Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Life Care Center Of Orange Park during CMS and state inspections, most recent first.
The facility failed to coordinate PASRR assessments for two residents, resulting in deficiencies. One resident was readmitted with updated diagnoses requiring a Level II PASRR, which was not conducted. Another resident's Level I PASRR indicated a need for a Level II evaluation, but it was not completed. Interviews revealed a lack of awareness and coordination among staff regarding the PASRR process, leading to these deficiencies.
A resident with a pressure ulcer did not receive timely wound care as per physician's orders, with a bandage left unchanged for several days. Staff interviews revealed lapses in communication and documentation, contributing to the deficiency. The facility's policy on pressure ulcer management was not followed, leading to inadequate care.
A resident with severe cognitive impairment and cardiac conditions was observed receiving oxygen at incorrect flow rates, contrary to the physician's order of 2L/min. Despite staff procedures for checking oxygen flow rates, the resident was found receiving 4L/min, indicating a failure in adhering to the prescribed care plan.
The facility failed to follow physician orders for two residents, leading to deficiencies in care. A resident with a stage 3 pressure ulcer did not receive prescribed wound care, as evidenced by an outdated bandage and inaccurate treatment records. Another resident with severe cognitive impairment and cardiac issues received incorrect oxygen flow rates, contrary to physician orders. Staff interviews confirmed lapses in care and documentation, highlighting a failure to adhere to facility policies and procedures.
Failure to Coordinate PASRR Assessments for Residents
Penalty
Summary
The facility failed to coordinate assessments with the Pre-Admission Screening and Resident Review (PASRR) program, resulting in deficiencies for two residents. Resident #40 was readmitted with updated diagnoses indicating a need for a Level II PASRR, but the facility did not provide this evaluation. The resident had a history of unspecified psychosis, bipolar disorder, unspecified dementia, and Alzheimer's disease. Despite these conditions and the use of antipsychotic and antidepressant medications, the facility did not conduct the necessary Level II review upon the resident's readmission. Resident #80's Level I PASRR indicated a requirement for a Level II evaluation, which was not conducted by the facility. The resident had diagnoses including cognitive impairments following a cerebrovascular accident, major depressive disorder, and anxiety disorder. The facility's failure to conduct the Level II evaluation was confirmed through interviews with the Social Services Director and other staff, who were unaware of any residents requiring Level II PASRR evaluations. Interviews with facility staff revealed a lack of awareness and coordination regarding the PASRR process. The Social Services Director and Admissions Director were responsible for managing PASRR documentation but failed to ensure that necessary evaluations were completed. The facility's policy required a Level II evaluation for positive Level I screens, but this was not adhered to, leading to the deficiencies identified during the survey.
Failure to Provide Timely Pressure Ulcer Care
Penalty
Summary
The facility failed to provide necessary treatment and services for a resident with a pressure ulcer, as observed during a survey. The resident, who had a history of Alzheimer's disease and peripheral vascular disease, was found with a bandage on her right ankle that had not been changed as per the physician's orders. The bandage was dated several days prior, indicating a lapse in the scheduled wound care treatment. Despite the resident reporting foot pain and throbbing, the bandage was not changed in a timely manner, and the treatment administration record inaccurately reflected that the care had been provided. Interviews with facility staff revealed further issues in the administration of wound care. A CNA assigned to the resident was unaware of the frequency of bandage changes and did not report the outdated bandage to the unit manager. An LPN admitted to not completing the wound care treatment due to the resident's postponement and failed to document the missed treatment or inform the oncoming staff. This lack of communication and documentation contributed to the deficiency in care. The facility's policy on skin integrity and pressure ulcer management was not adhered to, as evidenced by the failure to follow physician's orders and document care accurately. The Assistant Director of Nursing confirmed that the expectation was to follow orders and document any refusals or late treatments, which was not done in this case. This deficiency highlights a breakdown in the facility's processes for managing pressure ulcers and ensuring proper wound care.
Failure to Administer Correct Oxygen Flow Rate
Penalty
Summary
The facility failed to provide appropriate respiratory care to a resident, as evidenced by the incorrect administration of oxygen therapy. Resident #226, who has severe cognitive impairment and multiple cardiac conditions, was observed receiving oxygen at a flow rate of 4 liters per minute, contrary to the physician's order of 2 liters per minute. This discrepancy was noted during observations on two separate occasions, with photographic evidence obtained. The resident was unable to confirm the correct oxygen flow rate and did not adjust it herself, indicating a lack of proper monitoring and adherence to the prescribed care plan. Interviews with facility staff revealed a lack of consistent communication and verification of oxygen orders during shift changes. A CNA stated that she was not permitted to adjust oxygen flow rates and would consult a nurse if there were any uncertainties. An LPN described her process for checking oxygen flow rates and confirmed that the current order for Resident #226 was 2 liters per minute. Despite this, the resident was found receiving oxygen at incorrect flow rates, highlighting a failure in ensuring that the care provided was consistent with the physician's orders and the comprehensive person-centered care plan.
Failure to Follow Physician Orders for Wound and Oxygen Care
Penalty
Summary
The facility failed to follow physician orders for two residents, leading to deficiencies in care. Resident #114, who was admitted with diagnoses including Alzheimer's disease and peripheral vascular disease, had a stage 3 pressure ulcer on her right heel. The physician's orders required specific wound care treatments every two days, but observations revealed that the bandage on her heel was dated several days prior, indicating that the treatment was not administered as prescribed. Interviews with staff confirmed that the wound care was not completed, and the treatment administration record was inaccurately marked as administered. Resident #226, who had severe cognitive impairment and multiple cardiac-related diagnoses, was prescribed oxygen therapy at a flow rate of 2 liters per minute. However, observations showed that the oxygen flow rate was set incorrectly at 4 liters per minute and later at 3 liters per minute. The resident was unable to adjust the oxygen flow rate herself, and staff interviews revealed a lack of adherence to the prescribed oxygen settings. The facility's policies and procedures for wound care and oxygen administration were not followed, resulting in a failure to provide necessary treatments and services as ordered by physicians. The staff did not document refusals or late administrations of treatments, and there was a lack of communication between shifts regarding incomplete care. These deficiencies highlight a significant lapse in the facility's adherence to physician orders and care protocols.
Plan Of Correction
The center provides the following Plan of Correction (POC) without admitting or denying the validity or existence of alleged deficiencies. The POC is prepared and/or executed solely because it is required by the provisions of federal and state law. The facility reserves all rights to contest survey findings through informal dispute resolutions, formal appeal proceedings, or any administrative or legal proceedings. On 2/3/2025, wound care treatment/services were immediately provided to resident #114, according to physician orders. The provider for resident #114 was notified of the missed dressing change/treatment identified on 2/3/2025. In addition, Unit Care Coordinator adjusted settings to oxygen delivery devices for resident #226, to reflect physicians orders. DON observed oxygen delivery devices for resident #226 to ensure following of physician orders pertaining to oxygen therapy. On 2/3/2025, the Director of Nursing/Designee completed an audit/review of other residents requiring dressing changes to ensure residents receive care consistent with professional standards of practice, to prevent pressure ulcers and to not develop pressure ulcers unless the individuals condition demonstrates that they were unavoidable. No additional concerns were identified. In addition, a facility-wide audit was completed by the DON/Designee on 2/4/25, to ensure no other residents affected. None were identified. Physician orders for oxygen were reviewed and delivery devices were observed to ensure accuracy of oxygen administration. On 2/10/25, the Director of Nursing/Designee initiated in-servicing with re-education for licensed nurses reviewing facility policies and procedures for Skin Integrity and Pressure Ulcer Prevention and Management. In addition, in-services with re-education for licensed nurses pertaining to the facility policy and procedures for Oxygen Administration, Safety, and Storage were initiated by the DON/Designee on 2/10/25. Newly hired licensed nurses will have the policy and procedures reviewed during orientation and the facility expectations explained. The Director of Nursing/Designee will conduct ongoing routine audits of residents requiring dressing changes, bi-weekly times 4, then monthly times 3 followed by as needed to ensure compliance with dressing change procedures to provide services necessary to prevent/heal pressure ulcers. These findings will be reviewed in Quality Assurance Performance Improvement Meeting monthly times 3 months and then as needed, if concerns arise. In addition, the Director of Nursing/Designee will conduct oxygen administration observations with focus on following physician orders, bi-weekly times 4, then monthly times 3 followed by as needed to ensure compliance with following physician orders, pertaining to respiratory care. These findings will be reviewed in Quality Assurance Performance Improvement Meeting monthly times 3 months and then as needed, if concerns arise.
What surveyors are citing around you — mapped
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What surveyors actually found near you
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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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A prioritized, do-first checklist
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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) |
|---|---|---|---|---|
| Orange Park Rehabilitation And Nursing Center | 0.2 mi | ★★★★★ | 0 | 0 |
| Aviata At Orange Park | 1.4 mi | ★★★★★ | 7 | 0 |
| Oak View Health And Rehabilitation Center | 1.9 mi | ★★★★★ | 0 | 0 |
| Life Care Center At Wells Crossing | 2 mi | ★★★★★ | 5 | 0 |
| Moosehaven | 2.5 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.