Inspection·December 5, 2024

F 0695 medications and continuous oxygen therapy as ordered was documented. Level of Harm - Minimal harm or potential for actual harm On 12/02/24 at 11:39 AM, an interview was conducted with Registered Nurse (RN) B. She was asked to come to the resident's location and check the resident's oxygen flow rate. RN B confirmed that Resident #7 was receiving oxygen via nasal cannula at a flow rate of 1 Liter per minute from the e-cylinder that was hanging on the back of his wheelchair. Residents Affected - Few On 12/04/24 at 1:42 PM, an interview was conducted with Certified Nursing Assistant (CNA) A. She was asked if she had cared for residents who required oxygen therapy and what her role was. She stated Yes, I make sure they get the right amount and make sure the tubing is not wrapped around so they will be able to breathe. She was asked how she made sure the resident was receiving the flow rate prescribed by the physician and she replied, I ask the nurse. A review of the facility's policy and procedure titled [NAME] county Medical services, Inc., Oxygen Administration, revised: 11/1/2024, pages 2 of 2, revealed: Policy: A physician's order shall be required for administering oxygen, may be implemented with standing orders in emergency situations. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105210 If continuation sheet Page 2 of 12 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 12/05/2024 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)

F 0800 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record review, and facility policy and procedure review, the facility failed to honor food preferences for one (Resident #2) of one resident reviewed for food preferences from a total survey sample of 23 residents. The findings include: On 12/02/24 at 10:07 AM, Resident #2 stated, I have already told them what foods I don't like and what foods I can't have because of my GERD but they still send it. On 12/04/24 at 8:54 AM, Resident #2 was observed in bed with her breakfast tray sitting on the bedside table. Registered Nurse (RN) I was observed administering the resident's medication. Another staff member entered the room to collect the resident's breakfast tray and was asked to remove the food tray cover so the percentage of food consumption could be observed. The surveyor and RN I observed bacon and sausage gravy (on top of an open biscuit) remaining on the plate. The tray card was reviewed with RN I and it indicated that the resident disliked .bacon, sausage . A review of the medical record revealed that Resident #2 was admitted to the facility on [DATE] with diagnosis including, but not limited to, type 2 diabetes mellitus with diabetic neuropathy and hyperglycemia, GERD (gastroesophageal reflux disease) without esophagitis, and hyperlipidemia. A review of the resident's Quarterly MDS (Minimum Data Set) assessment, dated 10/23/24, revealed a BIMS (Brief Interview for Mental Status) score of 15 out of 15 possible points, indicating intact cognition. The resident was also documented as requiring set-up or clean-up assistance with eating, partial/moderate assistance for bed mobility, and substantial/maximal assistance with toileting and transfers. A review of the resident's active physician's orders revealed the follwoing: Lipitor 10 mg (milligrams) daily for hyperlipidemia (ordered 7/26/24) Pantoprazole DR (delayed release) 40 mg by mouth daily for GERD (ordered 7/30/24) ACCU checks (blood glucose monitoring) before meals and bedtime, notify MD (physician) if less than 70 or greater than 400 and Consistent Carbohydrate (CHO), Diabetic diet, Soft & Bite-sized/Chopped texture, Thin consistency. A review of the resident's active care plan revealed the following Focus Area: Potential for nutritional complications related to her diagnosis including depression, insomnia, pain, hypertension, hyperlipidemia, GERD (gastroesophageal reflux disease), vitamin deficiencies, Diabetes, and occasional nausea. On 12/02/24 at 9:30 AM, an interview was conducted with the Registered Dietician. She was asked who assessed the residents for likes/dislikes/preferences. She stated, the certified dietary manager (CDM). She was asked who updated the meal cards/tickets to reflect the residents' dislikes and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105210 If continuation sheet Page 3 of 12 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 12/05/2024 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)

F 0800 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few preferences. She stated, The CDM does that as well. She was asked who provided nutrition/dietary teaching to residents who were having difficulty adhering to their therapeutic diets or mechanically altered diets. She stated, Well, I can provide teaching if needed. I've only been with the facility for a month and I haven't had to do any teaching thus far. She further stated, Speech therapy is really who provides teaching related to diet consistency. She was asked if the facility provided any dietary waivers for residents with therapeutic diets who had decided not to comply. She stated, We can provide a waiver and that is also initiated by Speech Therapy and is usually related to safety issues for non-compliance with mechanically altered diets. On 12/02/24 at 10:00 AM, an interview was conducted with the CDM. He was asked to review the diet ticket for Resident #2 that was retrieved by the surveyor from the resident's breakfast meal tray. He was asked to explain the documentation on the ticket. He explained that the category of dislikes documented on Resident #2's meal ticket was extensive and he was responsible for interviewing the residents for preferences and updating the meal tickets. He was made aware of the observation of uneaten food remaining on the resident's breakfast tray, including bacon and sausage gravy, which were documented on the meal ticket as dislikes. The CDM stated, That was an error and I will take care of this right away. On 12/04/24 at 1:42 PM, an interview was conducted with CNA A. She was asked what the facility process was for a situation in which a resident was served food they did not want or could not eat. She stated, I usually ask if they want something else that the kitchen has available like salads. A review of the facility's policy and procedure titled [NAME] County Medical Services Inc., Resident Rights, Policy#6300-10-012, effective: 08/11/2010, revised 12/19/2022, revealed: 1. Right to dignity and respect: resident will be treated with dignity, respect, and consideration of their personal preferences, without discrimination. 3. Right to make decisions: Residents have the right to participate in decisions about their care . . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105210 If continuation sheet Page 4 of 12 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 12/05/2024 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)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the kitchen food service observations, staff interviews, facility document review and facility policy and procedure review, the facility failed to follow proper sanitation and food handling practices to prevent the outbreak of foodborne illness with the potential to affect all of the residents in the facility. The facility failed to ensure that the dietary staff used proper procedures for hand hygiene, disposable glove use, food storage and proper sanitation practices in the kitchen and for the two ice machines located in the main dining room and the restorative dining area. Safe food handling and good sanitation is important in health care settings serving nursing home residents due to the risk of serious complications from foodborne illness as a result of their compromised health status. Unsafe food handling practices represent a potential source of pathogen exposure. The findings include: During the initial tour of the facility kitchen on 12/02/24 at 9:22 AM an observation of the reach in freezer revealed black biological growth on the gaskets and door (Photographic evidence obtained). Observed in the walk in cooler black biological growth on the gaskets and the door. In the cooler, there were three large plastic bins that contained unmarked boil-in-a-bag plastic bags with liquid egg product that had no date mark on the individual bags or the bins; two previously opened 5 pound (lb.) cottage cheese containers with no date mark; one 12 lb. container of prepared potato salad with no date mark; one resealable plastic bag of cooked chicken with a date mark of 11/10/2024. There was produce on the floor under the shelving and two water bottles (Photographic evidence obtained). Observation of the walk in freezer revealed food on the floor (Photographic evidence obtained). Observation of the stand mixer revealed dried on food debris on the mixer carriage and back (Photographic evidence obtained). The food slicer had dried on food debris on the cover for the blade sharpener, the blade guard, the blade and the back side of the back plate (Photographic evidence obtained). It was not covered. The CDM confirmed that the staff do use the meat slicer. A plastic bulk rice bin had a metal scoop nesting in the rice (Photographic evidence obtained). Dust and debris were observed on ceiling tiles over the cook line and preparation tables in the middle of the kitchen and the floors needed to be cleaned in the dish room and throughout the kitchen along the walls and under the shelving units/tables. Dead roach carcasses were observed in the dish room and near the ware washing sink in the kitchen (Photographic evidence obtained). Observation of the refrigerator in the Activities kitchenette in the main dining room revealed a 3 lb. container of sour cream that had been opened; two 15 ounce (oz.) containers of whipped topping dated 09/24/2024 with a best-by date of 09/19/2024; two previously opened jars of dip with no date mark and an unopened 8 oz. container of nutritional shake with no date mark and the expiration date of 12/01/2024 (Photographic evidence obtained). The ice machine in the main dining room had a black biological growth on the inside of the chute The ice machine next to the restorative dining area had dried on water deposits and slime on the inside of the chute (Photographic evidence obtained). During an interview with the Certified Dietary Manager (CDM) on 12/02/2024 at 10:12 AM. He stated that the dietary staff are responsible for date marking and food item they put in the coolers. They have all been trained to do so. He confirmed that he could not determine when the food items had been opened or how long they had been in the cooler. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105210 If continuation sheet Page 5 of 12 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 12/05/2024 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)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many During an interview with the Activities Director on 12/02/2024 at 11:19 AM. She stated that the nurses are responsible for the supplements in the refrigerator in the kitchenette. She took the food out that were not date marked and confirmed that they had already been opened and used but had no date mark. She stated she understood that they all need a date mark once opened. During observations of the kitchen and lunch meal service on 12/04/2024 from 11:24 am until 12:20 pm. Dietary staff was observed. Observed Employee C, Cook, plating food during the lunch meal service at 11:24 AM. At 11:45 AM she changed gloves without washing her hands. At 11:56 AM she changed gloves without washing her hands. At 11:59 AM she changed gloves without washing her hands. At 12:03 PM she changed gloves without washing her hands. At 12:12 PM she doffed her gloves, threw them away in a garbage can and washed hands inappropriately by not washing for 15-20 seconds at the handwash sink. She then donned a new pair of gloves and proceeded to continue to plate food. At 12:18 PM she changed gloves without washing her hands. When she doffed her disposable gloves she put them on a plate under the tray line. After the meal service she threw away multiple sets of disposable gloves she had put on the plate. Observed Employee D, Dietary Aide, at 11:55 AM change gloves without washing her hands. At 12:14 PM she donned new gloves without washing her hands. Observed the CDM at 12:10 PM leave the kitchen. He returned at 12:11 PM. He did not wash his hands. He informed the cook he needed a divided plate with pureed food for a resident. She plated the food and handed it to him. He left the kitchen with the covered plate of food. At 12:14 PM he re-entered kitchen and did not wash his hands. A second tour of the kitchen was conducted on 12/04/2024 at 12:20 PM. The meat slicer was observed to have dried stuck on food debris on the cover to the blade sharpener, the backside of the back plate and the blade. It was not covered. The CDM confirmed that the staff are to clean the meat slicer after each use and that there was dried on food debris that should have been cleaned off after the last use. He was not sure when the slicer was used last. Observation of the stand mixer revealed dried on food debris on the mixer carriage and back (Photographic evidence obtained). The CDM confirmed that the staff are to clean the mixer after each use and it appeared it had not been cleaned for some time. He stated the parts of the mixer that are removable are ware washed. He stated the mixer is over [AGE] years old and has rust on the carriage. He acknowledged that dried on food debris, rust and peeling paint could get into the food while the mixer is running. He asked Employee I to come over to the mixer and look at the dried on food debris. She confirmed it needed to be cleaned. The floors had not been cleaned in the dish room or kitchen, the gaskets on the cooling units had not been cleaned, the plastic bins in the walk-in cooler with the boil-in-a-bag egg product had not been date marked and the metal scoop was still nesting in the bulk rice bin since the tour on 12/02/2024. During an interview with 12/04/2024 at 12:37 PM with the CDM and Employee I, Assistant Dietary Director, the CDM took the safety guard off the mixer and showed Employee I how there was stuck on food debris on it and other places on the slicer. She confirmed that she had cleaned the slicer after she used last. She acknowledged that she could see that the mixer was not clean. She stated that she had worked at the facility for 14 years and had been trained on how to clean the mixer. He then showed her the stand mixer and again she acknowledged that it was not clean. During an interview with the CDM on 12/04/2024 at 12:45 PM he stated that he was unaware of the black biological growth on the gaskets and the dust on the ceiling tiles. He stated that the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105210 If continuation sheet Page 6 of 12 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 12/05/2024 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)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many maintenance department is responsible for cleaning the ceiling tiles. He acknowledged that the floors needed to be cleaned in the dish room and throughout the kitchen. He was not aware that the dietary staff serving food during the lunch meal service had changed gloves without washing their hands in between. During an interview on 12/04/24 at 01:28 PM with Employees C and D, Employee C stated that she was not trained to wash her hands between glove changes. She stated that she did not think she needed to change them unless she changed tasks. She stated she takes the gloves off and puts them on a plate under the tray line and then throws them all away at once. She indicated she understood that she was not supposed to pile up the used gloves under the tray line but throw them away in the garbage can each time. Employee D was not aware that she had changed gloves without washing her hands each time. Review of the staff training Donning Gloves dated 03/29/2023 revealed Employee C attended the training. The training read: How to [NAME] Gloves. 1. Clean your hands thoroughly. Before touching the gloves, wash your hands with soap and water. Make sure to rub your hands together for at least 20 seconds while washing. Thoroughly dry your hands. How to remove gloves. 3. Dispose of both gloves in a proper bin. Review of the staff training certificates for Employees C and D revealed they received training on hand hygiene basics on 11/18/2024. Review of the training materials provided by the CDM revealed a staff training on date marking and labeling dated 12/02/2024 that read: Food rotation labels allow you to identify food products quickly and set up a storage system that helps to keep food properly labeled. It is also an FDA requirement that you maintain accurate labeling of your food. Labeling food in a commercial kitchen minimizes foodborne illness. By placing food rotation label on your storage bins you can easily label the type of food in the storage container, the date it was added to the storage bin, and the date the food will expire. All dietary staff attended the training (Copy obtained). Review of the instruction manual for the slicer revealed it read: To prevent illness or death caused by the spread of food-borne pathogens, it is important to properly clean and sanitize the entire slicer as any surface of the slicer can become contaminated. Once your slicer makes contact with food product, the entire slicer, including the removable parts, must be thoroughly cleaned and sanitized. This process is to be repeated at least every 4 hours using these procedures. An important step to kill bacteria is to allow the parts to air dry before reassembly (Copy obtained). Review of the facility policy and procedure entitled Dietary/Prevention of Food borne Illness, effective 05/10/1993 and revised 09/10/2016 revealed it read: Purpose: To establish guidelines for the prevention of an outbreak of food borne illness. Policy: Food shall be purchased, stored, prepared and served under approved sanitary conditions designed to control contamination and protect consumer against food infection. Bare Hand Contact with Food and Use of Plastic Gloves: Policy: Single-use gloves will be worn when handling food directly with hands to assure that bacteria are not transferred from the food handler's hands to the food product being served. Procedures: 1. Staff use good hygienic practices and techniques with access to proper hand washing facilities. 2. Staff use clean barriers such as single-use gloves. 3. Gloved hands are considered a food contact surface that can get contaminated or soiled. If used, single use gloves shall be used for only one task and for no other purpose and discarded when damaged or soiled or when interruptions occur in the operation. 4. Hands are to be washed when entering the kitchen and before putting on the single-use gloves. 6. Gloves are (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105210 If continuation sheet Page 7 of 12 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 12/05/2024 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)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many just like hands. They get soiled. Anytime a contaminated surface is touched, the gloves must be changed. Any time a contaminated surface is touched. 7. Wash hands after removing the gloves. Hand Washing. Policy: Staff will wash hands as frequently as needed throughout the day following proper hand washing procedures. 1. When to wash hands: Before donning new gloves for working with food. 2. How to wash hands: Scrub well with soap and additional water as needed, scrubbing all areas thoroughly. Scrub for a minimum of 10 to 15 seconds with a 20-second hand washing procedure. Apply vigorous friction between fingers and fingertips. Rinse with clean, running warm water. Rinse thoroughly. Staff is educated on the importance of hand washing and retrained and reminded as necessary on the above philosophy/guidelines. Cleaning and Sanitation of Dining and Food Service Areas. Policy: The food service staff will maintain the cleanliness and sanitation not the dining and food service areas through compliance with a written, comprehensive cleaning schedule. 3 All staff will be trained on the frequency of cleaning necessary. 6. Staff will be held accountable for cleaning assignments. Meat Slicer. Sanitation of Equipment. Frequency: After each use. 2. Remove all parts. 4. Scrub, rinse and sanitize parts in ware washing sink. 5. Allow parts to air dry. 6. Wash blade and machine shell. 7. Rinse, using clean hot water. 8. Sanitize blade and machine shell. Use clean water, and sanitizing solution. 9. Re-assemble parts. 11. Cover slicer after it has air dried and not in use. Mixer. Sanitation of Equipment. Frequency: After each use. 5. Scrub machine (beater shaft, bowl saddle, shell, and base) Use a sanitizing solution with a brush or clean cloth. 6. Rinse with clean water and clean cloth. 7. Allow to air dry (Copy obtained). Review of the staff training entitled F812 Food Safety Requirements dated 04/25/2024 revealed all of the dietary staff received training on food storage, preparation, distribution and serving in accordance with professional standards for food safety. Topic covered included hand washing, disposable glove use, food storage and labeling, cleaning fixed food equipment (mixers, slicers and ice machines)(Copy obtained). . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105210 If continuation sheet Page 8 of 12 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 12/05/2024 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)

F 0868 Have the Quality Assessment and Assurance group have the required members and meet at least quarterly Level of Harm - Minimal harm or potential for actual harm Based on facility document review, staff interview and facility policy and procedure review the facility failed to maintain a Quality Assurance and Performance Improvement (QAPI) committee composed of required members when the Medical Director failed to attend QAPI meetings on a monthly or quarterly basis from July 2024 through November 2024. The facility failed to provide evidence of communication of the program data to the Medical Director for his review and receive meaningful feedback from him on possible quality deficiencies and trends that might have required more frequent monitoring and may have resulted in negative health outcomes for the residents of the facility. Residents Affected - Many The findings include: A review of the QAPI meeting minutes for the months of June 2024 through November 2024 revealed the facility QAPI committee met on 06/14/2024, 07/09/2024, 08/20/2024, 10/03/2024, 10/31/2024 and 11/06/2024. The meeting attendance was recorded and the Medical Director attended only the June meeting by phone (Copies obtained). During an interview on 12/04/2024 at 10:30 AM with the Administrator and the Chief Nursing Officer. They described the changes to their QAPI program since April of 2024 after they received an Immediate Jeopardy citation for an elopement case. They are meeting monthly and collecting data on the Performance Improvement Plans (PIPs) developed by the QAPI committee. They confirmed that the Medical Director is a committee member. During an interview on 12/04/2024 at 02:12 PM with Administrator and Director of Nursing (DON) the administrator produced the contract and the job description of the Medical Director and stated that it does not specifically include his responsibilities as part of the QAPI Committee but by his title as Medical Director he is responsible for attending the meetings or sending a delegate. The DON stated that the Chief Nursing Officer over the hospital and nursing home, discusses the PIPs with him but does not send him any data and he does not give any feedback to the committee on the PIPs. The Medical Director has not ever sent a delegate to attend the meetings. Review of the Agreement for Physician Services dated 07/23/2023 between the Medical Director and the facility revealed it read: This agreement shall commence on August 1, 2023 and shall continue for a period of one (1) year unless earlier terminated as provided herein Therefore this agreement shall automatically renew for additional successive one (1) year periods unless either party give written notice of non-renewal not less than ninety (90) days prior to the expiration of the then current term. Duties of the physician: a. Physician shall provide [Facility] physician coverage on-site at the nursing facility during the term. The coverage shall entail the services set forth on Exhibit A which his attached (Copy obtained). Review of Exhibit A-Services read: The physician shall provide the following services to [Facility]. 1. Serve as Medical Director of [Facility]. Medical Director assists in developing, training, reviewing, updated, implementation of policies, protocols and standards of care that are intended to improve quality of resident care. 10. Ensure all Federal, State, accrediting bodies and facility regulations are met for clinical care (Copy obtained). Review of the facility QAPI Plan revised 06/14/2024 revealed the Medical Director was listed as a committee member. The Purpose statement read: To develop standardized processes and identify areas of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105210 If continuation sheet Page 9 of 12 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 12/05/2024 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)

F 0868 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many improvement to reduce variation, achieve predictable results, and improve outcomes for patients, systems of care and quality of life. Guiding Principles: Our organization uses quality assurance and performance improvement to make decisions and guide our day-to-day operations. In our organization, QAPI includes all employees, all departments, and all services provided. Our organization makes decisions based on data which include the input and experience of health care practitioners. The scope of the QAPI program encompasses all segments of the facility including Clinical Care Services. The QAPI Committee annually prioritizes activities, endorses or re-endorses policies and procedures and continually monitors for improvement through the use of QAPI self-assessment (Copy obtained). . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105210 If continuation sheet Page 10 of 12 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 12/05/2024 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)

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews, the facility failed to address missing wall trim mid-wall, leaving sharp and splintered wood exposed in three (rooms [ROOM NUMBER]) of 16 rooms observed on the east hall, from a total of 36 rooms in the facility. Sharp and splintered wood in resident rooms could result in resident injury with pain and possible infection. The findings include: During room observations, starting on December 2, 2024, at 11:50 a.m., the following was observed: a. In room [ROOM NUMBER], Bed A was missing the wall trim above the bed, mid-wall. Bed B was missing wall-trim above the bed, with partial trim still in place and jagged edges exposed. (Photographic evidence obtained) b. In room [ROOM NUMBER], Bed A was missing the wall trim at the headboard of the bed. [NAME] beams from the base of the wall, running up mid-wall were still in place with unfinished wood exposed. Bed B was missing the wall trim, mid-wall above the bed. (Photographic evidence obtained) c. In room [ROOM NUMBER], Bed A was missing the wall trim, mid-wall above the bed. Bed B was missing the wall trim, mid-wall above the bed with partial trim still in place, and unfinished, jagged edges exposed. (Photographic evidence obtained) During an interview on 12/03/24 at 2:52 p.m., the Maintenance Operations Director stated the facility used Service Desk, an electronic program to report facility repair requests. He reported that work orders came in daily via email and were checked daily by all plant operation personnel. Work orders were addressed as soon as possible unless parts needed to be ordered, and whomever oversaw the work order would sign off once completed. The Maintenance Operations Director followed up to ensure the job was completed with rounds being made daily. On 12/4/24 at 9:45 a.m., maintenance requests made through the Service Desk tickets were provided by the Administrator for 30 days. A review of the maintenance request tickets revealed there were no current work orders in place to address the missing wall trim mid-wall, for rooms 224, 226, or 232. During an interview on 12/5/24 at 9:25 a.m., the Maintenance Director stated his department had no current projects or current improvement plans in place that he could report. During a round of the east hall conducted on 12/5/24 at 9:30 a.m. with the Maintenance Director, the following was observed: a. In room [ROOM NUMBER], Bed A was missing the wall trim above the bed, mid-wall. Bed B was missing wall-trim above the bed with partial trim still in place and jagged edges exposed. b. In room [ROOM NUMBER], Bed A was missing the wall trim at the headboard of the bed. [NAME] beams from the base of the wall, running up mid-wall were still in place with unfinished wood exposed. Bed B was missing the wall trim, mid-wall above the bed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105210 If continuation sheet Page 11 of 12 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 12/05/2024 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)

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some c. In room [ROOM NUMBER], Bed A was missing the wall trim mid-wall above the bed. Bed B was missing the wall trim, mid-wall above the bed with partial trim still in place and unfinished, jagged edges exposed. The Maintenance Director stated he failed to follow up and missed those rooms. He had the maintenance personnel, removing the splintered boards, and it looks like they just didn't finish the job. He further indicated that they would start working on fixing these as soon as possible. During an interview on 12/05/24 at 10:47 a.m., Certified Nursing Assistant (CNA) F stated she was assigned to the east hall. Environmental concerns were reported to the [NAME] Clerk, who then communicated the concerns to the maintenance department. She stated the concerns about the walls in rooms [ROOM NUMBER] had been reported a number of times to the [NAME] Clerk, with nothing having been done. During an interview on 12/05/24 at 11:20 a.m., [NAME] Clerk G stated she was responsible for submitting work order requests through the Service Desk. She reported the requests the same day she received them. There was no specific maintenance personnel assigned to the facility. The maintenance personnel worked at the hospital across the parking lot but came to the facility when called, or when working on a request. She admitted to having knowledge of missing wall-trim in rooms [ROOM NUMBER], and confirmed reporting the concerns to maintenance. On 12/05/24 at 11:35 a.m., the Administrator reported that there was no facility policy for maintenance repairs/requests. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105210 If continuation sheet Page 12 of 12