Inspection·November 20, 2024

K 291 NFPA 101 Emergency Lighting K 291 12/13/24 Emergency Lighting Emergency lighting of at least 1-1/2-hour duration is provided automatically in accordance with 7.9.18.2.9.1, 19.2.9.1. This Statute or Rule is not met as evidenced by: Based on record review and interview with the Maintenance Director, the facility failed to provide and maintain reliable emergency lighting. Testing is required to insure the durability of the batteries for the required period of time. This condition could jeopardize the safety of patients and staff in an emergency situation. The findings include: During the Fire & Life Safety document review of the facility with the Director of Maintenance on #1 Corrective Action for affected residents. Monthly and Annual 90 minute testing of the Emergency Lighting System as specified in NFPA 101 (2012 edition) will be completed and documents maintained in Life Safety Binder by Maintenance Director. Battery Packs are on order for the lights that need them. #2 How will the facility identify other like residents? AHCA Form 3020-0001 LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE Electronically Signed 12/02/24 STATE FORM 8899 P3CC21 If continuation sheet 1 of 11 Agency for Health Care Administration PRINTED: 01/14/2025 FORM APPROVED STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 35961023 (X2) MULTIPLE CONSTRUCTION A. BUILDING: 01, 05 B. WING ______ (X3) DATE SURVEY COMPLETED 11/20/2024 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

K 291 Continued From page 1 11/20/2024, no records were provided to verify the emergency backup lighting received 90 minute testing. The Maintenance Director verified these findings at the times observed. Monthly testing of emergency lights is required to insure reliable operation in the event of a power failure. Annual testing is required to insure the durability of the batteries for the required period of time as specified in NFPA 101 (2021 edition). Class III

K 291 The Administrator and Maintenance Director will ensure the Emergency Lighting system is audited monthly and annually per Life Safety Code to ensure no further residents and staff will be potentially affected in an emergency situation by leaving areas dark. #3 What will you do to prevent recurrence? To prevent this deficient practice from recurring, the Maintenance Director has been educated on the importance of completing the required inspection of the Emergency Lighting System per Life Safety guidelines found in NFPA 101 (2012) and maintaining proper documentation. #4 How will you monitor and maintain ongoing compliance? To monitor and maintain ongoing compliance the maintenance director will document the inspection of the Emergency Lighting System and report findings to the Administrator monthly x 3 months. The Administrator will source any needed repair/replacement parts for the Lighting System. #4 QAPI The Administrator will report the results of the monitoring to the QAPI committee for review and recommendations for the time framed of the monitoring period or as it is amended by the committee. This plan has been reviewed at an ad hoc Quality Assurance committee meeting held on 12/13/2024. AHCA Form 3020-0001 STATE FORM 696 P3CC21 If continuation sheet, 2 of 11 PRINTED: 01/14/2025 FORM APPROVED Agency for Health Care Administration | STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 35961023 | (X2) MULTIPLE CONSTRUCTION A. BUILDING: 01, 05 B. WING | (X3) DATE SURVEY COMPLETED 11/20/2024 | |---|---|---|---| 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 | |---|---|---|---|---| | K 345 | Continued From page 2 | K 345 | | | | K 345 SS=D | NFPA 101 Fire Alarm System - Testing and Maintenance | K 345 | | 12/13/24 | Fire Alarm System - Testing and Maintenance A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available. 9.6.5, 9.6.7, 9.6.8, and NFPA 70, NFPA 72 This Statute or Rule is not met as evidenced by: Based on document review and interview, the facility failed to maintain the Fire Alarm System. Maintaining the Fire Alarm System ensures proper operation and lessens the chance of a delayed alarm activation under hazardous conditions. The findings include: During the document review with the Maintenance Director on 11/20/2024, the facility failed to provide evidence of the annual duct detector differential testing and biennial sensitivity inspection. An interview was conducted with the Maintenance Director confirmed the findings. Please refer to: NFPA 101(2021 Edition) sections 19.3.4.1, 19.3.4.4, 9.6, and 9.6.1.5 NFPA 72 (2010 Edition) sections 14.4.2.2, 14.4.2.2(14)(g)(6), and 14.4.5.3 Class III #1 Corrective Action for affected residents. Fire System vendor completed the annual Duct Detector Differential and sensitivity test on 11/26/24. This was completed per the guidelines of NFPA 70 National Electric Code, and NFPA 72. #2 How will the facility identify other like residents? An audit by Maintenance Director of documentation required by Life Safety was completed 11/21/24 and annual duct detector testing and sensitivity of the Fire Alarm System. #3 What will you do to prevent recurrence? To prevent this from recurring the Maintenance Director has been educated on importance of completing audits and to follow the AHCA Life Safety guidelines for annual testing of the Fire Alarm System per requirements. #4 How will you monitor and maintain ongoing compliance? AHCA Form 3020-0001 STATE FORM 6956 P3CC21 If continuation sheet 3 of 11 PRINTED: 01/14/2025 FORM APPROVED Agency for Health Care Administration STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 35961023 (X2) MULTIPLE CONSTRUCTION A. BUILDING: 01, 05 B. WING ____ (X3) DATE SURVEY COMPLETED 11/20/2024 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 ---|---|---|---|---

K 345 | Continued From page 3 | K 345 | To monitor and maintain ongoing compliance the Maintenance Director and/or Designee will document audit of fire alarm system monthly x 4 months. #4 QAPI This plan has been reviewed at an ad hoc Quality Assurance committee meeting held on 12/13/24 The Administrator will report the results of the monitoring to the QAPI committee for review and recommendations for the time frame of the monitoring period or as it is amended by the committee. |

K 363 | NFPA 101 Corridor - Doors SS=D Corridor - Doors 2015 EXISTING Doors protecting corridor openings in other than required enclosures of vertical openings, exts, or hazardous areas shall be substantial doors, such as those constructed of 1-3/4 inch solid-bonded core wood, or capable of resisting fire for at least 20 minutes. Doors in fully sprinklered smoke compartments are only required to resist the passage of smoke. Doors shall be provided with a means suitable for keeping the door closed. There is no impediment to the closing of the Doors. Clearance between bottom of door and floor covering is not exceeding 1 inch. Roller latches are prohibited by CMS regulations (only for Federal survey citation) only on corridor doors and rooms containing flammable or combustible materials. Powered doors complying with 7.2.1.9 are permissible. Hold open devices that release when the door is pushed or pulled are permitted. Nonrated protective plates of unlimited height are | K 363 | | 12/13/24 AHCA Form 3020-0001 STATE FORM esss P3CC21 If continuation sheet 4 of 11 Agency for Health Care Administration PRINTED: 01/14/2025 FORM APPROVED STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING: 01, 05 B. WING __ (X3) DATE SURVEY COMPLETED 35961023 11/20/2024 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 PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL ID REGULATORY OR LSC IDENTIFYING INFORMATION) PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE

K 363 Continued From page 4 K 363 permitted. Dutch doors meeting 19.3.6.3.6 are permitted. Door frames shall be labeled and made of steel or other materials in compliance with 8.3, unless the smoke compartment is sprinklered. Fixed fire window assemblies are allowed per 8.3. In sprinklered compartments there are no restrictions in area or fire resistance of glass or frames in window assemblies. 19.3.6.3, 42 CFR Parts 403, 418, 460, 482, 483, and 485 Show in REMARKS details of doors such as fire protection ratings, automatics closing devices, etc. 2015 NEW Doors protecting corridor openings shall be constructed to resist the passage of smoke. Clearance between bottom of door and floor covering is not exceeding 1 inch. There is no impediment to the closing of the doors. Hold open devices that release when the door is pushed or pulled are permitted. Doors shall be provided with self-latching and positive latching hardware. Annotated protective plates of unlimited height are permitted. Dutch doors meeting 18.3.6.3.6 are permitted. Roller latches are prohibited by CMS regulations (only for Federal survey citation) on corridor doors and rooms containing flammable or combustible materials. 18.3.6.3, 42 CFR Parts 403, 418, 460, 482, 483, and 485 Show in REMARKS details of doors such as fire protection ratings, automatic closing devices, etc. This Statute or Rule is not met as evidenced by: AHCA Form 3020-0001 STATE FORM e899 P3CC21 If continuation sheet, 5 of 11 Agency for Health Care Administration PRINTED: 01/14/2025 FORM APPROVED STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 35961023 (X2) MULTIPLE CONSTRUCTION A. BUILDING: 01, 05 B. WING __________ (X3) DATE SURVEY COMPLETED 11/20/2024 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 --- | --- | --- | --- | ---

K 363 | Continued From page 5 Based on observation and interview made during the Fire & Life Safety tour, the facility failed to maintain proper maintenance of the Fire/Smoke doors. This condition could result in smoke compartments becoming involved in a fire and/or smoke situation. This could allow fire, smoke and fire gasses to enter the compartment, which could impede or deny the exiting of occupants in an emergency. The findings include: During the Fire & Life Safety tour of the facility with the Maintenance staff on 11/20/2024 from 10:00 am to 1:00 pm, it was observed that the following fire and smoke doors had issues: 1. The nourishment room had holes in the door. 2. The soiled utility room had holes in the door. 3. The laundry room door was not latching. 4. The medical records room was not closing. The Director of Maintenance was present during the observation, and confirmed the findings. Per NFPA 101 (2021 edition) Chapter 19, section 19.3.6.3.5, "Doors shall be provided with a means for keeping the door closed that is acceptable to the authority having jurisdiction." Class III | K 363 | #1 Corrective Action for affected residents. The auto closing latches on the Medical Records Office door and the Laundry Room door have been adjusted to close properly on 11/21/2024. The Smoke Doors leading into the Nourishment Room and the Soiled Utility Room that have holes in them are being repaired. Vendor contacted 12/2/2024 ( Life Safety Services ) #2 How will the facility identify other like residents? An audit of all facility doors has been completed by the Maintenance director to identify any doors that do not close properly per NFPA 101 (2012 edition), Chapter 19, 19.3.6.3.5. Doors that are provided with a means for keeping the door closed that is acceptable to the authority having jurisdiction. The audit was completed 11/21/24. #3 What will you do to prevent recurrence? To prevent this deficient practice from recurring, the Maintenance Director has been educated to round and visualize any doors in the facility that do not latch properly and to initiate repairs. Staff has been re-educated at mandatory in-service meeting to not place any tape over a door latch or use a wedge to prop a door open or prevent proper closing and latching of any door per NFPA 101 guidelines. #4 How will you monitor and maintain ongoing compliance? To monitor and maintain ongoing compliance, the Maintenance Director will document the rounding and report findings | | AHCA Form 3020-0001 STATE FORM 6989 P3CC21 If continuation sheet, 6 of 11 PRINTED: 01/14/2025 FORM APPROVED Agency for Health Care Administration | STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 35961023 | (X2) MULTIPLE CONSTRUCTION A. BUILDING: 01, 05 B. WING | (X3) DATE SURVEY COMPLETED 11/20/2024 | 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 |

K 363 | Continued From page 6 | K 363 | to the Administrator weekly x 12 weeks. The Administrator will source any needed repair or replacement parts as needed. #4 QAPI This plan has been reviewed at an ad hoc Quality Assurance committee meeting held on 12/13/24. The Administrator will report the results of the monitoring to the QAPI committee for review and recommendations for the time frame of the monitoring period or as it is amended by the committee. |

K 914 SS=D | NFPA 99 Electrical Systems - Maintenance and Testing Electrical Systems - Maintenance and Testing Hospital-grade receptacles at patient bed locations and where deep sedation or general anesthesia is administered, are tested after initial installation, replacement or servicing. Additional testing is performed at intervals defined by documented performance data. Receptacles not listed as hospital-grade at these locations are tested at intervals not exceeding 12 months. Line isolation monitors (LIM), if installed, are tested at intervals of less than or equal to 1 month by actuating the LIM test switch per 6.3.2.6.3.6, which activates both visual and audible alarm. For LIM circuits with automated self-testing, this manual test is performed at intervals less than or equal to 12 months. LIM circuits are tested per 6.3.3.3.2 after any repair or renovation to the electric distribution system. Records are maintained of required tests and associated repairs or modifications, containing date, room or area tested, and results. 6.3.4 (NFPA 99) | K 914 | | 12/13/24 | AHCA Form 3020-0001 STATE FORM 8899 P3CC21 If continuation sheet 7 of 11 Agency for Health Care Administration PRINTED: 01/14/2025 FORM APPROVED STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 35961023 (X2) MULTIPLE CONSTRUCTION A. BUILDING: 01, 05 B. WING __ (X3) DATE SURVEY COMPLETED 11/20/2024 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 | |-------------------|----------------------------------------------------------------------------------------------------------------|--------------|---------------------------------------------------------------------------------------------------------------|-------------------| | K 914 | Continued From page 7 | K 914 | | | | | This Statute or Rule is not met as evidenced by: Based on record review and interview with the Maintenance Director, the facility failed to maintain documentation on the exercising of the main and feeder breakers. Failure to exercise these breakers as required by the manufacturer can lead to corrosion, among other issues, which can cause a delay or an inability to transfer power in a time of emergency. This could result in loss of power to the facility in the event of a simultaneous failure of the local utility and the emergency generator, potentially endangering the patients and occupants of the facility. | | | | | | The findings include: | | | | | | During the Fire & Life Safety document review of the facility with the Director of Maintenance on 11/20/2024, no documentation was provided to show that the Main & Feeder Circuit Breakers were inspected annually as required, including periodic exercise in accordance with the manufacturer's recommendations. | | | | | | An interview with the Maintenance Director revealed and acknowledged that the facility did not have a system in place or a preventative maintenance program to ensure compliance with NFPA 110 (2021 Edition). | | | | | | Please refer to NFPA 101 (2018 Edition) section 9.1.2 and NFPA 110 (2021 Edition) section 8.4.7. | | | | | | Class III | | | | | | | | #1 Corrective Action for affected residents. Maintenance Director is responsible and competent to complete an inhouse annual inspection of Main and Feeder Circuit Breaker test per NFPA 110 guidelines. Completed on 12/10/2024. | | | | | | #2 How will the facility identify other like residents? Maintenance Director to complete the Main and Feeder Circuit Breaker testing to ensure no delay in transfer of power in the event of an emergency or loss of power per NFPA 101 9.1.2 and 110 8.4.7 (2012 edition). | | | | | | #3 What will you do to prevent recurrence? To prevent this from recurring the Maintenance Director has been educated on the importance of completing necessary audits of the generator main and feeder circuits and maintaining documentation of audits and as part of our maintenance program to ensure compliance with NFPA 110 (2012 edition). | | | | | | #4 How will you monitor and maintain ongoing compliance? Maintenance Director and/or designee to maintain documentation and scheduling of the annual Main and Feeder /Breaker test annually and/or as required by guidelines. | | | | | | #4 QAPI This plan has been reviewed at an ad hoc Quality Assurance committee meeting held on 12/13/24 | | AHCA Form 3020-0001 STATE FORM 696 P3CC21 If continuation sheet, 8 of 11 Agency for Health Care Administration PRINTED: 01/14/2025 FORM APPROVED STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 35961023 (X2) MULTIPLE CONSTRUCTION A. BUILDING: 01, 05 B. WING ______ (X3) DATE SURVEY COMPLETED 11/20/2024 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

K 914 Continued From page 8

K 914 The Administrator will report the results of the monitoring to the QAPI committee for review and recommendations for the time frame of the monitoring period or as it is amended by the committee. 12/13/24

K 918 NFPA 99 Electrical Systems - Essential Electric SS=D Syste

K 918 Electrical Systems - Essential Electric System Maintenance and Testing The generator or other alternate power source and associated equipment is capable of supplying service within 10 seconds. If the 10-second criterion is not met during the monthly test, a process shall be provided to annually confirm this capability for the life safety and critical branches. Maintenance and testing of the generator and transfer switches are performed in accordance with NFPA 110. Generator sets are inspected weekly, exercised under load 30 minutes 12 times a year in 20-40 day intervals, and exercised once every 36 months for 4 continuous hours. Every test under load conditions include a complete simulated cold start and automatic or manual transfer of all EES loads, and are conducted by competent personnel. Maintenance and testing of stored energy power sources (Type 3 EES) are in accordance with NFPA 111. Main and feeder circuit breakers are inspected annually, and a program for periodically exercising the components is established according to manufacturer requirements. Written records of maintenance and testing are maintained and readily available. EES electrical panels and circuits are marked and readily identifiable. Minimizing the possibility of damage of the emergency power source is a design AHCA Form 3020-0001 STATE FORM 899 P3CC21 If continuation sheet 9 of 11 PRINTED: 01/14/2025 FORM APPROVED Agency for Health Care Administration | STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 35961023 | (X2) MULTIPLE CONSTRUCTION A. BUILDING: 01, 05 B. WING _______________ | (X3) DATE SURVEY COMPLETED 11/20/2024 | 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 | |---|---|---|---|

K 918 | Continued From page 9 consideration for new installations. 6.4.4, 6.5.4, 6.6.4 (NFPA 99), NFPA 110, NFPA 111, 700.10 (NFPA 70) This Statute or Rule is not met as evidenced by: Based on observations and interview with the Maintenance Director, the facility failed to maintain replacement parts for the emergency back-up generator in accordance with NFPA 99. This could result in a loss of power to the emergency generator, thereby endangering the patients and occupants of the facility. The findings include: During the Fire & Life Safety tour of the facility with the Director of Maintenance on 11/20/2024 between 10:00 am and 1:00 pm, it was revealed that the facility failed to maintain replacement parts for the emergency generator identified as having a high mortality, or as recommended by the manufacturer, in a secure location on the premises. The Maintenance Director confirmed this at the time of the observation. Please refer to: NFPA 101 (2021 Edition) sections 19.7.6 and 4.6.12.1 NFPA 99 (2021 Edition) section 6.7.4.1.1.3 NFPA 110 (2019 Edition) sections 8.2.4 and 8.2.4.1 Class III | K 918 | #1 Corrective Action for affected residents. Maintenance Director requested quote and ordered mortality parts for the Kohler generator on 12/10/24 from Generator Maintenance Service Provider after a Preventative Maintenance Service performed on existing generator. #2 How will the facility identify other like residents? An audit of Mortality parts will be maintained by Maintenance Director and/or Designee. Administrator will replace any parts needed for repairs to the generator as needed. #3 What will you do to prevent recurrence? In order to prevent this from recurring, Maintenance director has been educated on the importance of Maintaining replacement parts for existing generator in accordance with NFPA 99 in a secured location on the premises. #4 How will you monitor and maintain ongoing compliance? To monitor and maintain ongoing compliance with this matter, the Maintenance Director and/or designee will audit replacements parts provided by Provider monthly x 3 months. Administrator will replace any parts needed for repairs to existing generator. | AHCA Form 3020-0001 STATE FORM 6956 P3CC21 If continuation sheet 10 of 11 Agency for Health Care Administration PRINTED: 01/14/2025 FORM APPROVED STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION IDENTIFICATION NUMBER: A. BUILDING: 01, 05 B. WING ____ 35961023 11/20/2024 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 ID PROVIDER'S PLAN OF CORRECTION PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)

K 918 Continued From page 10 K 918 #4 QAPI This plan has been reviewed at an ad hoc Quality Assurance committee meeting held on 12/13/24 The Administrator will report the results of the monitoring to the QAPI committee for review and recommendations for the time frame of the monitoring period or as it is amended by the committee. (X5) COMPLETE DATE AHCA Form 3020-0001 STATE FORM 6559 P3CC21 If continuation sheet 11 of 11 DEPARTMENT OF HEALTH AND HUMAN SERVICES PRINTED: 01/14/2025 CENTERS FOR MEDICARE & MEDICAID SERVICES FORM APPROVED OMB NO. 0938-0391 SUMMARY OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING 01, 05 (X3) DATE SURVEY COMPLETED 106081 B. WING 11/20/2024 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 ID (X5) PREFIX TAG (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) COMPLETION DATE

E 000 Initial Comments

E 000 During the recertification survey conducted on 11/20/2024 at Arabella Health and Wellness of Carrabelle, a nursing home in Carrabelle, FL, the Emergency Preparedness Program was reviewed. Arabella Health and Wellness of Carrabelle complies with the Emergency Preparedness rule per Code of Federal Regulations (CFR) 42, Part 483.73, Requirement for Long-Term Care Facilities.

K 000 INITIAL COMMENTS

K 000 An unannounced Fire & Life Safety recertification survey was conducted on 11/20/2024 at Arabella Health and Wellness of Carrabelle, a nursing home in Carrabelle, Florida. The facility was not in compliance with Code of Federal Regulations (CFR) 42, Part 483.90, Requirement for Long Term Care Facilities: Physical Environment and National Fire Protection Association (NFPA) 101 (2012 edition) requirements for nursing homes. Initial Plan Review: 1986 Existing NFPA 220 Construction Type: V (111) Number of beds: 90 Census: 74

K 291 Emergency Lighting

K 291 12/13/24 SS=D CFR(s): NFPA 101 Emergency Lighting Emergency lighting of at least 1-1/2-hour duration is provided automatically in accordance with 7.9. 18.2.9.1, 19.2.9.1 THIS REQUIREMENT is not met as evidenced by: Based on record review and interview with the #1 Corrective Action for affected LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE Electronically Signed 12/02/2024 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:P3CC21 Facility ID: 35961023 If continuation sheet Page 1 of 7 DEPARTMENT OF HEALTH AND HUMAN SERVICES PRINTED: 01/14/2025 CENTERS FOR MEDICARE & MEDICAID SERVICES FORM APPROVED OMB NO. 0938-0391 SUMMARY OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING 01, 05 (X3) DATE SURVEY COMPLETED 106081 B. WING 11/20/2024 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 ID (X5) PREFIX TAG (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE COMPLETION REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY)

K 291 Continued From page 1 Maintenance Director, the facility failed to provide and maintain reliable emergency lighting. Testing is required to insure the durability of the batteries for the required period of time. This condition could jeopardize the safety of patients and staff in an emergency situation. The findings include: During the Fire & Life Safety document review of the facility with the Director of Maintenance on 11/20/2024, no records were provided to verify the emergency backup lighting received 90 minute testing. The Maintenance Director verified these findings at the times observed. Monthly testing of emergency lights is required to insure reliable operation in the event of a power failure. Annual testing is required to insure the durability of the batteries for the required period of time as specified in NFPA 101 (2012 edition).

K 291 residents. Monthly and Annual 90 minute testing of the Emergency Lighting System as specified in NFPA 101 (2012 edition) will be completed and documents maintained in Life Safety Binder by Maintenance Director. Battery Packs are on order for the lights that need them. #2 How will the facility identify other like residents? The Administrator and Maintenance Director will ensure the Emergency Lighting system is audited monthly and annually per Life Safety Code to ensure no further residents and staff will be potentially affected in an emergency situation by leaving areas dark. #3 What will you do to prevent recurrence? To prevent this deficient practice from recurring, the Maintenance Director has been educated on the importance of completing the required inspection of the Emergency Lighting System per Life Safety guidelines found in NFPA 101 (2012) and maintaining proper documentation. #4 How will you monitor and maintain ongoing compliance? To monitor and maintain ongoing compliance the maintenance director will document the inspection of the Emergency Lighting System and report findings to the Administrator monthly x 3 months. The Administrator will source any needed FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:P3CC21 Facility ID: 35991023 If continuation sheet Page 2 of 7 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES PRINTED: 01/14/2025 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 106081 (X2) MULTIPLE CONSTRUCTION A. BUILDING 01, 05 B. WING (X3) DATE SURVEY COMPLETED 11/20/2024 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) COMPLETION DATE

K 291 Continued From page 2

K 291 repair/replacement parts for the Lighting System. #4 QAPI The Administrator will report the results of the monitoring to the QAPI committee for review and recommendations for the time frame of the monitoring period or as it is amended by the committee. This plan has been reviewed at an ad hoc Quality Assurance committee meeting held on 12/13/2024.

K 363 SS=D Corridor - Doors CFR(s): NFPA 101 Corridor - Doors Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas resist the passage of smoke and are made of 1 3/4 inch solid-bonded core wood or other material capable of resisting fire for at least 20 minutes. Doors in fully sprinklered smoke compartments are only required to resist the passage of smoke. Corridor doors and doors to rooms containing flammable or combustible materials have positive latching hardware. Roller latches are prohibited by CMS regulation. These requirements do not apply to auxiliary spaces that do not contain flammable or combustible material. Clearance between bottom of door and floor covering is not exceeding 1 inch. Powered doors complying with 7.2.1.9 are permissible if provided with a device capable of keeping the door closed when a force of 5 lbf is applied. There is no impediment to the closing of the doors. Hold open devices that release when the door is pushed or pulled are permitted. Nonrated protective plates of unlimited height are permitted. Dutch doors

K 363 12/13/24 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: P3CCZ1 Facility ID: 36961023 If continuation sheet Page 3 of 7 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES PRINTED: 01/14/2025 FORM APPROVED OMB NO. 0938-0391 LIST OF DEFICIENCIES AND PLAN OF CORRECTION PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING 01, 05 (X3) DATE SURVEY COMPLETED 106081 11/20/2024 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) COMPLETION DATE

K 363 Continued From page 3

K 363 meeting 19.3.6.3.6 are permitted. Door frames shall be labeled and made of steel or other materials in compliance with 8.3, unless the smoke compartment is sprinklered. Fixed fire window assemblies are allowed per 8.3. In sprinklered compartments there are no restrictions in area or fire resistance of glass or frames in window assemblies. 19.3.6.3, 42 CFR Parts 403, 418, 460, 482, 483, and 485 Show in REMARKS details of doors such as a fire protection ratings, automatics closing devices, etc. This REQUIREMENT is not met as evidenced by: Based on observation and interview made during the Fire & Life Safety Tour, the facility failed to maintain proper maintenance of the Fire/Smoke doors. This condition could result in smoke compartments becoming involved in a fire and/or smoke situation. This could allow fire, smoke and fire gasses to enter the compartment, which could impede or deny the exiting of occupants in an emergency. The findings include: During the Fire & Life Safety tour of the facility with the Maintenance Staff on 11/20/2024 from 10:00 am to 1:00 pm, it was observed that the following fire and smoke doors had issues: 1. The nourishment room had holes in the door. 2. The soiled utility room had holes in the door. 3. The laundry room door was not latching. 4. The medical records room was not closing. The Director of Maintenance was present during the observation, and confirmed the findings. #1 Corrective Action for affected residents. The auto closing latches on the Medical Records Office door and the Laundry Room door have been adjusted to close properly on 11/21/2024. The Smoke Doors leading into the Nourishment Room and the Soiled Utility Room that have holes are being repaired. Vendor contacted 12/2/2024 ( Life Safety Services ) #2 How will the facility identify other like residents? An audit of all facility doors has been completed by the Maintenance director to identify any doors that do not close properly per NFPA 101 (2012 edition), Chapter 19, 19.3.6.3.5, Doors shall be provided with a means for keeping the door closed that is acceptable to the authority having jurisdiction. The audit was completed 11/21/24. #3 What will you do to prevent FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:P3CC21 Facility ID: 35991023 If continuation sheet Page 4 of 7 DEPARTMENT OF HEALTH AND HUMAN SERVICES PRINTED: 01/14/2025 CENTERS FOR MEDICARE & MEDICAID SERVICES FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING 01, 05 (X3) DATE SURVEY COMPLETED 106081 B. WING 11/20/2024 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 ID PROVIDER'S PLAN OF CORRECTION PREFIX TAG (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) PREFIX TAG (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE

K 363 Continued From page 4

K 363 Per NFPA 101 (2012 edition) Chapter 19, section 19.3.6.3.5, "Doors shall be provided with a means for keeping the door closed that is acceptable to the authority having jurisdiction." recurrence? To prevent this deficient practice from recurring, the Maintenance Director has been educated to round and visualize any doors in the facility that do not latch properly and to initiate repairs. Staff has been re-educated at mandatory in-service meeting to not place any tape over a door latch or use a wedge to prop a door open or prevent proper closing and latching of any door per NFPA 101 guidelines. #4 How will you monitor and maintain ongoing compliance? To monitor and maintain ongoing compliance, the Maintenance Director will document the rounding and report findings to the Administrator weekly x 12 weeks. The Administrator will source any needed repair or replacement parts as needed. #4 QAPI This plan has been reviewed at an ad hoc Quality Assurance committee meeting held on 12/13/24. The Administrator will report the results of the monitoring to the QAPI committee for review and recommendations for the time frame of the monitoring period or as it is amended by the committee.

K 914 Electrical Systems - Maintenance and Testing

K 914 SS=D CFR(s): NFPA 101 12/13/24 Electrical Systems - Maintenance and Testing Hospital-grade receptacles at patient bed locations and where deep sedation or general FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:P3OC21 Facility ID: 35981023 If continuation sheet Page 5 of 7 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES PRINTED: 01/14/2025 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING 01, 05 (X3) DATE SURVEY COMPLETED 106081 11/20/2024 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 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

K 914 Continued From page 5 anesthesia is administered, are tested after initial installation, replacement or servicing. Additional testing is performed at intervals defined by documented performance data. Receptacles not listed as hospital-grade at these locations are tested at intervals not exceeding 12 months. Line isolation monitors (LIM), if installed, are tested at intervals of less than or equal to 1 month by actuating the LIM test switch per 6.3.2.6.3.6, which activates both visual and audible alarm. For LIM circuits with automated self-testing, this manual test is performed at intervals less than or equal to 12 months. LIM circuits are tested per 6.3.3.3.2 after any repair or renovation to the electric distribution system. Records are maintained of required tests and associated repairs or modifications, containing date, room or area tested, and results. 6.3.4 (NFPA 99) This REQUIREMENT is not met as evidenced by: Based on record review and interview with the Maintenance Director, the facility failed to maintain documentation for the exercising of the main and feeder breakers. Failure to exercise these breakers as required by the manufacturer can lead to corrosion, among other issues, which can cause a delay or an inability to transfer power in a time of emergency. This could result in loss of power to the facility in the event of a simultaneous failure of the local utility and the emergency generator, potentially endangering the patients and occupants of the facility. The findings include: During the Fire & Life Safety document review of the facility with the Director of Maintenance on 11/20/2024, no documentation was provided to

K 914 #1 Corrective Action for affected residents. Maintenance Director is responsible and competent to complete an inhouse annual inspection of Main and Feeder Circuit Breaker test per NFPA 110 guidelines. Completed on 12/10/2024. #2 How will the facility identify other like residents? Maintenance Director to complete the Main and Feeder Circuit Breaker testing to ensure no delay in transfer or loss in the event of emergency or power of power per NFPA 101 9.1.2 and 110 8.4.7 (2012 edition). #3 What will you do to prevent FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:P3CC21 Facility ID: 35991023 If continuation sheet Page 6 of 7 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES PRINTED: 01/14/2025 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 106081 (X2) MULTIPLE CONSTRUCTION A. BUILDING 01, 05 B. WING (X3) DATE SURVEY COMPLETED 11/20/2024 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) COMPLETION DATE

K 914 Continued From page 6 show that the Main & Feeder Circuit Breakers were inspected annually as required, including periodic exercise in accordance with the manufacturer's recommendations. An interview with the Maintenance Director revealed and acknowledged that the facility did not have a system in place or a preventative maintenance program to ensure compliance with NFPA 110 (2012 Edition). Please refer to NFPA 101 (2012 Edition) section 9.1.2 and NFPA 110 (2012 Edition) section 8.4.7.

K 914 recurrence? To prevent this from recurring the Maintenance Director has been educated on the importance of completing necessary audits of the generator main and feeder circuits and maintaining documentation of audits as part of our maintenance program to ensure compliance with NFPA 110 (2012 edition). #4 How will you monitor and maintain ongoing compliance? Maintenance Director and/or designee to maintain documentation and scheduling of the annual Main and Feeder /Breaker test annually and/or as required by guidelines. #4 QAPI This plan has been reviewed at an ad hoc Quality Assurance committee meeting held on 12/13/24 The Administrator will report the results of the monitoring to the QAPI committee for review and recommendations for the time frame of the monitoring period or as it is amended by the committee. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PSCCZ1 Facility ID: 36961023 If continuation sheet Page 7 of 7