01 / INSPECTION LEDGER
Survey cycles in this release
| Cycle | Health date | Health deficiencies | Fire date | Fire deficiencies |
|---|---|---|---|---|
| Cycle 1 | 2026-07-01 | 0 | 2026-07-01 | 0 |
| Cycle 2 | 2024-12-05 | 5 | 2024-12-05 | 3 |
| Cycle 3 | 2023-01-26 | 8 | 2023-01-26 | 2 |
CMS CCN 1052102026-08-01 PROCESSING DATE
NURSING HOME PUBLIC RECORD
W Frank Wells Nursing Home
210 N 2Nd St · Macclenny, FL 32063 · Baker County
Certified beds69CMS provider file
Recent citation rows18current CMS citation release
Penalty rows1current CMS penalties file
Read this record carefully.
The citation files cover the three most recent standard inspections plus qualifying complaint and infection-control inspections in the prior three years. A correction date is a CMS field; this site does not independently verify conditions. Absence from a file is not proof that no issue exists.
02 / CITATION DETAIL
18 rows in the current release
4 rows carry G–L scope/severity codes; 4 carry J–L. 2 tag codes appear on more than one survey date. These counts describe citation rows, not residents or incidents.
2024-12-05 · HEALTHF0695Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide safe and appropriate respiratory care for a resident when needed.
Correction field: Deficient, Provider has date of correction · 2025-01-052024-12-05 · HEALTHF0800Severity D · isolated; potential for more than minimal harm
Nutrition and Dietary Deficiencies
Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
Correction field: Deficient, Provider has date of correction · 2025-01-052024-12-05 · HEALTHF0812Severity F · widespread; potential for more than minimal harm
Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Correction field: Deficient, Provider has date of correction · 2025-01-052024-12-05 · HEALTHF0868Severity F · widespread; potential for more than minimal harm
Administration Deficiencies
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Correction field: Deficient, Provider has date of correction · 2025-01-052024-12-05 · HEALTHF0921Severity E · pattern; potential for more than minimal harm
Environmental Deficiencies
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Correction field: Deficient, Provider has date of correction · 2025-01-052024-12-05 · FIREK0345Severity E · pattern; potential for more than minimal harm
Smoke Deficiencies
Have approved installation, maintenance and testing program for fire alarm systems.
Correction field: Deficient, Provider has date of correction · 2025-01-052024-12-05 · FIREK0761Severity E · pattern; potential for more than minimal harm
Miscellaneous Deficiencies
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Correction field: Deficient, Provider has date of correction · 2025-01-052024-12-05 · FIREK0920Severity D · isolated; potential for more than minimal harm
Gas, Vacuum, and Electrical Systems Deficiencies
Ensure proper usage of power strips and extension cords.
Correction field: Deficient, Provider has date of correction · 2025-01-052024-06-13 · HEALTHF0600Severity J · isolated immediate jeopardy
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Correction field: Deficient, Provider has date of correction · 2024-07-13 · complaint2024-06-13 · HEALTHF0689Severity J · isolated immediate jeopardy
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Correction field: Deficient, Provider has date of correction · 2024-07-13 · complaint2024-06-13 · HEALTHF0835Severity L · widespread immediate jeopardy
Administration Deficiencies
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Correction field: Deficient, Provider has date of correction · 2024-07-13 · complaint2024-06-13 · HEALTHF0867Severity L · widespread immediate jeopardy
Administration Deficiencies
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Correction field: Deficient, Provider has date of correction · 2024-07-13 · complaint2023-01-26 · HEALTHF0690Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Correction field: Deficient, Provider has date of correction · 2023-03-142023-01-26 · HEALTHF0865Severity F · widespread; potential for more than minimal harm
Administration Deficiencies
Have a plan that describes the process for conducting QAPI and QAA activities.
Correction field: Deficient, Provider has date of correction · 2023-03-142023-01-26 · HEALTHF0867Severity F · widespread; potential for more than minimal harm
Administration Deficiencies
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Correction field: Deficient, Provider has date of correction · 2023-03-142023-01-26 · HEALTHF0880Severity D · isolated; potential for more than minimal harm
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Correction field: Deficient, Provider has date of correction · 2023-03-142023-01-26 · FIREK0345Severity D · isolated; potential for more than minimal harm
Smoke Deficiencies
Have approved installation, maintenance and testing program for fire alarm systems.
Correction field: Deficient, Provider has date of correction · 2023-03-142023-01-26 · FIREK0914Severity D · isolated; potential for more than minimal harm
Gas, Vacuum, and Electrical Systems Deficiencies
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Correction field: Deficient, Provider has date of correction · 2023-03-1403 / ENFORCEMENT FILE
Penalties reported by CMS
Fine amounts and payment-denial days are shown exactly as aggregated from the current penalties file. They do not imply an unpaid balance.
| Date | Type | Fine amount | Payment-denial days |
|---|---|---|---|
| 2024-06-13 | Fine | $26,320 | 0 |
04 / OWNERSHIP DISCLOSURES
Who appears in the CMS file
- CHILSON, JEFFREYIndividual · W-2 MANAGING EMPLOYEENOT APPLICABLE · since 01/31/2024
- VARNADOE, TIFFANYIndividual · W-2 MANAGING EMPLOYEENOT APPLICABLE · since 06/14/2021
- KENNEDY, CHARLESIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 09/13/2007
- RAULERSON, SHERRIEIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 09/13/2007
- VARNADOE, TIFFANYIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 06/14/2021
- WILSON, CHARLESIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 09/13/2007
- CHILSON, JEFFREYIndividual · CORPORATE OFFICERNOT APPLICABLE · since 01/31/2024
- VARNADOE, TIFFANYIndividual · CORPORATE OFFICERNOT APPLICABLE · since 06/14/2021
- BAKER COUNTY MEDICAL SERVICES INCOrganization · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 09/13/2007
- JACKSON, CHARLESIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 01/21/2023
Names and roles are self-reported CMS disclosure fields. Exact-name pages do not prove that similarly named people or organizations are the same entity.
05 / CMS STAFFING FIELDS
Reported hours and turnover
Staffing fields are provider-reported and case-mix context matters. CMS applies footnotes and exclusions not reproduced as a new score here.
Total nurse hours6.08per resident day
RN hours0.82per resident day
Weekend nurse hours4.60per resident day
Staff turnover27.9%CMS reported field
06 / LOCAL RECORDS
Open the Macclenny ledger →