Inspection·January 28, 2025

PRINTED: 01/09/2026 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 R 01/28/2025 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 000] | INITIAL COMMENTS | (K 000) | | An unannounced Fire & Life Safety Desk Review revisit survey for the relicensure survey, which originally occurred on 11/20/2024, was conducted on 01/28/2025 at Arabella Health & Wellness Of Carrabelle, a Nursing Home in Carabelle, Florida. All previously cited Fire & Life Safety deficiencies were found corrected. AHCA Form 3020-0001 LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE Electronically Signed TITLE (X6) DATE 02/19/25 STATE FORM 6899 P3CC22 If continuation sheet 1 of 1 DEPARTMENT OF HEALTH AND HUMAN SERVICES PRINTED: 01/09/2026 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 R 01/28/2025 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 DATE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) [E 000] Initial Comments [E 000] [K 000] INITIAL COMMENTS [K 000] An unannounced desk review revisit for the Life Safety recertification, which originally occurred on 11/20/2024, was conducted on 01/28/2025 for Arabella Health & Wellness Of Carrabelle, a nursing home in Carrabelle, FL. The facility was in compliance with Code of Federal Regulations (CFR) 42, Part 483.90, Requirement for Long Term Care Facilities: Physical Environment. Previously cited deficiencies were found corrected. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE Electronically Signed 02/19/2025 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:P3CC22 Facility ID: 35961023 If continuation sheet Page 1 of 1