barrier Precautions (EBP) (reviewed 07/03/25 and revised 08/19/25) states, EBP
refers to an infection control intervention designed to reduce transmission of multidrug-resistant organisms
that employs targeted gown and glove use during high contact resident care activities. Policy for use of EBP
as an additional Multidrug-Resistant Organism (MDRO) mitigation strategy for residents that meet the
following criteria, during high contact resident care activities. EBP are indicated for residents with the
following wounds even if the resident is not known to be infected or colonized with a MDRO Wounds
generally include chronic wounds that include, but are not limited to pressure ulcers, diabetic foot ulcers,
unhealed surgical wounds, wound care, skin opening requiring a dressing. EBP should be used for any
residents who meet the above criteria, wherever they reside in the facility. The facility may choose to post
Residents Affected - Few
(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 2
Event ID:
106073
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
106073
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
09/10/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Life Care Center of Pensacola
3291 East Olive Rd
Pensacola, FL 32514
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
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
signage on the door or wall outside of the resident room indicating the resident is on EBP. The facility
should ensure PPE and alcohol-based hand rub are readily accessible to associates.A review of the Center
for Disease Control and Prevention website at:
https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/PPE.html#cdc_generic_section_2-enhanced-barrier-precau
titled Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of
Multidrug-resistant Organisms (MRDO), dated 04/02/2024 was reviewed. It reveals that: when
implementing Contact Precautions or Enhanced Barrier Precautions, it is critical to ensure that staff
awareness of the facility's expectations about hand hygiene and gown/gloves use, initial and refresher
training, and access to appropriate supplies. To accomplish this, post clear signage on the door or wall
outside of the resident room indicating the type of Precautions and indications for high contact resident
care activities the use of gown and gloves; make PPE available immediately outside of the resident's door.
Event ID:
Facility ID:
106073
If continuation sheet
Page 2 of 2