Average — CMS composite of the measures below.
The next survey window likely opens around March 2027
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 Port Orange Nursing And Rehab Center during CMS and state inspections, most recent first.
Failure to provide ordered ROM, splinting, and compression services: Two residents with significant mobility limitations and contractures were observed without their prescribed hand/elbow splints, palm guard, or BLE compression stockings. One resident reported inconsistent ROM care because the aide was pulled to the floor, and a CNA/restorative aide confirmed she had not been providing restorative services for weeks due to staffing coverage. Records showed orders and care plans for splinting, passive ROM, and compression, but the residents were not receiving the documented services.
Failure to Provide Needed ADL Grooming and Hygiene Assistance: Two residents who required assistance with bathing and personal hygiene did not receive consistent grooming support. One resident with cognitive impairment, an AKA, and skin itching had no documented bathing task completion and limited shower documentation despite care plan needs. Another resident with severe cognitive impairment and multiple diagnoses was observed with coarse facial hair, stated staff had not offered grooming help, and had missing shower sheet documentation despite scheduled showers and ADL care needs.
Incorrect Oxygen Flow Rate: A resident with CHF, asthma, acute respiratory failure w/ hypoxia, and dependence on supplemental O2 was observed with the concentrator set at 1.5 LPM even though the MD order was for 2 LPM via NC. The resident, who had moderate cognitive impairment, stated she did not adjust the oxygen. An LPN later confirmed the concentrator was still set below the ordered rate and reported documenting 2 LPM on the MAR.
A resident with AFIB, HTN, dementia, anemia, overactive bladder, history of breast cancer, and an end-stage disease process had a care plan requiring substantial/maximal two-person assistance for bed mobility and total, two-person mechanical-lift transfers due to impaired mobility and fall risk. Over multiple days, CNA documentation showed the resident frequently received one-person ADL assistance instead of the ordered two-person assist. On one occasion, a CNA, without reviewing the care plan or Kardex, provided care alone, left the bed in a high position with the resident on her side holding a mobility bar, and briefly walked to the doorway to request nursing assistance for a soiled dressing; during this time, the resident’s leg movement caused her to fall from the bed to the floor. The resident complained of right hip pain and hitting her head, and subsequent SBAR, radiology, and ED documentation confirmed an acute, mildly displaced sub-capital fracture of the right femoral neck with femoral shaft impaction.
A resident with multiple comorbidities, including CVA, stage IV sacral pressure ulcer, breast cancer, chronic pain, and AFIB on Eliquis, had a care plan requiring substantial/maximal two-person assistance for bed mobility and dependent transfers with a mechanical lift due to impaired mobility and fall risk. Over the month prior to the incident, CNA documentation frequently reflected one-person ADL assistance despite the two-person requirement. On a morning when a new CNA was being coached, the coaching CNA provided care alone without reviewing the Kardex, left the bed in a high position, and the resident fell from bed during care. The resident was found on the floor between the beds complaining of head and right hip pain and was later confirmed by radiology and ED evaluation to have sustained a mildly displaced right femoral neck fracture with acute sub-capital fracture.
Failure to Provide Ordered ROM, Splinting, and Compression Services
Penalty
Summary
The facility failed to ensure that two residents with limited ROM and mobility needs received appropriate treatment and services to maintain or improve ROM and to prevent further decrease in ROM. One resident was observed in bed with a contracted right arm and contracted fingers on the left hand, and she stated she wanted more ROM and reported inconsistent ROM care because the aide was often pulled away to work on the floor. Her record showed diagnoses including quadriplegia and peripheral vascular disease, dependence on staff for bed mobility, transfers, and hygiene/grooming, and orders for bilateral hand splints and a right elbow splint to be worn in the morning after breakfast and removed before lunch as tolerated. She also had a care plan identifying the need for splints and gentle ROM prior to splint application. A second resident was observed seated in a wheelchair with a contracted left wrist, inability to open her palm, and swollen bilateral lower extremities without compression stockings in place. Her record showed diagnoses including cerebral palsy, severe intellectual disability, anxiety disorder, and major depressive disorder, along with orders for compression to both lower extremities in the morning and removal at bedtime, and a left palm guard to be worn after breakfast and removed before lunch or as tolerated. Her care plan also identified passive ROM through a nursing restorative program, compression hose per order, and a left palm guard as tolerated. During interviews, the Regional Clinical Director stated the facility did not have a restorative nursing program and instead used a national maintenance program through skilled therapy, but the two residents were not on that list. The Director of Rehab and Regional Rehab Manager stated therapy determined whether residents needed the maintenance program and that some services were added to CNA Kardexes, but confirmed the two residents were not on those programs. A CNA/restorative aide later confirmed both residents were on the restorative nursing program, but said she had not been providing restorative services for the last 7 weeks because she was repeatedly pulled to work on the floor due to staffing coverage. When she was asked to check the residents, she found the splints in their drawers and confirmed that neither resident had been wearing the splints or, for the second resident, compression stockings.
Failure to Provide Needed ADL Grooming and Hygiene Assistance
Penalty
Summary
The facility failed to ensure that residents who were unable to complete activities of daily living received needed assistance with grooming and personal hygiene. For one resident, the clinical record showed diagnoses including type 1 diabetes mellitus with diabetic chronic kidney disease, left above-knee amputation, carotid artery disease, and major depressive disorder. Her MDS indicated moderate cognitive impairment and that she required substantial to maximum assistance for showers. During an observation, she stated that her body had been itching for over a week and she could not recall when she last had a shower. Her record included multiple topical treatments for rash and dermatitis, and the ARNP noted scratches on her left thigh and started triamcinolone for pruritus. The resident’s care plan identified an ADL self-care deficit and stated she required partial to moderate assistance with personal hygiene. However, the CNA task look-back for the month showed the bathing task did not occur. The assigned CNA stated showers were scheduled twice weekly and should be documented in the computer and shower sheet, but she had to review the Kardex to determine whether the resident had recently showered. The unit manager later checked the records and could not find documented showers in the electronic record, and only found two documented showers and one refused shower on the paper shower sheets for the month. For another resident, the record showed diagnoses including left femur fracture, gait and mobility abnormalities, sacral deep tissue pressure injury, Alzheimer’s disease, and generalized muscle weakness. Her MDS showed severe cognitive impairment and that she required supervision or touching assistance for personal hygiene and substantial to maximum assistance for showering. During observation, she was noted to have coarse facial hair on her chin, jawline, and upper lip, and she stated that staff had not offered to help trim or shave it. The CNA assigned to her was unaware of the facial hair until it was pointed out, and the shower sheets for the prior three weeks lacked documentation. The electronic record showed only a few shower entries, while the care plan called for bathing with substantial assistance and personal hygiene with touch or supervision assistance.
Incorrect Oxygen Flow Rate
Penalty
Summary
The facility failed to ensure that Resident #131 received the physician-ordered oxygen flow rate. On 3/29/26, the resident was observed lying in bed with oxygen via nasal cannula, and the oxygen concentrator was set at 1.5 liters per minute even though the physician order written on 3/22/26 specified oxygen via nasal cannula at 2 liters per minute. When asked whether she adjusted the oxygen flow, the resident stated, "No, I don't touch it." The resident's record showed diagnoses including congestive heart failure, dependence on supplemental oxygen, unspecified asthma, acute respiratory failure with hypoxia, and shortness of breath, and the admission MDS dated 03/27/26 indicated a BIMS score of 11 out of 15 and that the resident receives oxygen therapy. On 3/31/26, the resident was again observed in bed with oxygen via nasal cannula, and the concentrator remained set at 1.5 liters per minute. The care plan created on 03/22/2026 identified oxygen therapy related to congestive heart failure and included a goal related to minimizing signs and symptoms of poor oxygen absorption, but no interventions were documented. Later that day, an LPN entered the room, confirmed the concentrator was set at 1.5 liters per minute, reviewed the record, and stated the oxygen order was for 2 liters per minute. She also stated that she had documented 2 liters per minute on the MAR that morning. The facility's Oxygen Administration policy stated to check the physician's order and turn the unit on to the desired flow rate.
Neglect Due to Failure to Follow Two-Person ADL Assistance Care Plan Resulting in Hip Fracture
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from neglect by not implementing care plan interventions requiring two-person assistance with activities of daily living (ADLs). The resident had an active care plan, revised on 10/16/25, that identified an ADL self-care performance deficit related to atrial fibrillation, hypertension, overactive bladder, history of breast cancer, dementia, anemia, and an end-stage disease process. The care plan specified that the resident required substantial/maximal assistance of two staff for bed mobility and was dependent/total with transfers, requiring a mechanical lift, two-person assistance, and a medium pad. The care plan also documented that the resident was at risk for falls or fall-related injury due to impaired mobility and decreased safety awareness, with interventions including a bariatric mattress, bed in lowest position, bolsters to bed, a left-side mobility bar, and cues for safety awareness. Despite these documented needs, the resident’s CNA task list from 12/10/25 through 01/10/26 showed that the resident received one-person ADL assistance on 21 of 31 reviewed days. On 01/10/26, the resident’s ADL care was again provided by only one CNA instead of two, contrary to the care plan. CNA B reported that this was her first day of work and that she was being coached by CNA A. When they entered the room around 5:15 AM, CNA A directed CNA B to care for the other resident in the room while CNA A cared for this resident. CNA B pulled the privacy curtain and began care on the other resident. She then heard a thud and CNA A exclaiming that the resident was on the floor. When CNA B looked, she saw the resident on her back, toward her right side, with her head toward the top of the bed, which was in a high position, and the resident was complaining of right hip pain. The DON later learned that the resident had fallen from the bed while CNA A was providing care alone. CNA A admitted she had not reviewed the care plan or Kardex before providing care and confirmed she provided care by herself. During a reenactment, CNA A demonstrated that the resident had been positioned on her right side, holding the mobility bar, with the bed at about waist height. CNA A walked to the doorway to ask the nurse to perform a dressing change because the resident’s dressing was soiled, leaving the resident in that side-lying position with the bed elevated. As CNA A was returning from the doorway, the resident’s left leg bent and its weight pulled the resident over the side of the bed to the floor, where she landed on her back and rolled to her left side. The resident complained of hitting her head, and CNA A called for help. Subsequent clinical documentation, including an SBAR note and radiology and emergency department reports, confirmed that the resident sustained a mildly displaced right femoral neck fracture with femoral shaft impaction, described as an acute sub-capital fracture of the right femoral neck, after being dropped or falling during transfer/bed mobility care provided by one CNA instead of the two-person assistance required by the care plan.
Removal Plan
- Suspended the CNA involved with the incident and terminated the CNA.
- Reported the CNA to the board of nursing.
- Held an ad hoc QAPI committee meeting with the Administrator, DON, and Medical Director to review the incident and implement a plan.
- Completed neglect education for licensed nurses and CNAs on proper positioning during routine care, wound care, and repositioning in bed, with emphasis on abuse and neglect, and obtained staff signatures prior to the staff's first shift.
- Completed assessments of residents to determine ADL assistance needs while in bed, proper positioning during care, and the number of persons required to assist during in-bed care.
- Completed competencies for licensed nurses and CNAs in providing ADL care and repositioning during in-bed ADL care.
- Conducted an ad hoc QAPI meeting to complete root cause analysis and discussion.
- Completed the root cause analysis identifying the root cause as the CNA's failure to follow the resident's plan of care.
- Conducted an ad hoc QAPI meeting to ensure all QAA/QAPI components were addressed and the facility was in substantial compliance.
- Initiated ongoing monitoring by the Administrator, NHA, DON, Unit Managers, IPCO, SDC, shift supervisor, and weekend supervisor to ensure CNA documentation matched the Kardex, the appropriate number of staff were observed providing care, and resident interviews were conducted when possible to confirm appropriate staffing was used.
- Provided education for all newly hired licensed staff and CNAs on reviewing the Kardex prior to providing care and using the appropriate number of staff for bed mobility.
Failure to Follow Two-Person ADL Assistance Care Plan Resulting in Hip Fracture
Penalty
Summary
The deficiency involves the facility’s failure to ensure that staff followed a resident’s care plan requiring two-person assistance for Activities of Daily Living (ADL) care, resulting in a fall and right hip fracture. The resident had multiple significant diagnoses, including cerebrovascular disease, a stage IV sacral pressure ulcer, malignant neoplasm of the breast, chronic pain syndrome, atrial fibrillation, and was receiving palliative care. The active care plan, revised in October 2025, documented that the resident had an ADL self-care performance deficit related to multiple conditions and required substantial/maximal assistance of two staff for bed mobility and dependent/total assistance with transfers using a mechanical lift with two staff and a medium pad. The care plan also identified the resident as being at risk for falls or fall-related injury due to impaired mobility and decreased safety awareness, and included interventions such as a bariatric mattress, bed in lowest position, bolsters, a left side mobility bar, and cues for safety awareness. On the date of the incident, the resident’s ADL care was provided by one CNA instead of two, contrary to the care plan. A review of the CNA task list from early December through early January showed that the resident had been documented as receiving one-person ADL assistance on 21 of 31 days reviewed, despite the care plan specifying two-person assistance for bed mobility and transfers. On the morning of the fall, a newly hired CNA (CNA B) reported that it was her first day of work and that she was being coached by another CNA (CNA A). When they entered the room, CNA A directed CNA B to care for the other resident in the room while CNA A cared for the resident with the two-person assistance requirement. CNA B pulled the privacy curtain and began providing care to the other resident. While doing so, she heard a thud and then heard CNA A exclaim that the resident was on the floor. When CNA B looked out from behind the curtain, she saw CNA A running toward the resident’s bed from the doorway, and observed the resident on her back toward her right side with her head toward the top of the bed; the bed was in a high position, and the resident was complaining of right hip pain. Further interviews and documentation clarified the circumstances of the fall. CNA B stated that she and CNA A had not reviewed the Kardex prior to entering the room and that, as a new employee, she did not know how to access the Kardex at that time; she later learned that the resident was obese and required two people for transfers and bed mobility. An LPN familiar with the resident reported that the resident was totally dependent for care by two staff members and confirmed that she was assigned to the resident on the day of the fall. The LPN stated that CNA A had asked her to obtain a wound dressing because the resident’s dressing was soiled, and while the LPN was getting the dressing, she heard CNA A yell that the resident was on the floor. The LPN found the bed raised and the resident lying on the floor between the beds, initially on her right side and then rolled to her back, with her head close to the wall and her hands on her head; the resident complained of head pain and stated she had hit her head. The resident was assisted back to bed with a mechanical lift and multiple staff, and shortly thereafter complained of severe right hip pain. Subsequent SBAR documentation, radiology reports, and hospital emergency department notes confirmed that the resident had sustained a mildly displaced right femoral neck fracture with femoral shaft impaction and an acute sub-capital fracture of the right femoral neck after being dropped by staff during a transfer, while taking Eliquis for atrial fibrillation and reporting right hip pain.
Removal Plan
- Suspended the CNA involved with the incident and terminated the CNA.
- Reported the CNA to the board of nursing.
- Held an ad hoc QAPI committee meeting with the Administrator, DON, and Medical Director to review the incident and plan to be implemented.
- Initiated and completed neglect education for licensed nurses and CNAs regarding proper positioning of residents in bed during routine care, wound care, and repositioning, with emphasis on abuse and neglect, and obtained staff signatures prior to the staff's first shift.
- Completed assessments to determine which residents required assistance with ADL care while in bed, proper positioning during care, and the number of people required to assist during care while in bed.
- Completed a comparison to ensure all residents' care plans and Kardexes accurately reflected residents' bed mobility needs and the number of staff required to assist.
- Initiated competencies for licensed nurses and CNAs in providing ADL care and repositioning residents during ADL care while in bed.
- Conducted an ad hoc QAPI meeting with root cause analysis and discussion.
- Completed the root cause analysis identifying the root cause as the CNA's failure to follow the resident's plan of care.
- Conducted an ad hoc QAPI meeting to ensure all QAA/QAPI components of the incident were addressed and in substantial compliance.
- Initiated ongoing monitoring of CNA documentation to ensure it matched the Kardex, visual confirmation that the appropriate number of staff provided care, and resident interviews when possible to confirm appropriate staffing was used for care.
- Provided education for all newly hired licensed staff and CNAs on reviewing the Kardex prior to providing care and using the appropriate number of staff for bed mobility.
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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 Port Orange
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Aviata At South Daytona | 2.8 mi | ★★★★★ | 2 | 2 |
| Carlton Shores Healthcare And Rehabilitation Cente | 4.3 mi | ★★★★★ | 4 | 0 |
| Seaside Health And Rehabilitation Center | 4.8 mi | ★★★★★ | 0 | 0 |
| Beach Street Health And Rehabilitation Center | 5.2 mi | ★★★★★ | 0 | 0 |
| Blue Palms Health And Rehabilitation Center Of Day | 5.9 mi | ★★★★★ | 6 | 0 |
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