Inspection·July 14, 2022

F 0554 Allow residents to self-administer drugs if determined clinically appropriate. Level of Harm - Minimal harm or potential for actual harm Based on observation, resident and staff interviews, and record and policy review, the facility failed to ensure the interdisciplinary team assessed and determined a resident was capable of self-administration of medications prior to allowing 1 of 21 sampled residents to self-administer medications. (Resident #16) Residents Affected - Few The findings include: An observation of Resident #16 was conducted on 7/11/2022 at 2:01 PM. A medication cup containing 6 pills was observed to be sitting on her over bed table. No staff were present in the room with the medications and resident. (Photographic evidence obtained) An interview was conducted with Resident #16 on 7/11/2022 at 2:01 PM. Resident #16 stated the nurse does not have to observe her take her pills because she knows she will take them. An interview was conducted with Employee B (Licensed Practical Nurse) on 7/11/2022 at 2:04 PM. Employee B stated she had just walked out of the room and confirmed she leaves the pills with Resident #16 because she is good about taking them. She further confirmed she is supposed to watch the resident take her pills. Review of Resident #16's record revealed no assessments to conclude the resident was capable of self-administration of medications. An interview was conducted with the Director of Nursing (DON) on 7/13/2022 at 3:01 PM. The DON stated Resident #16 had not been assessed to self-administer medications. Review of the policy Medication Management: Self Administration of Medication Review (3F-3.7.1-A) with an original date of 05/2014 revealed the purpose of completing the Self Administration of Medication Review form is to evaluate the resident's ability to safely self-administer medications. The responsible person was listed as the Licensed Nurse. The policy indicated this review should be completed upon admission if the resident requests to self administer, when there is a change in clinical condition, and quarterly. Review of instructions revealed the following: Enter the resident information at the bottom of the form. Explain the questions and required demonstration to the resident. Enter a check mark next to each question that best describes resident's ability to complete task: a. fully capable, b. able with assist, c. unable, d. not applicable. Enter the signature/title and date as the person completing the evaluation. Enter date that the interdisciplinary team reviewed. Enter a check mark to indicate if approval to self-administer was granted. Enter a brief explanation if approval is not granted in the lines provided. Each member of the interdisciplinary team enters signature and title. File in resident's clinical record upon completion. (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 5 Event ID: 105628 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 105628 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arabella Health & Wellness of Pensacola 1717 W Avery St Pensacola, FL 32501 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)