Above average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Isle Healthcare & Rehabilitation Center during CMS and state inspections, most recent first.
Two residents with complex medical and cognitive conditions were found with cigarette lighters and cigarettes in their rooms, despite facility policy requiring smoking materials to be stored by staff. Staff interviews and photographic evidence confirmed that smoking materials were not secured as required, resulting in a failure to maintain a safe environment and prevent accident hazards.
A resident with a documented DNR order was found unresponsive, but staff initiated a Code Blue and performed CPR after incorrectly identifying her as Full Code in the EMR. The error was discovered only after the resident was transferred to the hospital, where her DNR status was confirmed. Despite clear facility policies and accessible documentation of the DNR, staff failed to verify the correct code status before starting resuscitation.
The facility did not provide required quarterly statements or account balance notifications to residents with personal funds accounts, as confirmed by interviews and record review. A resident with intact cognition was unaware of her account balance, and several residents had account balances exceeding the Medicaid eligibility limit without being notified. The Business Office Manager acknowledged that statements had not been distributed since assuming the role.
Six residents with personal funds accounts had balances exceeding the SSI resource limit for Medicaid eligibility, and none were notified as required. A resident reported not knowing her account balance or receiving statements, and the BOM confirmed that notifications had not been provided to affected residents.
Failure to Enforce Smoking Material Storage Policy
Penalty
Summary
The facility failed to maintain a safe environment by not enforcing its smoking policy for two residents with significant medical and cognitive conditions. Both residents were permitted to smoke unsupervised in designated areas, with the requirement that smoking materials be stored by staff and not kept in their rooms. However, during observations and interviews, it was found that both residents had cigarette lighters and cigarettes in their personal living spaces, contrary to facility policy. Staff confirmed that residents were not allowed to keep smoking materials in their rooms, and photographic evidence documented the presence of these items. Resident medical records indicated multiple diagnoses, including heart disease, chronic respiratory failure, cognitive deficits, and mental health disorders. Despite care plans and staff instructions outlining the risks and facility rules, both residents were found with prohibited smoking materials in their rooms. Staff interviews further confirmed awareness of the policy, yet the materials were not secured as required, resulting in a failure to prevent potential accident hazards related to smoking.
Failure to Honor Resident's DNR Order During Medical Emergency
Penalty
Summary
A deficiency occurred when facility staff failed to honor a resident's Do Not Resuscitate (DNR) order during a medical emergency. The resident, who had a documented DNR order signed by her health care surrogate and physician, was found unresponsive by a registered nurse (RN) during medication administration. Despite the presence of the DNR order in both the electronic medical record (EMR) and the facility's DNR book, the RN incorrectly identified the resident as Full Code and initiated a Code Blue, leading to the commencement of cardiopulmonary resuscitation (CPR) by staff. The resident was subsequently transferred to the hospital by emergency medical services (EMS), where it was confirmed that she was a DNR. The hospital contacted the facility to verify the resident's code status, and only then did the RN realize the error after rechecking the EMR. The resident, who had multiple medical diagnoses including alcohol dependency with withdrawal delirium, encephalopathy, heart failure, and other chronic conditions, was intubated and received advanced life support measures at the hospital before passing away after comfort measures were initiated. Facility policy and guidelines required staff to verify code status using the EMR or DNR book before initiating CPR, and the resident's DNR status was clearly documented and accessible. Interviews with staff confirmed that procedures for code status verification were in place and that the code status was prominently displayed in the EMR. However, the RN failed to follow these procedures, resulting in the administration of unwanted resuscitative efforts in direct contradiction to the resident's advance directives.
Failure to Provide Resident Personal Funds Account Statements
Penalty
Summary
The facility failed to provide individual financial records to residents with personal funds accounts, as required by policy. Specifically, none of the 56 residents with personal funds accounts received quarterly statements or statements upon request since at least May 2024. During interviews, a resident reported not knowing her account balance or being aware that statements should be provided. Review of her medical record indicated she had intact cognition and was capable of understanding such information. The Business Office Manager (BOM) confirmed that she had not provided statements since assuming her role in May 2024 and was unsure how residents were notified about accessing their funds. Additionally, residents with account balances exceeding $2000.00 were not notified of their balances, which is significant for Medicaid eligibility. The Regional BOM corroborated that quarterly statements had not been distributed and stated that notifications would begin in the future. Facility policy requires that residents have access to their account records through quarterly statements and upon request. The deficiency was substantiated through resident and staff interviews, record review, and policy review, with photographic evidence obtained.
Failure to Notify Residents of Personal Funds Account Balances Exceeding Medicaid Limits
Penalty
Summary
The facility failed to notify residents who receive Medicaid benefits when their personal funds account balances approached $200.00 less than the Social Security Income (SSI) resource limit for one person, as required. Record review showed that six out of 56 residents with personal funds accounts had balances exceeding $2,000.00, which is the SSI resource limit for Medicaid eligibility in Florida. During interviews, a resident stated she was unaware of her account balance and had not received statements regarding her personal funds account. The Business Office Manager (BOM) confirmed that she was responsible for maintaining residents' accounts and acknowledged that none of the residents with balances over $2,000.00 had been notified of their balances. The BOM and Regional BOM were in the process of reconciling accounts and preparing to send notices, but no timeframe for completion was provided. The deficiency was identified through interviews and review of account records.
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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.
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Nursing homes near Orange Park
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pruitthealth - Fleming Island | 1.1 mi | ★★★★★ | 3 | 0 |
| Aviata At Green Cove Springs | 5.8 mi | ★★★★★ | 0 | 0 |
| Westminster Woods On Julington Creek | 6 mi | ★★★★★ | 0 | 0 |
| Middleburg Rehabilitation And Nursing Center | 6.3 mi | ★★★★★ | 5 | 0 |
| Oak View Health And Rehabilitation Center | 6.7 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.