Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at W Frank Wells Nursing Home during CMS and state inspections, most recent first.
The facility failed to maintain proper sanitation and food handling practices, with black biological growth observed on kitchen equipment, undated food items in storage, and improper hand hygiene by staff during meal service. Despite training, staff did not adhere to procedures, leading to potential foodborne illness risks.
The facility's QAPI committee lacked the required participation of the Medical Director, who did not attend meetings from July to November 2024, except for one in June by phone. The Medical Director did not receive program data or provide feedback on quality deficiencies, and no delegate was sent in his place. The facility's QAPI Plan included the Medical Director as a member, but his contract did not specify QAPI responsibilities.
The facility failed to address missing wall trim in three rooms on the east hall, leaving sharp and splintered wood exposed. Observations revealed that several beds were missing wall trim, resulting in jagged edges and unfinished wood. The Maintenance Operations Director acknowledged the issue, but no current work orders were in place. Staff interviews indicated a breakdown in communication and follow-up regarding maintenance requests, with no specific maintenance personnel assigned to the facility.
A resident with a history of encephalopathy and dependence on supplemental oxygen was observed receiving oxygen at 1 liter per minute, contrary to the physician's order of 2 liters per minute. This discrepancy was confirmed by a nurse, and staff interviews revealed a lack of clarity in ensuring the correct oxygen flow rate. The facility's policy required adherence to physician orders for oxygen administration.
A resident with dietary restrictions due to GERD and other medical conditions was served food items they disliked and could not consume, despite having informed the facility of their preferences. The certified dietary manager acknowledged an error in updating the resident's meal ticket, leading to a deficiency in meeting the resident's nutritional needs.
A resident with severe cognitive impairment managed to leave the facility unsupervised twice due to inadequate oversight and resources. The facility failed to ensure proper functioning of wander monitoring devices and door alarms, and lacked systematic staff training on elopement prevention. The administration did not investigate why a fire exit door alarm was disarmed, contributing to the resident's ability to exit the facility.
A resident with severe cognitive impairment and a history of elopement risk managed to exit a facility through a disarmed fire exit door, highlighting deficiencies in the facility's QAPI process. The facility failed to conduct a thorough investigation, lacked comprehensive staff training on elopement procedures, and had insufficient wander monitoring systems. Only a small portion of the staff received training on the use of fire door alarms, and no elopement drills were conducted in the year prior to the incident.
A resident with severe cognitive impairment and a history of wandering managed to exit the facility undetected on two occasions. The facility lacked a systematic process to protect residents at risk of elopement, with no investigation into disarmed fire exit alarms and inadequate staff training on elopement prevention. The resident's care plan was not revised after the initial incident, and safety checks were inconsistently documented, contributing to the resident's ability to elope again.
A resident with severe cognitive impairment and a history of wandering exited a facility through a disarmed fire exit door without staff knowledge. The facility lacked a systematic process for staff education on elopement risks, did not revise care plans after previous elopement attempts, and had insufficient staff training and elopement drills. The absence of a comprehensive policy for wander monitoring devices and inadequate documentation of door checks contributed to the deficiency.
Sanitation and Food Handling Deficiencies in Kitchen
Penalty
Summary
The facility failed to adhere to proper sanitation and food handling practices, which could potentially lead to foodborne illness affecting all residents. During an initial tour of the kitchen, surveyors observed black biological growth on the gaskets and doors of the reach-in freezer and walk-in cooler. Additionally, several food items in the cooler were found without date marks, including liquid egg products, cottage cheese, potato salad, and cooked chicken. The walk-in freezer had food on the floor, and the stand mixer and food slicer were found with dried food debris. Dust and debris were also noted on ceiling tiles, and dead roach carcasses were found in the dish room and near the ware washing sink. Further observations revealed improper hand hygiene and glove use by dietary staff during meal service. Employees were seen changing gloves without washing their hands multiple times, and one employee washed her hands inappropriately. The Certified Dietary Manager (CDM) and other staff members confirmed that they were responsible for date marking and cleaning but failed to ensure these tasks were completed. The CDM was unaware of the black biological growth and dust on the ceiling tiles and acknowledged the need for cleaning the floors and equipment. Interviews with staff revealed a lack of training and awareness regarding proper hand hygiene and glove use. Employee C admitted to not being trained to wash hands between glove changes and improperly disposing of used gloves. Despite attending training sessions on hand hygiene and food safety, staff did not consistently follow procedures. The facility's policies and procedures outlined the importance of proper sanitation and food handling, but these were not effectively implemented, leading to the observed deficiencies.
Medical Director's Absence from QAPI Meetings
Penalty
Summary
The facility failed to maintain a Quality Assurance and Performance Improvement (QAPI) committee with the required members, as the Medical Director did not attend QAPI meetings on a monthly or quarterly basis from July 2024 through November 2024. The QAPI meeting minutes revealed that the Medical Director only attended the June meeting by phone, and there was no evidence of communication of program data to the Medical Director for his review. Consequently, the Medical Director did not provide meaningful feedback on potential quality deficiencies and trends that might have required more frequent monitoring. Interviews with the Administrator, Chief Nursing Officer, and Director of Nursing confirmed that the Medical Director is a committee member, but his contract and job description did not specifically include responsibilities related to the QAPI Committee. The Chief Nursing Officer discussed Performance Improvement Plans (PIPs) with the Medical Director but did not send him any data, and he did not provide feedback to the committee. The Medical Director also did not send a delegate to attend the meetings. The facility's QAPI Plan listed the Medical Director as a committee member, emphasizing the importance of data-driven decisions and the involvement of healthcare practitioners in the QAPI process.
Failure to Address Missing Wall Trim in Resident Rooms
Penalty
Summary
The facility failed to address missing wall trim in three rooms on the east hall, leaving sharp and splintered wood exposed. This deficiency was observed during room inspections, where it was noted that several beds were missing wall trim, resulting in jagged edges and unfinished wood being exposed. Photographic evidence was obtained to document these conditions. The Maintenance Operations Director acknowledged the issue, stating that work orders were typically managed through an electronic program called Service Desk, but no current work orders were in place to address the missing wall trim in the affected rooms. Interviews with staff revealed a breakdown in communication and follow-up regarding maintenance requests. A Certified Nursing Assistant reported that environmental concerns, including the missing wall trim, had been communicated multiple times to the clerk responsible for submitting work orders. However, the Maintenance Director admitted to missing these rooms during follow-up rounds. Additionally, it was noted that there was no specific maintenance personnel assigned to the facility, as they worked at a nearby hospital and only attended to the facility when called. The Administrator confirmed that there was no facility policy for maintenance repairs or requests.
Failure to Administer Prescribed Oxygen Flow Rate
Penalty
Summary
The facility failed to provide oxygen at the prescribed flow rate for a resident who was dependent on supplemental oxygen. Observations on two separate occasions revealed that the resident was receiving oxygen at 1 liter per minute via nasal cannula, despite the physician's order specifying a flow rate of 2 liters per minute. This discrepancy was confirmed by a registered nurse during an interview. The resident's medical record indicated a history of encephalopathy, dependence on supplemental oxygen, and generalized anxiety disorder, with moderately impaired cognition as assessed by the BIMS score. The resident's care plan highlighted an altered respiratory status and a risk for ineffective breathing patterns due to cardiovascular compromise and a history of upper respiratory infection. Despite these documented needs, the facility's staff did not adhere to the prescribed oxygen therapy. Interviews with staff revealed a lack of clarity in ensuring the correct oxygen flow rate, as a certified nursing assistant stated she relied on the nurse to verify the prescribed rate. The facility's policy required a physician's order for oxygen administration, which was not followed in this instance.
Failure to Honor Resident's Food Preferences
Penalty
Summary
The facility failed to honor the food preferences of a resident, leading to a deficiency in providing a nourishing, palatable, well-balanced diet that meets the resident's daily nutritional and special dietary needs. The resident, who has a diagnosis of type 2 diabetes mellitus with diabetic neuropathy and hyperglycemia, GERD, and hyperlipidemia, expressed that despite informing the facility of their food dislikes and dietary restrictions due to GERD, they continued to receive meals containing those items. Specifically, the resident was served bacon and sausage gravy, which were documented as dislikes on their meal ticket. Interviews with facility staff revealed that the certified dietary manager (CDM) was responsible for assessing residents' food preferences and updating meal tickets, but an error occurred in this case. The CDM acknowledged the mistake upon being informed of the uneaten food on the resident's tray. The facility's policy emphasizes the residents' right to dignity, respect, and participation in decisions about their care, which was not upheld in this instance. The registered dietician, who had been with the facility for a month, indicated that she had not yet provided dietary teaching, and the CDM was responsible for updating meal preferences, highlighting a gap in the process that led to the deficiency.
Failure to Prevent Resident Elopement Due to Inadequate Oversight and Training
Penalty
Summary
The facility administration failed to provide adequate oversight and resources to prevent elopement, resulting in a resident with severe cognitive impairment leaving the premises unsupervised. The resident, who was assessed as at risk for elopement, had a wander monitoring device placed on her ankle. Despite this, she managed to exit the facility through a fire exit door on two occasions. The first incident occurred when the resident pushed open the fire exit door, triggering the alarm, but no care plan interventions were reviewed or revised afterward. The second incident involved the resident being found outside the facility, with the fire exit door alarm disarmed, and no investigation was conducted to determine why the alarm was disarmed. The facility lacked a systematic process to educate staff, identify environmental risks, and implement relevant interventions to protect residents from elopement. There were no documented elopement drills in the year preceding the incident, and staff orientation and annual training did not include information on elopement or wandering. After the incident, only a portion of the staff received training on elopement prevention and response, and the facility's elopement policy and procedures were not included in the new hire orientation. The facility's failure to ensure proper functioning of the wander monitoring devices and door alarms, along with inadequate staff training and oversight, contributed to the resident's ability to leave the facility unsupervised. The administration's lack of investigation into the disarmed door alarm and insufficient staff training on elopement prevention and response were significant factors in the deficiency.
Removal Plan
- Frequent visual checks to monitor for increased wandering behaviors.
- Education for door monitoring and wander monitoring device use and function.
- Education for elopement will be provided.
- All residents re-evaluated for wandering risk.
- Facility reviews of the elopement policy and procedure.
- Quotes obtained, and a project initiated for providing upgraded wander guard systems to the east wing, west wing, restorative dining room (doors), and south hall exit doors.
- Verification of wander guard placement and use for all residents.
- Review of monitoring tools for door checks, wander guard device checks.
- Staff education on the arming of the door system with the key.
- Continue with wander guard device checks and placement as ordered for those residents at wandering risk.
- Staff education of the Elopement policy and procedures.
- Performance Improvement Plan to assess and monitor progress of the initiatives put into place to avoid further occurrence. Review of PIP with QA&A committee.
- Review of Interdisciplinary Team assessment upon resident admission for residents deemed to be at risk for wandering behaviors, and continuation of wandering resident assessments with updates to elopement book as required.
- All residents re-evaluated for wandering resident risk assessment.
Deficiency in Elopement Prevention and Staff Training
Penalty
Summary
The facility failed to maintain an effective Quality Assurance and Performance Improvement (QAPI) process to monitor and audit practices related to resident elopements. This deficiency was highlighted by the incident involving a resident identified as an elopement risk, who managed to exit the facility through a disarmed fire exit door. The QAPI committee did not adequately address the incomplete investigation following the resident's elopement, nor did it ensure comprehensive staff training on elopement procedures and the proper use of fire exit door alarms. The resident in question had a history of severe cognitive impairment, as indicated by a Brief Interview for Mental Status (BIMS) score of 00 out of 15, and was assessed as at risk for elopement upon admission. Despite these assessments, the facility's interventions were insufficient, as evidenced by the resident's ability to exit the facility undetected. The fire exit door alarm was found to be disarmed, and there was no investigation into why this occurred. Additionally, the facility lacked a policy and procedure for wander monitoring devices, and only two of the seven facility exits were equipped with wander monitoring device sensor alarms. Staff training and participation in elopement drills were also inadequate. Only a small fraction of the staff received training on elopement procedures and the use of the key to arm and disarm fire door alarms. Furthermore, no elopement drills were conducted in the year leading up to the incident, and the only drill conducted afterward involved a limited number of staff. This lack of preparedness and training contributed to the facility's inability to prevent the resident's elopement and ensure the safety of other residents at risk for wandering.
Removal Plan
- Frequent visual checks to monitor for increased wandering behaviors.
- Education for door monitoring and wander monitoring device use and function.
- Education for elopement will be provided.
- All residents re-evaluated for wandering risk.
- Facility reviews of the elopement policy and procedure.
- Quotes obtained, and a project initiated for providing upgraded wander guard systems to the east wing, west wing, restorative dining room (doors), and south hall exit doors.
- Verification of wander guard placement and use for all residents.
- Review of monitoring tools for door checks, wander guard device checks.
- Staff education on the arming of the door system with the key.
- Continue with wander guard device checks and placement as ordered for those residents at wandering risk.
- Staff education of the Elopement policy and procedures.
- Performance Improvement Plan to assess and monitor progress of the initiatives put into place to avoid further occurrence. Review of PIP with QA&A committee.
- Review of Interdisciplinary Team assessment upon resident admission for residents deemed to be at risk for wandering behaviors, and continuation of wandering resident assessments with updates to elopement book as required.
- All residents re-evaluated for wandering resident risk assessment.
Failure to Protect Resident from Elopement
Penalty
Summary
The facility failed to protect a resident, identified as at risk for elopement, from leaving the premises undetected. The resident, who had severe cognitive impairment and a history of wandering, was admitted with a wander monitoring device placed on her ankle. Despite this, she managed to exit the facility through a fire exit door on two occasions. The first incident occurred when the resident pushed open the fire exit door, triggering the alarm, but no care plan interventions were reviewed or revised afterward. The second incident involved the resident being found outside the facility, with the fire exit door alarm disarmed, allowing her to leave undetected. The facility did not have a systematic process in place to protect residents at risk of elopement. There was no investigation into why the fire exit door's alarm was disarmed, and the facility lacked a policy and procedure for wander monitoring devices. Additionally, the facility's staff orientation and annual training did not include information on elopement or wandering, and there were no documented elopement drills in the year preceding the incident. The facility's failure to implement necessary interventions and revise the care plan after the initial incident contributed to the resident's ability to elope a second time. The facility's environment posed additional risks, with only two of seven exits fitted with wander monitoring device sensor alarms, both near the front entrance. The resident's care plan and physician's orders were not adequately followed, as evidenced by missing documentation of 15-minute safety checks ordered after the second elopement incident. The facility's lack of consistent staff training and failure to conduct regular elopement drills further exacerbated the risk to residents, particularly those identified as at risk for elopement.
Removal Plan
- Frequent visual checks to monitor for increased wandering behaviors.
- Education for door monitoring and wander monitoring device use and function.
- Education for elopement will be provided.
- All residents re-evaluated for wandering risk.
- Facility reviews of the elopement policy and procedure.
- Quotes obtained, and a project initiated for providing upgraded wander guard systems to the east wing, west wing, restorative dining room (doors), and south hall exit doors.
- Verification of wander guard placement and use for all residents.
- Review of monitoring tools for door checks, wander guard device checks.
- Staff education on the arming of the door system with the key.
- Continue with wander guard device checks and placement as ordered for those residents at wandering risk.
- Staff education of the Elopement policy and procedures.
- Performance Improvement Plan to assess and monitor progress of the initiatives put into place to avoid further occurrence. Review of PIP with QA&A committee.
- Review of Interdisciplinary Team assessment upon resident admission for residents deemed to be at risk for wandering behaviors, and continuation of wandering resident assessments with updates to elopement book as required.
- All residents re-evaluated for wandering resident risk assessment.
Failure to Prevent Resident Elopement Due to Inadequate Supervision and Intervention
Penalty
Summary
The facility failed to provide adequate supervision and implement sufficient interventions to prevent elopement for a resident identified as at risk. The resident, who had severe cognitive impairment and a history of wandering, was able to exit the facility through a fire exit door that was disarmed. This door was not equipped with a wander monitoring device sensor, and the alarm system was not properly engaged, allowing the resident to leave the premises without staff knowledge. The facility did not have a systematic process in place to educate staff on elopement risks, identify environmental hazards, or revise care plans to protect residents at risk of elopement. Despite the resident's known risk and previous attempts to leave the facility, there were no revisions to the care plan or additional interventions implemented after the resident's initial attempt to exit through the same door. The facility's lack of a comprehensive policy and procedure for wander monitoring devices contributed to the deficiency. Staff training and elopement drills were insufficient, with many staff members not receiving training on elopement prevention and response. The facility's failure to conduct regular elopement drills and ensure all staff were trained in the use of door alarms and wander monitoring devices further exacerbated the risk to residents. The lack of documentation and oversight regarding door checks and alarm functionality also played a significant role in the deficiency.
Removal Plan
- Frequent visual checks to monitor for increased wandering behaviors.
- Education for door monitoring and wander monitoring device use and function.
- Education for elopement will be provided.
- All residents re-evaluated for wandering risk.
- Facility reviews of the elopement policy and procedure.
- Quotes obtained, and a project initiated for providing upgraded wander guard systems to the east wing, west wing, restorative dining room (doors), and south hall exit doors.
- Verification of wander guard placement and use for all residents.
- Review of monitoring tools for door checks, wander guard device checks.
- Staff education on the arming of the door system with the key.
- Continue with wander guard device checks and placement as ordered for those residents at wandering risk.
- Staff education of the Elopement policy and procedures.
- Performance Improvement Plan to assess and monitor progress of the initiatives put into place to avoid further occurrence. Review of PIP with QA&A committee.
- Review of Interdisciplinary Team assessment upon resident admission for residents deemed to be at risk for wandering behaviors, and continuation of wandering resident assessments with updates to elopement book as required.
- All residents re-evaluated for wandering resident risk assessment.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 40 citations issued within 25 miles in the last 12 months — including the 4 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Macclenny
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Macclenny Nursing And Rehab Center | 0.7 mi | — | 0 | 0 |
| Vivo Healthcare Normandy | 19.5 mi | — | 9 | 0 |
| Fouraker Hills Rehab And Nursing Center | 20.1 mi | — | 0 | 0 |
| Westside Oaks Rehabilitation & Nursing Center | 22.2 mi | — | 19 | 4 |
| Middleburg Rehabilitation And Nursing Center | 22.6 mi | — | 5 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for W Frank Wells Nursing Home.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.