Above average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Arabella Health & Wellness Of Pensacola during CMS and state inspections, most recent first.
Failure to supervise smokers and secure smoking materials. Surveyors found that 27 smokers were not adequately monitored and that residents were able to keep cigarettes and lighters in their possession despite care plan directions to return them after smoking. One resident with severe cognitive impairment, dementia, schizophrenia, and continuous oxygen use was observed with cigarettes and a lighter while on oxygen, and staff confirmed she was an unsafe smoker requiring direct supervision.
A resident with dementia, schizophrenia, and continuous O2 was observed on the smoking patio with cigarettes and a lighter in a plastic bag in her lap, despite staff stating she was supposed to use a smoking apron and that smoking materials were to be held by staff. Interviews showed the Administrator, DON, and Activity Director knew residents were keeping cigarettes and lighters on their person, that the smoking policy was not being enforced, and that residents with cognitive impairment or on O2 should not have access to smoking materials.
QAPI Failure Related to Resident Smoking Material Supervision: A resident with dementia, schizophrenia, severe cognitive impairment, and continuous O2 was observed with cigarettes and a lighter in a plastic bag while on the smoking patio. Records showed the resident was supposed to have smoking materials stored by staff, and the Medical Director stated residents were not allowed to keep cigarettes or lighters. The FA stated smoking concerns had been identified earlier, but they were never brought to QAPI and no PIP was in place.
Failure to Provide Scheduled Bathing and Shower Care: Multiple residents reported missed baths or showers, and records showed repeated gaps in bathing documentation and missed scheduled care. One resident with stroke-related hemiplegia remained in bed in a hospital gown and said staff did not routinely offer him a chance to get up, dress, or bathe. Other residents with significant mobility and ADL needs reported long periods without showers or baths, while CNA task records and bath logs showed only limited bathing completed and several missed scheduled bathing dates.
Failure to Document and Investigate Resident Grievances: The facility did not consistently follow its grievance process for two residents. One resident reported missing clothing from laundry on more than one occasion and said staff told him they would notify the SW and management, but he received no further information. Another resident reported a missing wheelchair charger and said she was told the facility would not pay for it. The grievance logbook did not contain either concern, and the DOSS stated she had not written a grievance for the issue.
Failure to update care plan after change in condition: A resident was hospitalized with acute urinary retention and constipation related to neurogenic bowel, but the care plan was not revised to reflect the new diagnosis or related interventions. The MDS Director and MDS Coordinator stated they were unaware of the hospital transfer and acknowledged the care plan should have been updated to support coordinated, individualized care.
The facility failed to properly assess and manage urinary complaints for two residents. One resident requested transfer for possible UTI, but staff did not document a physical assessment, provider notification, or any discussion of alternatives before sending the resident out. Another resident with a history of urinary retention and self-catheterization reported not voiding for 24 hours and requested straight cath, but the LPN did not document a nursing assessment or provider communication, and the resident was transferred to the hospital despite the facility having catheter supplies, bladder scanning access, and an after-hours telehealth/on-call system.
Failure to monitor weights and provide ordered nutritional supplements. A resident who appeared thin and reported poor appetite after a hospital stay had a 15.8% weight loss over 6 months, yet no weekly weights were documented despite an RD order. The Dietary Manager stated the resident had orders for supplements TID and liquid protein, but none were present on the meal tray, and the resident did not recall receiving supplements with meals.
Failure to Properly Reconcile and Destroy Controlled Medications: The facility failed to ensure accurate and periodic reconciliation and proper disposal of controlled meds. The DON and Administrator found the double locked drawer for discontinued narcotics full, with the last documented destruction occurring months earlier and only one of six pages in the destruction log containing the required witness signature. The DON stated she had not conducted any narcotic destruction since her hire, and facility policy required disposal of controlled substances within 3 days of discontinuation with two witness signatures.
An LPN administering meds to a resident with a heart condition dropped 4 tablets from a bubble pack onto the medication cart and left them unsecured on top of the cart while entering the resident's room. Other residents were observed in the hallway, and the LPN confirmed she did not maintain direct oversight of the cart or the pills. The DON stated this did not meet facility expectations, and the facility policy prohibited keeping meds on top of medication carts.
Staff failed to use required PPE during catheter and incontinent care for two residents with indwelling devices. CNAs wore gloves but did not wear gowns during observed care, and one pair of CNAs incorrectly described EBP requirements. One resident had a catheter with PPE and EBP signage posted at the door, and another resident had a suprapubic catheter with an EBP order and care plan entry; the DON confirmed gowns and gloves were required for this care.
A resident who depended on staff for ADL care reported not receiving a bath that day or the previous night and stated she was only cleaned sometimes during the day when wet or after a bowel movement. At the time of observation, she had oily hair, noticeable body odor, dry flaky skin, and stained clothing with a urine-type smell. An LPN stated the resident was scheduled for baths on the night shift, but night staff frequently reported at shift change that the bath was not done, with day shift sometimes providing a full bath only upon request. Review of bath records showed that, despite being scheduled for regular night-shift baths three times weekly, the resident received very few documented baths over several weeks, and the Administrator and DON could not locate any additional documentation of bathing beyond what was recorded.
A resident did not receive their scheduled medications, Azelastine HCL Nasal Solution and Breo Elipta Inhalation aerosol powder, due to unavailability during a medication pass. The LPN was unsure of the reason for the unavailability and planned to contact the pharmacy and notify the physician. The facility's policy requires timely communication with the pharmacy for medication reorders, which was not adhered to in this instance.
The facility failed to follow infection control protocols during care procedures, including catheter and tracheostomy care, legionella prevention, and medication administration. A CNA did not wear a barrier gown during catheter care, an LPN did not maintain sterility during tracheostomy care, and a nurse mishandled medication administration. Additionally, the facility's legionella prevention plan was not properly implemented.
Failure to Supervise Smokers and Secure Smoking Materials
Penalty
Summary
The facility failed to adequately supervise 27 identified smokers and failed to secure resident smoking materials, including lighters and cigarettes. Surveyors found that the facility’s smoking policy required smoking-related privileges, restrictions, and concerns to be documented in the care plan and communicated to personnel, and required residents with restricted smoking privileges to be monitored under direct supervision while smoking. Resident #15 was observed sitting up in bed with oxygen in use, and later was observed on the smoking patio sitting in a wheelchair with a plastic bag containing cigarettes and a lighter in her lap. Staff confirmed she was identified as an unsafe smoker and required a smoking apron while smoking. Her record showed severe cognitive impairment with a BIMS score of 6, diagnoses including dementia and schizophrenia, and continuous oxygen at 2 liters per minute via nasal cannula for COPD. Review of the records for all 27 smokers showed care plan interventions requiring them to return smoking materials to the Activities Department after re-entering the building from the smoking patio. Interviews with the Activity Director, LPN, MDS staff, CNA, DON, Administrator, and Medical Director showed conflicting descriptions of where smoking materials were kept, but multiple staff acknowledged that residents kept cigarettes and lighters in their possession and that residents were expected to turn them in after smoking. The Medical Director stated residents were not permitted to keep cigarettes or lighters and that residents with low BIMS scores or those receiving oxygen should not have access to smoking materials.
Smoking Materials Not Controlled and Policy Not Enforced
Penalty
Summary
The facility administrative staff failed to use available resources effectively and efficiently to maintain the facility in a safe manner and to ensure the smoking policy was properly implemented. Surveyors observed a designated smoking patio where a resident was sitting in a wheelchair with a plastic bag in her lap that contained cigarettes and a lighter. Staff acknowledged that the resident was supposed to use a smoking apron while smoking and stated they were going to remove the cigarettes from her possession. Review of the resident’s record showed diagnoses of dementia, schizophrenia, and continuous oxygen use. The resident also had a roommate who was ordered to receive continuous oxygen. During interviews, the Administrator stated residents were only permitted to smoke during designated times and were not allowed to smoke in non-designated areas, and that staff were responsible for holding and storing residents’ lighters. The DON stated lighters were expected to be turned in after each smoking session and that the smoking box was kept at the nurse’s station, but acknowledged this restriction was not being enforced by staff. The Medical Director stated that, per facility policy, residents were not permitted to keep cigarettes or lighters and that smoking materials were to be supervised by staff regardless of cognitive level. He further stated that residents with cognitive issues or those receiving oxygen should not have access to smoking materials. The Activity Director acknowledged that multiple residents kept cigarettes and lighters with them and that some families provided smoking supplies. She also stated that she should begin auditing residents to determine who had smoking materials. The Administrator and DON further stated that smoking concerns had been identified months earlier, including residents smoking whenever they wanted, a nonworking fire alarm, and no fire watch, and that the issue had not been brought to QAPI and no PIP was in place.
QAPI Failure Related to Resident Smoking Material Supervision
Penalty
Summary
The facility failed to develop, implement, and maintain an effective QAPI program after identifying smoking material concerns for residents, including a resident with dementia, schizophrenia, and continuous oxygen use. Resident #15’s record showed chronic obstructive pulmonary disease requiring oxygen at 2 liters per minute via nasal cannula, impaired cognitive function related to dementia, and a supervised smoker status with instructions to return all smoking materials to the Activities Department after smoking. A quarterly smoking assessment documented that staff were responsible for storing the resident’s lighter and cigarettes, and the resident’s BIMS score was 6, indicating severe cognitive impairment. During observation of the designated smoking patio, Resident #15 was seen sitting in a wheelchair with a plastic bag on her lap. Closer observation showed the bag contained cigarettes and a lighter. Staff B, a CNA and Activities Director, stated the resident required a smoking apron and that they were in the process of removing the cigarettes from her possession. Review of the smoking records for all 27 residents identified as smokers showed care plan interventions requiring return of smoking materials to the Activities Department after re-entering the building after smoking. The Medical Director stated that residents were not permitted to keep cigarettes or lighters and that smoking materials were to be supervised by staff regardless of BIMS score. He also stated that residents with a low BIMS score or those receiving oxygen should not have access to smoking materials. The Facility Administrator stated she had identified smoking concerns when she was hired, including residents smoking whenever they wanted, a nonworking fire alarm, and no fire watch, but she never brought the issue to QAPI and had no active or completed PIPs for identified quality deficiencies. The DON stated the smoking concerns related to residents keeping smoking paraphernalia on their person were planned for the next QAPI meeting.
Failure to Provide Scheduled Bathing and Shower Care
Penalty
Summary
The facility failed to provide required bathing and shower services needed to maintain residents’ personal hygiene for 6 of 6 residents reviewed. The report documents that residents were not bathed or showered as scheduled, that some residents reported long gaps without a bath or shower, and that documentation showed missed bathing care without recorded refusals or unavailability in several cases. Resident #4, who had hemiplegia and hemiparesis following a stroke, a neurocognitive disorder, and depression, stated he needed help getting out of bed and wanted to get up in his wheelchair, but staff were busy and he was not routinely offered the choice to get up, dress, or receive a shower or bath. He was observed multiple times lying in bed in a hospital-type gown, and during those observations he confirmed no one had asked him if he wanted to get dressed or get out of bed. His MDS showed he required extensive assistance for transfers and was dependent for bathing, and the record showed no shower or bath documented for 14 days during the reviewed period. Resident #10 reported not having a good shower in about a month and said she had only been given a few baths that did not make her feel clean. Resident #38 stated she had not received her scheduled showers and had been told the showers were out of service; her record showed diagnoses including functional quadriplegia and that she was scheduled for showers twice weekly, yet no shower documentation was found for the reviewed week. Resident #81 stated she did not receive 3 baths per week, and the CNA task record showed only 2 baths in 30 days with no refusals or notes that she was unavailable. Resident #98 reported she had not had a bath in more than two months and no shower in two years, preferred daytime showers, and said staff often deferred bathing to another shift; her record showed only 2 documented baths in 30 days, and staff later confirmed she had not had a proper bath during the prior 5 days. Resident #108 was observed in a wheelchair wearing a facility gown with disheveled hair and stated she had not received a bath since admission; staff confirmed she was scheduled for baths twice weekly, but the bath log and electronic record showed missed baths on scheduled dates and no bath documentation for those dates.
Failure to Document and Investigate Resident Grievances
Penalty
Summary
The facility failed to consistently implement its grievance procedures and failed to document, investigate, track, and follow up on resident grievances for two residents. One resident reported that clothing items had gone missing from the laundry on more than one occasion and stated the items were marked with his name. He said he reported the missing clothing to two staff members, who told him they would notify the social worker and management, but he did not receive any further information. A CNA stated that missing clothing concerns would be reported to the Charge Nurse or Social Worker, but she was not aware of how to obtain or assist a resident with a grievance form. A second resident stated during a Resident Council Meeting that the charger for her wheelchair was missing and that a staff member took it. She said she informed the facility and was told they would not pay for it. The Director of Social Services stated a search was done and a new charger would be ordered, but she had not written a grievance about the issue. The Administrator stated the Director of Social Services was responsible for grievance management, and the Director of Social Services stated she was not aware of a grievance from the first resident. Review of the grievance logbook for 2025 and 2026 confirmed that neither resident’s concern was documented. The facility policy required oral or written grievances to be investigated by Social Services, with findings reported to the Administrator within five working days and the resident informed within ten working days.
Failure to Update Care Plan After Hospitalization
Penalty
Summary
The facility failed to revise the comprehensive care plan for Resident #38 to reflect a significant change in condition after the resident was diagnosed in the hospital with acute urinary retention and constipation related to neurogenic bowel. A review of the resident’s hospital record showed this diagnosis on 04/21/2026 at 12:05 AM, but none of the resident’s care plans reflected the new condition or related needs. During an interview on 04/27/2026, Resident #38 stated that episodes of constipation had previously led to urinary retention requiring self-catheterization. On 04/30/2026, the MDS Director and MDS Coordinator stated that care plans were revised after hospitalizations and with changes in condition, but they were not aware the resident had been transferred to the hospital. They acknowledged that the care plan should have been updated to include the resident’s new diagnosis and appropriate interventions and monitoring, and the facility policy stated that care plans are revised as residents’ information and condition change.
Failure to Assess and Manage Urinary Symptoms Before Transfer
Penalty
Summary
The facility failed to provide proper assessment and assistance in urinary and catheter care for two residents. For one resident, staff documented a request for transfer to the emergency department for a possible UTI, but there was no documentation of a physical assessment, no evidence that the medical director was notified, no resident interview about signs or symptoms, and no documentation that alternatives to transfer were offered. The transfer form also left the physician-notified field blank. Interviews with nursing leadership and the medical director confirmed that the expected process was to assess the resident, notify the provider, and document the communication, but no record could be found showing that the on-call provider was contacted after hours. For the second resident, who had a history of constipation leading to urinary retention and self-catheterization, the resident reported not voiding for 24 hours and requested straight catheterization because of pain and discomfort. Nursing documentation showed the resident was told straight catheterization was not an option and was later transferred to the hospital for further evaluation related to not voiding for 24 hours. The nursing note documented the resident’s request for straight catheterization and the statement that administration had been notified, but it did not include a nursing assessment of the change in condition. The emergency transport record noted the resident was unable to void, requested straight catheterization, and had abdominal distention. The hospital record showed the resident received urinary catheter insertion with 450 milliliters of output and was diagnosed with acute urinary retention and constipation related to neurogenic bowel. Interviews with staff and leadership confirmed that straight catheterization was within the LPN scope of practice, catheter kits were available in the facility, and the facility had an after-hours telehealth/on-call system and bladder scanning service, but there was no documentation that these resources were used. Leadership also confirmed there was no documented provider communication supporting the transfer and no evidence that the resident’s needs could not be met in the facility before the hospital transfer.
Failure to Monitor Weights and Nutritional Supplements
Penalty
Summary
The facility failed to monitor weights for a resident who had significant weight loss and orders for nutritional support. The resident was observed eating breakfast and appeared thin, and she stated that since returning from the hospital she had not had much of an appetite but was trying to eat. No supplements were present on her meal tray at the time of the observation, even though the Dietary Manager later stated the resident had orders for nutritional supplements three times per day and liquid protein supplements for nutritional needs. Record review showed the resident weighed 172.2 pounds and later weighed 145 pounds, reflecting a 15.8% weight loss over 6 months. The resident was also supposed to receive weekly weights per the Registered Dietitian’s order, but no weekly weights were documented in the medical record. The Dietary Manager acknowledged the resident had been hospitalized and had lost a lot of weight, and an LPN confirmed that the ordered weekly weights were not done, stating that a restorative CNA was responsible for taking and documenting resident weights.
Failure to Properly Reconcile and Destroy Controlled Medications
Penalty
Summary
The facility failed to ensure the accurate and periodic reconciliation and proper disposal of controlled medications. During review of the controlled substance destruction records with the DON and Administrator, the double locked drawer used to store discontinued narcotics was observed to be full. The logbook showed that the last documented destruction of narcotics occurred on 11/06/25, and only one of six pages in the destruction log contained the required witness signature to validate the destruction process and ensure accountability. In a joint interview, the DON and Administrator stated that all discontinued narcotics were kept in a double locked drawer in the DON's office and acknowledged a significant accumulation of discontinued controlled substances. The DON reported that since her hire in December 2025, she had not conducted any narcotic destruction. They reviewed the narcotic destruction logbook and confirmed that the last documented destruction was on 11/06/25 and that only one of six pages contained the required witness signature. Facility policy titled Discarding and Destroying Medications stated that controlled substances were to be disposed of immediately, no longer than 3 days after discontinuation, and that disposal records were to include the signatures of two witnesses.
Unsecured Medications Left on Medication Cart During Administration
Penalty
Summary
The facility failed to ensure medications were under direct observation of the person administering them during a medication pass for Resident #109. During the observation, an LPN prepared to administer medications from a bubble pack, and 4 tablets fell out of the medication cup onto the top of the medication cart. Three of the tablets were for Resident #109's heart condition. The LPN acknowledged the tablets had fallen onto the cart but did not immediately secure or dispose of them; instead, she pushed the tablets aside on the cart next to the computer. The LPN then locked the medication cart and entered Resident #109's room, leaving the unsecured tablets on top of the cart and out of her direct sight. While this occurred, other residents were observed self-propelling in wheelchairs in the hallway, with potential access to the unsecured medications. The LPN confirmed she did not have direct oversight of the cart or the pills while in the resident's room and acknowledged that residents were present in the hallway, including some with a history of confusion. The DON stated this was not acceptable and did not meet facility expectations. The facility policy stated that no medications were to be kept on top of medication carts and that the cart must be clearly visible to the person administering medications, with all outward sides inaccessible to residents or others passing by.
Failure to Use Required PPE During Catheter and Incontinent Care
Penalty
Summary
The facility failed to use appropriate PPE during care for two residents with indwelling medical devices. Resident #5 had a catheter, and PPE gowns were available on a hanging organizer on the back of the resident’s door with signage indicating PPE and EBP requirements. During observed catheter care, two CNAs performed hand hygiene and wore gloves, but did not use gowns. When questioned, both CNAs incorrectly described EBP as barrier cream and skin prep rather than PPE requirements, although an LPN present during the care stated that gowns were required for residents with catheters. Resident #33 had a suprapubic catheter and an order for EBP documented in the medical record, with EBP also included in the care plan. During an observation of incontinent care, two CNAs wore gloves but did not wear protective gowns, despite an EBP sign being present on the room door. One CNA stated she did not know whether the resident was still on EBP and acknowledged the resident had a catheter, while the other stated she had just completed incontinent care. The DON confirmed that staff were expected to wear a gown and gloves when providing incontinent care to a resident with a catheter who had an EBP order.
Failure to Provide Scheduled Bathing and Hygiene Care
Penalty
Summary
The facility failed to ensure that a resident dependent on staff for activities of daily living received necessary services to maintain grooming and personal hygiene. During an interview on 2/25/2026 at approximately 10:15 a.m., Resident #1 reported she had not received a bath that day or the previous night, and stated she is only cleaned sometimes during the day shift when she is wet or has a bowel movement. At that time, her hair appeared oily, she had a noticeable body odor, her skin was dry and flaky, and her clothes were stained with a urine-type smell noted. An LPN (Staff A) reported on 2/25/2025 at approximately 11:00 a.m. that the resident was scheduled for baths on the night shift, but that night shift routinely reported at shift change that the bath was not given for various reasons, with day shift sometimes providing a full bath only when requested by the resident or family. Record review on 2/26/2026 showed that Resident #1 was scheduled for baths on Monday, Wednesday, and Friday during the night shift, but documentation reflected that from 1/10/2026 through 1/25/2026 she received only one bath, from 1/26/2026 through 2/10/2026 she received only three bed baths, and from 2/11/2026 through 2/26/2026 she received only one bath. During an interview on 2/26/2026 at approximately 3:00 p.m., the Administrator and Director of Nursing, after extensive review of the records, were unable to provide any additional documentation of baths given to Resident #1 beyond what was already found in the record.
Medication Unavailability for Resident
Penalty
Summary
The facility failed to provide medications as ordered for one resident during a medication administration observation. Specifically, the medications Azelastine HCL Nasal Solution and Breo Elipta Inhalation aerosol powder were not available for administration to the resident. This deficiency was observed during a medication pass conducted by a Licensed Practical Nurse (LPN), who was unsure why the medications were unavailable and indicated she would contact the pharmacy and notify the physician to hold the medication until it was available. The facility's policy on reordering medications requires that all medication orders be communicated clearly to the pharmacy, including the resident's full name. The policy outlines procedures for reordering medications, such as using refill strips or electronic orders through the facility's electronic medication record system. Despite these procedures, the medications were not reordered in a timely manner, leading to the deficiency observed during the survey.
Infection Control Deficiencies in Care Procedures
Penalty
Summary
The facility failed to adhere to proper infection prevention and control protocols during various care procedures. During catheter care for a resident, a CNA did not wear a barrier gown as required by the enhanced barrier precautions policy, which was in place to prevent catheter-associated infections. The CNA acknowledged the oversight, and the Director of Nursing confirmed that a gown should have been worn according to the facility's policy. In another instance, an LPN did not maintain sterile technique during tracheostomy care for a resident. The sterile kit was mishandled, leading to contamination of the sterile gloves and other items. The LPN admitted to not using sterile procedures as required for changing the inner cannula, and could not recall when she last received training on tracheostomy care. The facility's policy mandates sterile technique for such procedures. Additionally, the facility did not implement its legionella surveillance and prevention plan effectively. The Maintenance Director admitted that water testing was conducted using test strips but was not documented, and there was no evidence of an annual risk assessment or a comprehensive water management program. Furthermore, during medication administration, a nurse failed to follow infection control protocols by touching the inside of medication and water cups with bare hands and not cleaning the insulin pen hub with an alcohol swab before use, contrary to the facility's infection prevention policy.
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Illustrative
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
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Nursing homes near Pensacola
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Rosewood Healthcare And Rehabilitation Center | 1 mi | ★★★★★ | 2 | 0 |
| Coral Bay At Pensacola, Llc | 1.5 mi | ★★★★★ | 32 | 9 |
| Pensacola Nursing & Rehabilitation Center | 3 mi | ★★★★★ | 20 | 0 |
| Havens At Pensacola, The | 3.4 mi | ★★★★★ | 4 | 0 |
| Bayside Health And Rehabilitation Center | 5.5 mi | ★★★★★ | 0 | 0 |
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