Inspection·February 20, 2025

F 0755 Level of Harm - Minimal harm or potential for actual harm 4. Electronic Orders: Refill orders can be submitted electronically from a prescriber through their escribing software or through a facilities EMAR (electronic medication record) system as long as the order is not discontinued. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105628 If continuation sheet Page 2 of 5 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 02/20/2025 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 Resident #21 Residents Affected - Few On 2/19/25 at approximately 9:36 AM, an observation was made of Nurse A during medication administration for Resident #21. Nurse A was observed to touch the inside of the medication cup, and the inside of the water cup with her bare hand. Further observations of Nurse A revealed that the nurse failed to clean the hub of the Lantus insulin pen (a medication used to treat Diabetes type II) with an alcohol swab prior to applying the needle. On 2/19/25 at approximately 10:00 AM, an interview was conducted with Nurse A, who indicated that touching the inside of the medication cup and water cup would be considered an infection control issue. Nurse A further confirmed that she did not clean the hub of the Lantus insulin pen prior to applying the needle and this too would be considered an infection control issue. On 2/19/25 at approximately 10:50 AM, an interview was conducted with the Regional Nurse, who indicated that it is the facility's expectation that the nurses do not touch the inside of the medication or water cups, and that the nurses also clean the hub of all insulin pens with alcohol prior to applying the needle. The Lantus SoloStar pen guide states under How to use your Lantus Solostar pen in 6 steps, Step 2. Attach the needle. * Wipe the pen tip (rubber seal) with an alcohol swab. The facility policy titled Infection Prevention and Control Program states, Policy: This facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines. Policy Explanation and Compliance Guidelines: 4. Standard Precautions: d. Licensed staff shall adhere to safe injection and medication administration practices, as described in relevant facility policies. Based on observations, interviews, policy review, and record review, the facility failed to wear proper protective equipment during catheter care for 1 of 1 resident observed during catheter care (Resident #13), failed to maintain sterile processes during tracheostomy care for 1 of 1 residents observed during tracheostomy care (Resident #36), failed to implement their legionella (a water born virus) plan for surveillance and prevention, and failed to follow infection control processes during medication pass for 1 of 5 residents observed during medication pass (Resident #21), The findings included: Resident #13 On 2/19/25 at approximately 9:30 AM, an observation of Staff B, a Certified Nursing Assistant (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105628 If continuation sheet Page 3 of 5 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 02/20/2025 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few (CNA), was conducted as she provided catheter care for Resident #13. Staff B failed to apply a barrier gown before she provided catheter care for Resident #13, who had been placed on enhanced barrier precautions to protect him from a catheter associated infections. A review of the physician orders for Resident #13 was conducted. A foley catheter was ordered to be inserted for Resident #13 on 1/9/25. Catheter care was ordered to be completed for the resident every shift. A physician order dated 1/14/25 indicated that the resident was to be placed on enhanced barrier precautions. On 2/19/25 at approximately 10:00 AM, an interview was conducted with Staff B. When asked about why she did not apply a gown during catheter care, the CNA indicated that she should have worn a gown while she provided catheter care. On 2/20/25 at approximately 9:00 AM, an interview was conducted with the Director of Nursing (DON). She was notified that Staff B did not wear a gown during catheter care for Resident #13. The DON indicated that a gown should have been worn. She indicated that staff retraining has already been initiated. A review of the facility policy titled Enhanced Barrier Precautions, dated 3/20/2024, was conducted. The policy states, Enhanced Barrier Precautions is an infection control intervention designed to reduce the transmission of multidrug-resistant organisms. Enhanced Barrier precautions were indicated to employ targeted gown and glove use during high contact resident care activities. The policy further indicated that Enhanced barrier precautions were to be unutilized for residents with urinary catheters to prevent infections with multi-drug-resistant organisms. Resident #36 On 2/19/25, an observation was made as Nurse C, a Licensed Practical Nurse (LPN), provided tracheostomy care to Resident #36. When she opened the sterile kit, the kit was upside down causing the sterile gloves to come out first and the suction catheter and other items to land on top of the sterile gloves. Nurse C handled the suction catheter, the container to hold the normal saline, and drain sponge prior to applying the sterile gloves, thus rendering those items unsterile. During the process, Nurse C touched multiple surfaces that were not clean as she provided tracheostomy care. Nurse C proceeded to change the inner canula next using the same gloves she applied at the beginning of the process. Immediately after the observation, an interview was conducted with Nurse C. She was asked if tracheostomy care/changing the inner cannula should be conducted as a sterile procedure. She indicated that she will look at the physician orders to double check and see if sterile procedure should have been utilized. She later indicated that changing the inner canula should have been completed utilizing sterile processes. She was asked if she has received training regarding the process for tracheostomy care. She could not recall when she had been trained. On 2/20/25 at approximately 9:00 AM, an interview was conducted with the DON. The DON was notified that there was concerns regarding maintaining sterility during tracheostomy care as Nurse C changed the resident's inner cannula. The DON indicated that training had been completed regarding tracheostomy care by the facility recently. A review of the facility policy for Tracheostomy Care dated 1/5/25 was conducted. The policy (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105628 If continuation sheet Page 4 of 5 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 02/20/2025 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 indicated that suctioning should be performed utilizing sterile technique. Level of Harm - Minimal harm or potential for actual harm Legionella plan Residents Affected - Few On 2/20/25 at approximately 9:00 AM, the facility's maintenance director was asked to provide information regarding the facility's water surveillance process. The Maintenance Director indicated that water is being tested using test strips. A copy of the facility's water testing logs for the past year along with other documentation regarding the facility's program for prevention of waterborne disease was requested. The Maintenance Director indicated that water was being tested utilizing test strips but not being logged. He was asked to provide any documentation regarding the facility water management program along with a copy of the facility policy and procedure for water management. The Maintenance Director provided a copy of the facility water management program policy. The policy indicated that a risk assessment was to be conducted by the water management team annually to identify where Legionella and other opportunistic waterborne pathogens could grow and spread in the facility's water system. The policy indicated that the Maintenance Director would maintain the facility's water management action plan and keep a copy in the facility water management program binder. The policy indicated that control measures were to be applied to address potential hazards at each control point in the water system. The policy further stated that a variety of measures would be utilized including physical controls, temperature management, disinfectant level control, visual inspections, and environmental testing for pathogens. These measures should be specified in the water management program action plan. Testing protocols and control limits will be established for each control measure. Individuals responsible for testing or visual inspections will document findings. The water management team were directed by the policy to regularly verify that the water management program is being implemented as designed. The Maintenance Director did not provide information regarding the annual risk assessment as indicated in the facility's policy. There was no water management provided for review. The facility did not provide documentation that testing was being performed at the time of the survey. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105628 If continuation sheet Page 5 of 5