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. Page 1 of 6 105210 105210 06/24/2021 W Frank Wells Nursing Home 210 N 2nd St MacClenny, FL 32063

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 6/23/21 at 12:55 PM, an interview was attempted with the alleged perpetrator (Resident #24), however, the resident was not able to answer any questions due to impaired cognition. On 6/23/21 at 1:17 PM, an interview was conducted with the Medical Records Clerk. She explained that she was familiar with Resident #24, and that there were several instances during which she had heard that Resident #24 had hit other residents and that they had been fearful to go into their rooms. When asked whether she was aware of an incident involving Resident #36, she explained that she had heard from other staff members but that she hadn't witnessed the incident. The Medical Records Clerk further explained that Resident #24 had an extensive history of physical aggression toward residents and staff, that he had a pattern of entering other residents' rooms, and that facility administration was aware of his behaviors. She explained that the behaviors had been present since Resident #24's admission to the facility. On 6/23/21 at 2:15 PM, an interview was conducted with the Social Worker. She explained that she was aware of the incident involving Resident #36 and Resident #24. She stated she felt Resident #24 wasn't an appropriate admission due to his behavioral concerns and physical aggression. She explained that she interviewed Resident #36 at the time of the incident and asked the resident whether there was anything she wanted me to report or anything that she wanted reported. The Social Worker was asked about the facility's abuse reporting policies. She confirmed that all allegations of abuse were required to be reported to the Administrator and other applicable agencies, and that this allegation had been reported to the Administrator but not the applicable agencies. On 6/23/21 at 2:27 PM, a second interview was conducted with the Director of Nursing. She was asked about the facility's abuse reporting policies. She acknowledged that the incident involving Resident #24 and Resident #36 was a resident to resident altercation, and that it should have been reported to the required agencies. She added that she was not employed at the facility at the time of the incident. She explained that Resident #24's behaviors were still aggressive and very sporadic but seemed to be improving to the point where she didn't feel continuous supervision was required. On 6/23/21 at 3:12 PM, an interview was conducted with the Administrator. He acknowledged that he had been informed of the allegation of abuse between Resident #24 and Resident #36. He further acknowledged that an initial report to required agencies and the police had not been generated because neither resident required a change in level of care. A copy of the facility's abuse policy entitled Abuse/Resident was conducted. The policy had an effective date of 5/14/93 and a revision date of 1/23/15. It did not include written procedures for the screening of potential employees, prevention of abuse, identification of abuse, or accurate information for the reporting of and response to allegations of abuse. (Photographic Evidence Obtained) During a follow-up interview with the Administrator on 6/24/21 at 4:30 PM, he stated he had reviewed the applicable abuse regulations and now felt the incident should have been reported. The Administrator was asked whether the facility had an updated policy related to abuse. He explained that a majority of the facility's policies had not been updated in quite some time. . 105210 Page 2 of 6 105210 06/24/2021 W Frank Wells Nursing Home 210 N 2nd St MacClenny, FL 32063

F 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Minimal harm or potential for actual harm Based on resident and staff interviews and record reviews, the facility failed to fully develop/update written policies and procedures related to abuse. This affected for one (Resident #36) of one resident reviewed for abuse. Residents Affected - Few The findings include: 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. On 6/23/21 at 2:15 PM, an interview was conducted with the Social Worker. She was asked about the facility's abuse reporting policies. She confirmed that all allegations of abuse were required to be reported to the Administrator and other applicable agencies, and that this allegation had been reported to the Administrator but not the applicable agencies. On 6/23/21 at 2:27 PM, a second interview was conducted with the Director of Nursing. She was asked about the facility's abuse reporting policies. She acknowledged that the incident involving Resident #24 and Resident #36 was a resident to resident altercation, and that it should have been reported to the required agencies. On 6/23/21 at 3:12 PM, an interview was conducted with the Administrator. He acknowledged that he had been informed of the allegation of abuse between Resident #24 and Resident #36. He further acknowledged that an initial report to required agencies and the police had not been generated because neither resident required a change in level of care. A copy of the facility's abuse policy entitled Abuse/Resident was conducted. The policy had an effective date of 5/14/93 and a revision date of 1/23/15. It did not include written procedures for the screening of potential employees, prevention of abuse, identification of abuse, or accurate information for the reporting of and response to allegations of abuse. (Photographic Evidence Obtained) 105210 Page 3 of 6 105210 06/24/2021 W Frank Wells Nursing Home 210 N 2nd St MacClenny, FL 32063

F 0607 Level of Harm - Minimal harm or potential for actual harm During a follow-up interview with the Administrator on 6/24/21 at 4:30 PM, he stated he had reviewed the applicable abuse regulations and now felt the incident should have been reported. The Administrator was asked whether the facility had an updated policy related to abuse. He explained that a majority of the facility's policies had not been updated in quite some time. Residents Affected - Few . 105210 Page 4 of 6 105210 06/24/2021 W Frank Wells Nursing Home 210 N 2nd St MacClenny, FL 32063

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Based on resident and staff interviews and record reviews, the facility failed to ensure that all alleged violations involving abuse were reported immediately, but not later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse, to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for one (Resident #36) of one resident reviewed for abuse. The findings include: 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. 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. 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. On 6/23/21 at 1:17 PM, an interview was conducted with the Medical Records Clerk. She explained that she was familiar with Resident #24, and that there were several instances during which she had heard that Resident #24 had hit other residents and that they had been fearful to go into their rooms. When asked whether she was aware of an incident involving Resident #36, she explained that she had heard from other staff members but that she hadn't witnessed the incident. The Medical Records Clerk further explained that Resident #24 had an extensive history of physical aggression toward residents and staff, that he had a pattern of entering other residents' rooms, and that facility administration was aware of his behaviors. She explained that the behaviors had been present since Resident #24's admission to the facility. 105210 Page 5 of 6 105210 06/24/2021 W Frank Wells Nursing Home 210 N 2nd St MacClenny, FL 32063

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 6/23/21 at 2:15 PM, an interview was conducted with the Social Worker. She explained that she was aware of the incident involving Resident #36 and Resident #24. She stated she felt Resident #24 wasn't an appropriate admission due to his behavioral concerns and physical aggression. She explained that she interviewed Resident #36 at the time of the incident and asked the resident whether there was anything she wanted me to report or anything that she wanted reported. The Social Worker was asked about the facility's abuse reporting policies. She confirmed that all allegations of abuse were required to be reported to the Administrator and other applicable agencies, and that this allegation had been reported to the Administrator but not the applicable agencies. On 6/23/21 at 2:27 PM, a second interview was conducted with the Director of Nursing. She was asked about the facility's abuse reporting policies. She acknowledged that the incident involving Resident #24 and Resident #36 was a resident to resident altercation, and that it should have been reported to the required agencies. On 6/23/21 at 3:12 PM, an interview was conducted with the Administrator. He acknowledged that he had been informed of the allegation of abuse between Resident #24 and Resident #36. He further acknowledged that an initial report to required agencies and the police had not been generated because neither resident required a change in level of care. During a follow-up interview with the Administrator on 6/24/21 at 4:30 PM, he stated he had reviewed the applicable abuse regulations and now felt the incident should have been reported. . 105210 Page 6 of 6