Cycle 1
Health 2024-12-05 · Fire 2024-12-05
5 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
3 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Macclenny, FL
W Frank Wells Nursing Home
1-star overall rating with 1-star inspections with $26,320 in total fines with 5 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
210 N 2nd St, Macclenny, FL
(904) 259-6168
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
69
Certified beds
Average residents
57
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1969-06-20
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.59
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.63
Licensed practical nurse staffing · state 0.79 · national 0.87
Aide hours / resident day
1.29
Nurse aide staffing · state 2.34 · national 2.35
Total nurse hours
2.51
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.22
RN + LPN hours · state 1.52 · national 1.54
Weekend hours
1.72
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.20
Weekend registered nurse coverage · state 0.53 · national 0.47
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
0.62
CMS adjusted RN staffing hours
Adjusted total hours
2.63
CMS adjusted total nurse staffing hours
Case-mix index
1.30
Higher values indicate more complex resident acuity
RN turnover
47%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
37%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Value-based purchasing
Program rank
3,795
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
42.66
Composite VBP score used to determine payment impact.
Payment multiplier
0.9956
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 21.81% · Performance 26.02% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 6.12% · Performance 8.32% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
7.06
Baseline 98.08% · Performance 42.70% · Measure score 7.06 · Achievement 5.13 · Improvement 7.06
Adjusted total nurse staffing
10
Baseline 5.39 hours · Performance 5.92 hours · Measure score 10 · Achievement 10 · Improvement 9
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 14.94% |
10.72%
4.2 pts worse
|
No Different than the National Rate · Eligible stays 139 · Observed rate 19.42% · Lower 95% interval 10.19% |
| Discharge to community | 54.57% |
50.57%
4 pts better
|
No Different than the National Rate · Eligible stays 104 · Observed rate 50.96% · Lower 95% interval 46.77% |
| Medicare spending per beneficiary | 1.01 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 40.66% |
95.27%
54.6 pts worse
|
Numerator 37 · Denominator 91 |
| Falls with major injury | 1.1% |
0.77%
0.3 pts worse
|
Numerator 1 · Denominator 91 |
| Discharge self-care score | 52.73% |
53.69%
1 pts worse
|
Numerator 29 · Denominator 55 |
| Discharge mobility score | 34.55% |
50.94%
16.4 pts worse
|
Numerator 19 · Denominator 55 |
| Pressure ulcers or injuries, new or worsened | 5.49% |
2.29%
3.2 pts worse
|
Numerator 5 · Denominator 91 · Adjusted rate 4.28% |
| Healthcare-associated infections requiring hospitalization | 8.32% |
7.12%
1.2 pts worse
|
No Different than the National Rate · Eligible stays 92 · Observed rate 8.7% · Lower 95% interval 4.89% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 101 |
| Staff flu vaccination coverage | 25.19% |
42%
16.8 pts worse
|
Numerator 34 · Denominator 135 |
| Discharge function score | 49.09% |
56.45%
7.4 pts worse
|
Numerator 27 · Denominator 55 |
| Transfer of health information to provider | 77.36% |
95.95%
18.6 pts worse
|
Numerator 41 · Denominator 53 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 16.67% |
25.2%
8.5 pts worse
|
Numerator 7 · Denominator 42 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.3 |
2.1
0.2 pts worse
|
1.9
0.4 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.3 · Observed 2.0 · Expected 1.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 3.8 |
1.2
2.6 pts worse
|
1.8
2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.8 · Observed 3.4 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
97.8%
2.2 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
99.2%
0.8 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 6.9% |
2.6%
4.3 pts worse
|
3.3%
3.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.6% · Q2 5.6% · Q3 7.0% · Q4 9.6% · 4Q avg 6.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.7% |
3.7%
3 pts better
|
11.4%
10.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.7% |
| Percentage of long-stay residents who lose too much weight | 6.5% |
5.9%
0.6 pts worse
|
5.4%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 7.1% · Q3 4.7% · Q4 10.5% · 4Q avg 6.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 33.9% |
15.7%
18.2 pts worse
|
19.6%
14.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 32.0% · Q2 33.3% · Q3 34.9% · Q4 35.7% · 4Q avg 33.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 9.8% |
9.8%
About the same
|
16.7%
6.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.5% · Q2 8.6% · Q3 8.1% · Q4 9.7% · 4Q avg 9.8% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 24.2% |
11.7%
12.5 pts worse
|
16.3%
7.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.9% · 4Q avg 24.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 17.5% |
9.8%
7.7 pts worse
|
14.9%
2.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.7% · Q2 23.8% · Q3 12.5% · Q4 17.1% · 4Q avg 17.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.2% |
0.4%
1.8 pts worse
|
1.0%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.1% · Q3 2.6% · Q4 3.1% · 4Q avg 2.2% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 4.3% |
0.8%
3.5 pts worse
|
1.7%
2.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 5.9% · Q3 5.3% · Q4 4.2% · 4Q avg 4.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 26.4% |
12.5%
13.9 pts worse
|
19.8%
6.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.9% · Q2 23.9% · Q3 34.7% · Q4 22.1% · 4Q avg 26.4% |
| Percentage of long-stay residents with pressure ulcers | 2.0% |
5.1%
3.1 pts better
|
5.1%
3.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.1% · Q4 7.3% · 4Q avg 2.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 91.0% |
94.3%
3.3 pts worse
|
81.7%
9.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 91.5% · Q2 88.4% · Q3 90.0% · Q4 94.4% · 4Q avg 91.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 26.6% |
9.3%
17.3 pts worse
|
12.0%
14.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 26.6% · Observed 26.6% · Expected 11.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.5%
1.5 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 95.5% |
94.7%
0.8 pts better
|
79.7%
15.8 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 95.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 30.2% |
26.2%
4 pts worse
|
23.9%
6.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 30.2% · Observed 34.4% · Expected 27.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-01-26 · Fire 2023-01-26
8 health deficiencies
Top issue: Administration (4 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Cycle 3
Health 2021-06-24 · Fire 2021-06-24
3 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2024-12-05
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-01-05
E · Potential for more than minimal harm
2024-12-05
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2025-01-05
D · Potential for more than minimal harm
2024-12-05
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-01-05
D · Potential for more than minimal harm
2023-01-26
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-03-14
D · Potential for more than minimal harm
2023-01-26
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2023-03-14
Inspection history
Recent health citations
F · Potential for more than minimal harm
2024-12-05
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-01-05
F · Potential for more than minimal harm
2024-12-05
F868 · Administration Deficiencies
Health
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Corrected 2025-01-05
E · Potential for more than minimal harm
2024-12-05
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2025-01-05
D · Potential for more than minimal harm
2024-12-05
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-01-05
D · Potential for more than minimal harm
2024-12-05
F800 · Nutrition and Dietary Deficiencies
Health
Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
Corrected 2025-01-05
L · Immediate jeopardy
2024-06-13
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2024-07-13
L · Immediate jeopardy
2024-06-13
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2024-07-13
J · Immediate jeopardy
2024-06-13
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-07-13
J · Immediate jeopardy
2024-06-13
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-07-13
F · Potential for more than minimal harm
2023-01-26
F865 · Administration Deficiencies
Health
Have a plan that describes the process for conducting QAPI and QAA activities.
Corrected 2023-03-14
F · Potential for more than minimal harm
2023-01-26
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2023-03-14
D · Potential for more than minimal harm
2023-01-26
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2023-03-14
D · Potential for more than minimal harm
2023-01-26
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-03-14
D · Potential for more than minimal harm
2021-06-24
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2021-07-19
D · Potential for more than minimal harm
2021-06-24
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2021-07-19
D · Potential for more than minimal harm
2021-06-24
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2021-07-19
Penalties and ownership
What sits behind the stars
$26,320
2024-06-13
Fine
Fine · fine $26,320
Fine
Ownership
Baker County Medical Services Inc
Operational/Managerial Control · Organization
Chilson, Jeffrey
Corporate Officer · Individual
Chilson, Jeffrey
W-2 Managing Employee · Individual
Jackson, Charles
Operational/Managerial Control · Individual
Kennedy, Charles
Corporate Director · Individual
Raulerson, Sherrie
Corporate Director · Individual
Varnadoe, Tiffany
Corporate Director · Individual
Varnadoe, Tiffany
Corporate Officer · Individual
Varnadoe, Tiffany
W-2 Managing Employee · Individual
Wilson, Charles
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Macclenny Nursing And Rehab Center
Macclenny, FL
5-star overall rating with 5-star inspections with 5 fire-safety deficiencies in the latest cycle
#2
Vivo Healthcare Normandy
Jacksonville, FL
5-star overall rating with 4-star inspections with 9 fire-safety deficiencies in the latest cycle
#3
Fouraker Hills Rehab And Nursing Center
Jacksonville, FL
2-star overall rating with 3-star inspections with 5 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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