Inspection·October 21, 2024

Agency for Health Care Administration PRINTED: 01/10/2025 FORM APPROVED STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING: __________ B. WING __________ (X3) DATE SURVEY COMPLETED R-C 10/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ARABELLA HEALTH & WELLNESS OF CARRABELLE 239 CROOKED RIVER ROAD CARRABELLE, FL 32322 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) ID PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE (N 000) INITIAL COMMENTS (N 000) On 10/21/24 a desk review revisit survey was conducted for the complaint survey, 2024011827, ending on 10/7/2024 at Arabella Health & Wellness of Carrabelle. Based on an acceptable plan of correction, evidence of corrective actions and interview with the Administrator, the deficiency was found corrected. AHCA Form 3020-0001 LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE Electronically Signed 12/04/24 STATE FORM 8899 CWNN12 If continuation sheet 1 of 1 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES PRINTED: 01/10/2025 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING ______ B. WING ______ (X3) DATE SURVEY COMPLETED R-C 10/21/2024 106081 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ARABELLA HEALTH & WELLNESS OF CARRABELLE 239 CROOKED RIVER ROAD CARRABELLE, FL 32322 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE (F 000) INITIAL COMMENTS (F 000) On 10/21/24 a desk review revisit survey was conducted for the complaint survey, 2024011827, ending on 10/7/2024 at Arabella Health & Wellness of Carrabelle. Based on an acceptable plan of correction, evidence of corrective actions and interview with the Administrator, the deficiency was found corrected. The facility was in compliance with Code of Federal Regulations (CFR) 42, Part 483, Subparts B-F, Requirements for Long-Term Care Facilities. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE Electronically Signed 12/04/2024 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. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:CWWN12 Facility ID: 35961023 If continuation sheet Page 1 of 1 DEPARTMENT OF HEALTH AND HUMAN SERVICES PRINTED: 01/10/2025 CENTERS FOR MEDICARE & MEDICAID SERVICES FORM APPROVED OMB NO. 0938-0391 | STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: | (X2) MULTIPLE CONSTRUCTION | | | A. BUILDING ____________________ | | 106081 | B. WING | | | | NAME OF PROVIDER OR SUPPLIER | STREET ADDRESS, CITY, STATE, ZIP CODE | (X3) DATE SURVEY COMPLETED | ARABELLA HEALTH & WELLNESS OF CARRABELLE | 239 CROOKED RIVER ROAD | R-C | | CARRABELLE, FL 32322 | 10/21/2024 | (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | ID PREFIX TAG | PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) | (X5) COMPLETION DATE | | {F 000} | INITIAL COMMENTS | {F 000} | | | | | | | | | | | On 10/21/24 a desk review revisit survey was conducted for the complaint survey, 2024011827, ending on 10/7/2024 at Arabella Health & Wellness of Carrabelle. Based on an acceptable plan of correction, evidence of corrective actions and interview with the Administrator, the deficiency was found corrected. The facility was in compliance with Code of Federal Regulations (CFR) 42, Part 483, Subparts B-F, Requirements for Long-Term Care Facilities. | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE Electronically Signed 12/04/2024 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. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CWNN12 Facility ID: 35961023 If continuation sheet Page 1 of 1 Agency for Health Care Administration PRINTED: 01/10/2025 FORM APPROVED STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 35961023 (X2) MULTIPLE CONSTRUCTION A. BUILDING: __________ B. WING ______ (X3) DATE SURVEY COMPLETED R-C 10/21/2024 NAME OF PROVIDER OR SUPPLIER ARABELLA HEALTH & WELLNESS OF CARRABELLE STREET ADDRESS, CITY, STATE, ZIP CODE 239 CROOKED RIVER ROAD CARRABELLE, FL 32322 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE (N 000) INITIAL COMMENTS (N 000) On 10/21/24 a desk review revisit survey was conducted for the complaint survey, 2024011827, ending on 10/7/2024 at Arabella Health & Wellness of Carrabelle. Based on an acceptable plan of correction, evidence of corrective actions and interview with the Administrator, the deficiency was found corrected. AHCA Form 3020-0001 LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X8) DATE Electronically Signed 12/04/24 STATE FORM 8899 CWWN12 If continuation sheet 1 of 1