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 Orange City Nursing And Rehab Center during CMS and state inspections, most recent first.
A facility failed to develop and implement a care plan for a resident receiving anticoagulant therapy. The resident's physician's orders included Apixaban, but lacked monitoring instructions for side effects. The care plan did not address anticoagulant use, and the MAR lacked a monitoring tool. Interviews revealed the care plan was updated only after the deficiency was noted, contrary to facility policies requiring monitoring for bleeding and comprehensive care planning.
A resident with a Do Not Resuscitate (DNR) order received CPR due to a nurse mistakenly transcribing a Full Code order. Despite having a signed DNR form and physician's order in the electronic medical record, the resident's wishes were not honored. This incident highlights breakdowns in the facility's processes for Advance Directives (AD) and code status verification, leading to unnecessary pain and bodily harm for the resident.
A resident with a documented Do Not Resuscitate (DNR) order received CPR after being found unresponsive, due to a series of documentation errors. The resident's DNR status was recorded in the electronic medical record and a signed Florida DNR form was present. However, a care plan revision incorrectly listed the resident as Full Code. An LPN further compounded the error by discharging and reinstating the resident with the incorrect Full Code status. This led to the initiation of CPR, contrary to the resident's wishes. Staff interviews revealed that existing processes for verifying code statuses were not effectively implemented in this case.
Failure to Implement Anticoagulant Care Plan
Penalty
Summary
The facility failed to develop and implement a care plan for anticoagulant use for a resident, identified as Resident #68, who was part of a survey sample of 34 residents. Resident #68 was admitted with multiple diagnoses, including chronic ischemic heart disease and diabetes mellitus type 2 with diabetic kidney disease. The resident's physician's orders included an anticoagulant medication, Apixaban, but did not include orders to monitor for side effects related to anticoagulant use. Furthermore, the resident's care plan, initiated prior to the order for Apixaban, did not address anticoagulant use, and the medication administration record lacked a monitoring tool for side effects. Interviews with the LPN/Unit Manager revealed that the care plan for anticoagulant use was only added after the initial interview, indicating a lapse in timely documentation and planning. The facility's policy on anticoagulant therapy emphasized the need to monitor for signs and symptoms of bleeding, which was not reflected in the resident's care plan or MAR. Additionally, the facility's policy on comprehensive person-centered care plans required the inclusion of measurable objectives and interventions to manage risk factors, which were not adequately addressed in this case.
Failure to Honor DNR Order Due to Transcription Error
Penalty
Summary
The facility failed to honor a resident's Do Not Resuscitate (DNR) status, leading to a critical deficiency in care. Resident #1 had a DNR order in place upon admission but due to errors, including a nurse mistakenly transcribing a Full Code order instead of DNR, the resident received CPR against her wishes. This failure to review and honor the resident's DNR status resulted in unnecessary pain, bodily harm, and a prolonged resuscitation effort that ended in the resident's death in the hospital. The deficiency was exacerbated by breakdowns in the facility's processes related to Advance Directives (AD) and code status verification. Despite the presence of a signed DNR form and physician's order for DNR in the resident's electronic medical record, the staff failed to correctly identify and honor the resident's wishes. The facility's policy and procedure for ADs outlined clear steps for documenting and implementing resident preferences, but these protocols were not consistently followed, leading to the critical error in code status transcription for Resident #1.
Failure to Honor DNR Order Due to Documentation Errors
Penalty
Summary
The facility failed to act in accordance with a resident's Advance Directives and Do Not Resuscitate (DNR) status, resulting in the provision of CPR to a resident who had clearly expressed the desire to withhold CPR in the event of cardiac or respiratory arrest. Despite the resident having a DNR order in place, CPR was initiated upon finding the resident unresponsive with no pulse or respirations. This failure to honor the resident's wishes led to unnecessary pain and bodily damage, ultimately depriving the resident of a natural death. The resident, who had a complex medical history including diagnoses such as toxic encephalopathy, atrial fibrillation, and dementia, eventually expired in the hospital after prolonged life-sustaining efforts were made. The deficiency stemmed from a series of errors and oversights within the facility's processes and procedures. It was noted that the resident's DNR status was documented in the electronic medical record and a Florida DNR form had been signed by both the resident and her physician. However, a subsequent revision to the care plan mistakenly indicated the resident as a Full Code, contradicting the established DNR status. The confusion was further exacerbated when a licensed practical nurse (LPN) inadvertently discharged the resident from the electronic medical record, subsequently reinstating her with an incorrect Full Code status instead of the DNR order. This series of errors led to the initiation of CPR, contrary to the resident's expressed wishes. The facility's policy for CPR clearly outlined the requirement to initiate CPR unless a valid DNR order was in place. Despite this policy, the facility's staff failed to adhere to the resident's documented DNR status, leading to the initiation of CPR and subsequent resuscitation efforts. Interviews with staff members revealed that processes for verifying and documenting code statuses, especially in cases of similar names, were in place but were not effectively implemented in this instance. The failure to accurately verify and honor the resident's DNR status highlights a critical breakdown in communication, documentation, and adherence to established protocols within the facility.
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 260 citations issued within 25 miles in the last 12 months — including the 13 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 Debary
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Debary Health And Rehabilitation Center | 1.8 mi | ★★★★★ | 10 | 0 |
| Majestic Oaks | 2.6 mi | ★★★★★ | 0 | 0 |
| West Volusia Healthcare And Rehabilitation Center | 4.2 mi | ★★★★★ | 0 | 0 |
| Villa Healthcare & Rehabilitation Center | 6.9 mi | ★★★★★ | 9 | 0 |
| Healthcare And Rehab Of Sanford | 7.2 mi | ★★★★★ | 5 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.