Health inspection·June 24, 2021

F 0600 Level of Harm - Minimal harm or potential for actual harm Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Based on resident and staff interviews and record reviews, the facility failed to ensure residents were free from physical abuse for one (Resident #36) of one resident reviewed for abuse. Residents Affected - Few The findings include: A review of the medical record for Resident #36 revealed an admission date of 7/10/16. The primary medical diagnosis was dementia with a secondary diagnosis of depression. Resident #36 had a Brief Interview for Mental Status (BIMS) score of 13 out of a possible 15 points, indicating intact cognition. Resident #36 required limited assistance of one staff member for most activities of daily living. A review of the medical record for Resident #24 revealed an admission date of 8/4/20. The primary medical diagnosis was traumatic brain injury (TBI) with a secondary diagnosis of dementia. His cognition was impaired, and he was unable to complete a BIMS interview. Resident #24 required varying levels of assistance with activities of daily living. A review of the nursing progress notes for Resident #24 revealed an entry dated 1/13/21 at 6:49 PM, which indicated the resident was found in the room of another resident and that the other resident had sustained an injury as a result of Resident #24's aggression. Continued review of the nursing progress notes revealed a pattern of escalating behaviors and physical aggression. (Photographic Evidence Obtained) During an interview with the Director of Nursing (DON) on 6/22/21 at 11:30 AM, she confirmed that the resident who had sustained the injury was Resident #36. The DON was asked for a copy of the federal report related to the allegation of abuse. She explained that she would look but did not believe a report had been filed. The DON returned approximately thirty minutes later and confirmed that a report had not been filed. She explained that the Administrator would have been responsible for filing the report. On 6/23/21 at 12:45 PM, an interview was conducted with Resident #36 in her room. She was able to recall a male resident coming into her room and recalled that he would not leave until a staff member came and assisted him from the room. She explained that the incident occurred in her previous room (230). Resident #36 was able to recall a male resident bending her left middle finger backward. She stated it did hurt at the time. She explained that she had not seen the alleged perpetrator since the incident occurred. The resident explained that she did not recall any external agencies being notified of the alleged abuse, but that she believed facility administration was aware. Resident #36 denied any previous encounters with the alleged perpetrator and denied any past instances of abuse. (continued on next page) 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. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 6 Event ID: 105210 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 105210 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/24/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE W Frank Wells Nursing Home 210 N 2nd St MacClenny, FL 32063 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)