Inspection·November 30, 2023

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observations, interview, and record review, the facility failed to store food in accordance with professional standards in the facility's unit nourishment refrigerators. Residents Affected - Few The findings include: On 11/30/2023 at approximately 11:00 AM, the nourishment refrigerators at the two nurse's stations were inspected. The station #2 refrigerator was found to be filled with a number of resident personal food items that were out of date or unlabeled. Facility supplements were found to be in date but with one opened container. Both the freezer and refrigerator were found to have old food spills that had not been wiped up. (Photographic evidence obtained) The station #1 refrigerator appeared clean. There were no personal Resident food items present. All nourishment containers were unopened and within expiration dates. The floor under the refrigerator was stained with uncleaned food spills. The charge nurse stated she had called maintenance to have the floor cleaned. On 11/30/2023 at approximately 11:00 AM, the charge nurse station #2 verified that opened supplements should be discarded within 24 hours and that this container was outside of the facility policy of 24 hours. She also stated that food brought into the facility by families are supposed to be dated and the resident's name placed on container. She stated that prepared food brought in be family should be discarded after 72 hours. The policy entitled Food brought into residents from outside sources from the Nutrition Services Manual (dated June 2015) revealed, Any food, which is not to be eaten right away, should be transported in a clean, disposable, sealed container .Your nurse will label, date, and store this food in the nursing unit's nourishment refigerator. If the food is not used within 3 days, it will be discarded. The policy titled Cleaning and Sanitizing of Refrigerator, Cooler and Freezer from the Nutrition Services Manual (dated June 2015), Discard all leftover items over 72 hours old or per state/local regulation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105628 If continuation sheet Page 2 of 3 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 11/30/2023 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)

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 review, the facility failed to maintain infection control practices for 1 of 4 residents observed during medication administration observation. (Resident #5) Residents Affected - Few The findings include: On 11/29/23 at approximately 9:09 AM, an observation was made of Nurse A, a Licensed Practical Nurse (LPN), administering medications to Resident #5. Nurse A placed Resident #5's Azelastine Nasal spray (a medication used to treat sinus allergies), Breo Ellipta Aerosol Powder inhaler (a medication used to treat chronic obstructive pulmonary disease), and Visine ophthalmic solution (eye drops used to treat dry eyes) on Resident #5's over the bed table without placing a barrier between the table and the medications. Nurse A then applied clean gloves and assisted in pulling Resident #5 up in the bed. Nurse A then changed gloves without performing hand hygiene. Nurse A then administered Resident #5's inhaler, nasal spray and eye drops without changing gloves and performing hand hygiene in-between each medication, and between each eye. Nurse A then removed her gloves and performed hand hygiene. On 11/29/23 at approximately 9:28 AM, an interview was conducted with Nurse A. Nurse A confirmed that she did not place a barrier on the over the bed table prior to placing Resident #5's medications on the table. When asked if Nurse A changed gloves and performed hand hygiene after pulling the resident up in bed and administering resident #5's medications, Nurse A stated she changed gloves but did not wash her hands. When asked if Nurse A changed gloves and perform hand hygiene in between administering resident #5's nasal spray and eye drops, Nurse A stated, No I did not, and I know better. Nurse A confirmed that this would be considered an infection control issue. On 11/29/23 at approximately 1:45 PM, an interview was conducted with the Director of Nursing (DON). The DON confirmed that her expectation for infection control during medication administration is for the nurse to place a barrier in between medications and the over the bed table, and for the nurse to change gloves and perform hand hygiene in between administering nasal sprays and eye drops. A review of the facility policy titled Nursing Procedure Manual Medication Administration Nose Drops (dated January 2013) revealed, Purpose: To safely administer nose drops. Procedure: 6. Wash hands and apply gloves. 7. Assist resident/patient to lay back with head slightly lower than shoulders unless contraindicated. 10. Instill the number of drops ordered into each nostril. 12. Wipe any drainage with tissue. 14. Remove gloves and wash hands. A review of the facility policy titled Nursing Procedure Manual Medication Administration Eye Drops (also dated January 2013) revealed: Purpose: To safely administer medications to the eye(s). Procedure: 6. Assist the resident/patient into comfortable position for administration. 7. Wash hands. 8. Apply clean gloves. 16. Wash hands and apply new clean gloves if administering medication to the other eye. 17. Assist resident/patient into a comfortable position with call light in reach. 18. Remove gloves and wash hands. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105628 If continuation sheet Page 3 of 3