Havens at Pensacola, The

In the surveyor’s words

From the most serious findings on record at Havens at Pensacola, The, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF880Jun 3, 2026

  Based on observations, interviews, record review, and review of the facility policies and procedures, the facility failed to follow infection prevention and control standards including hand hygiene, proper use and ready availability of Personal Protective Equipment (PPE) and storage of oxygen tubing, to prevent the spread of infections by staff involved in direct resident care in 3 of 4 residents observed. (Resident #13, #85, #131)The findings include:1. An observation was conducted outside of Resident #13's room on 5/31/26 at approximately 2:00 PM. It was noted that two signs were posted on the room door, one for contact precautions and one for enhanced barrier precautions (EBP). […]

• No harm, potential for more than minimal, patternF732Dec 14, 2023

  Based on observations and interviews, the facility failed to post the required staffing data in a prominent place readily accessible to residents and visitors. The findings include: On 12/11/23 at 11:00 AM, an initial tour of the 100 Hall was conducted. There was no visible daily staffing observed throughout the unit. There was a daily staffing sheet inside the nourishment room that had the name of nurses and Certified Nurse Assistants (CNAs) working in each of the 4 units and the facility total census. The sheet did not contain the census per unit nor the rooms assigned to staff. On 12/11/23 at 11:10 AM, an interview was conducted with Staff D, a Licensed Practical Nurse (LPN), that was working in the 100 Hall. […]

• No harm, potential for more than minimal, isolatedF759Jun 3, 2026

  Based on observations, interviews, and record and policy review, the facility failed to maintain a medication error rate of less than 5% as evidenced by a medication error rate of 8% (2 errors out of 25 opportunities). The findings included: A medication administration observation was conducted with Staff I, Licensed Practical Nurse (LPN) on 6/1/26 at approximately 8:15 AM. Using the electronic medical record, Staff I prepared Resident #81's medications. Staff I was observed retrieving one Olmesartan/amlodipine/hydrochlorothiazide 40/10/25 milligram (mg) tablet (a combination medication used to treat high blood pressure) and one Meclizine 25mg tablet (a medication used to treat dizziness) and placing them into a medication cup. […]

• No harm, potential for more than minimal, isolatedF883Mar 6, 2025

  Based on review of the electronic medical record (EMR) and staff interviews, the facility failed to maintain complete and accurate documentation of the consent and administration for immunizations for 4 out of 5 residents sampled. (Resident #32, #46, #100, #261) The findings include: On 3/5/25 at approximately 11:00 AM, a review of vaccination consents and administration forms in the EMR was conducted with the Infection Control Nurse (ICN). The record revealed the consent form for Resident #58 did not have a completion date of the administration, nor did it have the vaccine lot number and expiration date. Resident #46 did not have a vaccine lot number or expiration date recorded. […]

• No harm, potential for more than minimal, isolatedF578Dec 14, 2023

  Based upon record review, resident interview and staff interview, the facility failed to ensure that a resident's preferred advanced directives were documented for 1 of 2 residents reviewed for advanced directives. (Resident #22) The findings include: On [DATE], a record review was conducted for Resident #22. The resident's electronic record contained an order for a Full Code dated [DATE]. However, the resident had a Living Will dated [DATE] which indicated the resident did not want Cardiopulmonary Resuscitation (CPR). On [DATE] at approximately 1:22 PM, an interview was conducted with Resident #22. The resident was asked if they she wanted CPR should she need it. […]