Orange Park Rehabilitation And Nursing Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a staff interview, record review, and a review of the facility's policies and procedures, the facility failed to update a resident's Pre-admission Screening and Resident Review (PASRR) to include the resident's mental illness diagnosis for one (Resident #11) of two residents reviewed for PASRR completion from a total survey sample of 31 residents. The findings include: A review of the medical record revealed that Resident #11 was admitted to the facility on [DATE] with diagnoses including schizoaffective disorder - bipolar type and unspecified mood [affective] disorder. On 5/13/2025 at 11:09 AM, further review of the record revealed a PASRR completed on 7/11/2020 that did not document the resident's mental illness diagnoses of schizoaffective disorder - bipolar type, or unspecified mood [affective] disorder. A review of the resident's Annual minimum data set (MDS) assessment with an assessment reference date (ARD) of 11/4/2024, revealed that the resident was diagnosed with epilepsy or seizure disorder,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interviews, record review, and a review of the facility's policies and procedures, the facility failed to provide one (Resident #25) of two residents reviewed for Preadmission Screening and Resident Review (PASRR) who had diagnoses indicating a serious mental illness (SMI) on admission, with a Level II PASRR screening. The findings include: A review of Resident #25's electronic medical record (EMR) revealed that the resident was admitted to the facility on [DATE] with a completed PASRR Level I dated 10/18/2024, which was located in the miscellaneous section of the EMR. The 10/18/2024 Level I PASRR indicated the need for a Level II screening to be conducted. No Level II screening was found in the record. The 3008 Hospital Transfer Form dated 10/31/2024 noted a primary diagnosis of schizoaffective disorder. Other diagnoses found in the resident's record included cerebral palsy, schizoaffective disorder - depressive type; major depressive disorder - recurrent/severe with psychotic symptoms;…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, a staff interview, and a review of the facility's policies and procedures, the facility failed to develop a comprehensive care plan to address anticoagulant therapy for one (Resident #65) of 25 residents whose care plans were reviewed, from total survey sample of 31 residents. The findings include: A review of the medical record revealed that Resident #65 was admitted to the facility on [DATE] with diagnoses including COPD (chronic obstructive pulmonary disease), traumatic amputation of the left great toe, PVD (peripheral vascular disease), bipolar disorder, major depressive disorder, partial traumatic amputation of the left 5th toe, chronic pain syndrome, and unspecified heart failure. A review of the admission MDS (minimum date set) assessment with an ARD (assessment reference date) of 4/18/25 revealed that the resident had a BIMS (brief interview for mental status) score of 15 out of 15 possible points, indicating intact cognition. Section N of the assessment indicated the resident…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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 provide a consistent, viable means of communicating in a language that the resident understood for one (Resident #42) of 31 sampled residents. Failure to provide interpretation during care may result in the resident's needs not being recognized or met. The findings include: During a tour of the facility on 5/13/2025 at 11:48 AM, Certified Nursing Assistant (CNA) L stated Resident #42 did not speak English. He spoke an African language. She was not sure which one; she had never heard of the language before. She did not know what country he was from. CNA L stated the resident had learned to say yes and no or shake/nod his head when asked questions. When he spoke, she did not understand him because he spoke in his native language. During an observation of Resident #42's room on 5/13/2025 at 11:49 AM , no communication board was observed. No interpreter services contact information was posted in the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on kitchen food service observations, staff interviews, facility record 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, by failing to record dish machine temperatures, and by failing to seal and date mark open bundles of bread on the bread rack. Food handling and sanitation is important in health care settings serving nursing home residents. Unsafe food handling practices represent a potential source of pathogen exposure. The findings include: A tour of the kitchen was conducted on 5/12/25 at 11:00 AM. During the tour, the dish machine temperature log for April 2025 was reviewed and was incomplete. Temperatures were not recorded for breakfast or lunch on 4/25/25 or 4/26/25. Temperatures were not recorded for breakfast, lunch or dinner from 4/27/25 through 4/30/25. (Photographic evidence obtained) No date markings were observed on one open package of noodles or five open bundles of bread located on the bread rack in the dry storage room. Another…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, and staff interview, the facility failed to provide respiratory care consistent with professional standards of practice for one (Resident #2) of 11 sampled residents who were receiving oxygen therapy, from a total sample of 28 residents. Resident #2's oxygen flow rate was set higher than the physician ordered. The findings include: On 06/26/2023 at 12:02 PM, Resident #2 was observed lying in bed at an elevated position wearing a nasal cannula (device used to provide supplemental oxygen). Resident #2 reported her oxygen should have been set to run at 2 liters per minute (L/min). Resident #2's oxygen concentrator was observed to be set on 3 L/min. (Photographic evidence obtained) A review of Resident #2's physician's order dated 05/20/2023, revealed that she should have been receiving oxygen at 2 L/min via nasal cannula as needed. (Photographic evidence obtained) On 06/27/2023 at 11:12 AM, another observation was made of Resident #2, who was sleeping in bed with her nasal cannula on and her oxygen concentrator set at 2.5 L/min. (Photographic…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, record review and policy and procedure review, the facility failed to ensure that two (Resident #228 and #229) of three residents on oxygen therapy, received the correct number of liters of oxygen ordered by the physician and failed to ensure one (Resident #17) of one resident reviewed for tracheostomies, received tracheostomy care as ordered by the physician, from a total sample of 34 residents. This could result in the resident not receiving appropriate care and/or clinical complications. The findings include: 1. A review of Resident #228's medical record revealed an admission date of 10/01/21 with a primary diagnosis of Corona Virus 2019 (COVID 19) and type two diabetes. A review of the physician's orders revealed, oxygen at 2-3L/min continuous via nasal cannula. The baseline care plan did not indicate oxygen therapy. On 10/05/21 at 11:40 AM, Resident #228 was observed lying in bed in supine position with oxygen via nasal cannula. An observation of her oxygen concentrator…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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 ensure appropriate administration of medication for one (Resident #33) resident, failed to ensure accurate records of receipt and disposition of all controlled drugs for one (Resident #2) resident, and failed to assure accurate storage of eyedrops during medication storage review for two of two carts reviewed, from a total of four carts in the facility. The findings include: On 10/05/21 at 12:00 PM, medication for Resident #33 was observed at her bedside. (Photographic evidence obtained) A record review for Resident #33 revealed an admission date of 2/15/21. A review of her quarterly minimum data set (MDS) assessment dated [DATE] revealed a brief interview for mental status (BIMS) score of 14, indicating cognitively intact. The resident required glasses for impaired vision. On 10/05/21 at 12:33 PM, Resident #33 stated that the nurse left the medication at her bedside after she asked the nurse what…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record reviews, the facility failed to provide a discharge summary for one (Residents #75) of three residents sampled, which included a recapitulation of each resident's stay, inclusive of diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology, and consultation results, and a final summary of the residents' status at the time of the discharge that was available for release to authorized persons and agencies, with the consent of the resident or resident's representative. The facility also failed to include in the discharge summary, a reconciliation of all pre-discharge medications with the resident's post-discharge medications (both prescribed and over-the-counter), as well as a post-discharge plan of care that was developed with the participation of the resident and, with the resident's consent, the resident representative(s), which would assist each resident to adjust to his or her new living environment. The findings include: A record review for Resident #79 revealed an admission date of 7/12/21 and discharge date of 7/15/21. There…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility failed to ensure residents received adequate supervision and assistance devices to prevent accidents for one (Resident #188) of three residents reviewed for accidents, from a total sample of 34 residents. The findings include: A record review for Resident #188 revealed an admission date of 10/16/2017. Her primary medical diagnosis was dementia with behavioral disturbance. Secondary diagnoses included schizophrenia and need for assistance with personal care. A review of Resident #188's annual minimum data set (MDS) assessment dated [DATE] revealed a brief interview for mental status score of 4, indicating severe cognitive impairment. The resident required extensive assistance with activities of daily living. On 10/04/2021 at 11:20 AM, Resident #188 was observed lying in bed. She was positioned diagonally in the bed with her feet hanging off the left side of the bed. Two floor mats were stacked against the wall. An event history note, dated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to obtain routine dental care for one (Resident #47) of one resident sampled for dental services from a total sample of 34 residents. The findings include: On 10/4/2021 during a tour of the facility at 11:13 AM, Resident #47 stated she was awaiting a dental consult to have two of her teeth removed before she could have knee surgery. A review of the clinical record for Resident #47 revealed a 7/9/2021 order for dental consult - Necrotic teeth extraction prior to knee surgery. On 9/30/2021 a second order for dental consult revealed - Extraction of decayed teeth. There was no documentation in the residents' record showing the dental consult order for 7/9/21 was completed. Further review of the clinical record for Resident #47 revealed an admission date of 8/14/20 with a primary diagnosis of unilateral primary osteoarthritis, right knee. A review of the annual minimum data set (MDS) assessment dated [DATE], revealed a brief interview for mental status…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews and record review, the facility failed to ensure a refrigerator in the nourishment room was maintained at acceptable temperatures and failed to store and label items appropriately in 1 of 1 nourishment rooms. The findings include: On 10/7/21 at 12:00 PM, the facility's nourishment room was observed and revealed the following: - Refrigerator temperature log was missing dates for 9/2, 9/3, and 9/16. (Copy obtained) - The freezer had ice cream in it but did not have a thermometer in it. - Freezer temperature logs for September and October 2021 were blank. (Copy obtained) - Refrigerator had a blue spill on bottom of unit. (Photo obtained) - Pizza box with 1 slice of pizza in the refrigerator with no name or date on the box. (Photo taken) - One container of cheese and ham in the refrigerator with no name and a date of 7/22/21 on it. (Photo taken) - One small container of sauce in the refrigerator with no lid, date, or name on it. (Photo obtained) - Pepsi bottle in the refrigerator with no date or name. - A sub in the refrigerator with no name or date on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.