Below 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 Pruitthealth - Fleming Island during CMS and state inspections, most recent first.
Improper Labeling and Dating of Food Items: Food items in the kitchen walk-in refrigerator, freezer, and nourishment rooms were observed stored without labels or dates, including opened items and resident food items. Staff stated that kitchen staff were responsible for labeling products with the date received and for labeling and dating opened items before returning them to storage, and that opened items should only be kept for 3 days after opening.
Inadequate Dietary Staff Training Records and In-Service Documentation: The facility failed to maintain an effective training program for dietary staff, with inconsistent in-service documentation, missing participant signatures and dates, and unclear records for repeated trainings. Training records also showed an aide signed for multiple sessions dated before his hire date, while interviews confirmed dietary training was done as needed and the facility had no written policy for training requirements.
A resident with a Full Code status was found unresponsive and without respirations. An LPN initiated CPR but did not call 911 or activate a Code Blue as required by protocol, stopping CPR after about five minutes. The LPN did not notify other nursing staff or emergency services in a timely manner and pronounced the resident's death without proper authority. The facility failed to follow its own policies and the resident's Advance Directives, resulting in the resident not being revived.
A resident with Full Code status was found unresponsive and without respirations. An LPN assessed the resident and initiated CPR but did not call 911 or activate a Code Blue, stopping CPR after about five minutes without further medical direction. The LPN pronounced the resident's death, which was outside their scope of practice, and did not promptly notify supervisory staff. These actions did not follow facility policy or the resident's advance directives.
A resident with multiple complex medical conditions and Full Code status was found unresponsive, and an LPN initiated CPR but did not call 911 or a Code Blue, later pronouncing the resident's death outside their scope of practice. The facility administration did not immediately investigate the death, failed to obtain timely witness statements, delayed reporting the incident, and allowed the LPN to continue working despite an ineligible background screening. These failures in following protocol and administrative oversight placed other residents at risk.
A resident was found unresponsive and, despite having a full code status, the LPN on duty did not call 911 or initiate a Code Blue, and pronounced the resident's death outside his scope of practice. The incident was not reported to authorities within the required timeframe, with reporting delayed by several days due to initial misjudgment by facility leadership and lack of proper documentation.
A resident with cognitive deficits and diabetes was found with untrimmed, dirty fingernails, indicating a failure in providing necessary ADL assistance. Staff interviews revealed confusion over responsibility for nail care, especially for diabetic residents, and the facility lacked a policy for ADL care.
Improper Labeling and Dating of Food Items
Penalty
Summary
The facility failed to follow proper sanitation and food handling practices by not ensuring food items were properly labeled and dated in the main kitchen and nourishment rooms. During observations on 4/13/2026, the walk-in refrigerator contained three Mountain Dew mini cans and one carton of yogurt stored in a bag on the top shelf with no labels or dates. Later that day, the same items were still present without labels or dates, and the freezer contained one opened bag of cut squash and one opened box of sub roll dough with no labels or dates. On 4/14/2026, the walk-in refrigerator again contained two Mountain Dew cans and one personal thermal container with no labels or dates. On 4/15/2026, the nourishment room contained one container of ice cream with no label or date, and later two bottles of coffee creamer and two cans of Coca-Cola were observed with no labels or dates. An opened container of yogurt was dated 4/13/2026 but was not marked with a resident name. Staff interviews confirmed that kitchen staff were responsible for labeling products with the date received and labeling and dating opened items before returning them to storage, and that opened items should only be kept for three days after opening.
Inadequate Dietary Staff Training Records and In-Service Documentation
Penalty
Summary
The facility failed to develop, implement, and maintain an effective training program for new and existing staff consistent with their expected roles. During a kitchen tour, the Certified Dietary Manager (CDM) was asked to provide staff training documents for the prior three and six months and produced only one training session titled "Calibrating Thermometer and Holding Temperatures on Tray Line." Additional training documents in the binder included "Food Allergies," "Fire safety," "Three-Compartment Sink Procedures," and "Outdated Product," but several lacked participant signatures, dates, or clear documentation showing which staff attended the original training versus the redone training. The documentation also showed a gap in required in-service training for kitchen staff, with the last recorded session occurring on 8/13/2024. A review of the training binder also showed Dietary Aide D's signature on multiple training sessions dated before his hire date of 7/8/2025, including "Pureed Foods," "Always Available Cart and Supplies," "Training Session with no title," "Temperatures," "Floors," and "Allergies." The employee roster, Florida Background Screening Clearinghouse, and personnel file confirmed his hire date and showed no prior employment at the facility. Interviews with the CDM, a Dietary Aide/Cook, and the Administrator indicated that kitchen staff training was conducted as needed rather than on a set schedule, and the Administrator stated the facility had no written policy and procedure for training requirements.
Failure to Honor Advance Directives and Full Code Status During Medical Emergency
Penalty
Summary
The facility failed to honor a resident's Advance Directives and Full Code status when the resident was found unresponsive and without respirations. The resident, who had multiple diagnoses including congestive heart failure, Alzheimer's disease, COPD, and diabetes with chronic kidney disease, was admitted with a documented Full Code status, indicating the desire to be resuscitated in the event of cardiac or respiratory arrest. On the night of the incident, the resident was found unresponsive by a CNA, who notified the assigned LPN. The LPN assessed the resident, verified the Full Code status, and initiated CPR. However, the LPN did not call 911 or activate a Code Blue as required by facility protocol, and stopped CPR after approximately five minutes when it appeared ineffective. The LPN then attempted to contact the provider and notified the resident's family, but did not involve emergency medical services or other nursing staff in a timely manner. Interviews with staff revealed that the LPN was aware of the facility's protocol, which required calling a Code Blue and 911, and continuing CPR until EMS arrived or a physician instructed otherwise. The LPN admitted to not following these steps, stating uncertainty and possible panic as reasons for the omission. The CNA present during the event confirmed that she assisted in moving the resident but was unsure if CPR was performed. The Acting Director of Health Services and other nursing staff were not notified until hours after the incident, and the LPN, who was not authorized to pronounce death, did so without proper authority. The facility's policy and staff interviews confirmed that the correct procedure was not followed, and the resident's Advance Directives were not fully honored. The deficiency was identified as Immediate Jeopardy due to the facility's failure to act in accordance with the resident's Advance Directives and Full Code status, depriving the resident of potentially lifesaving measures. The event was isolated to one resident but demonstrated a breakdown in communication, adherence to protocol, and timely response to a medical emergency. The facility's own policies and staff statements confirmed that the required actions were not taken, resulting in the resident not being revived and expiring in the facility.
Failure to Administer CPR and Follow Emergency Protocol for Full Code Resident
Penalty
Summary
A deficiency occurred when staff failed to administer cardiopulmonary resuscitation (CPR) to a resident with a documented Full Code status after the resident was found unresponsive and without respirations. The facility's policy and the resident's advance directives required that CPR be initiated in such circumstances unless there were clear signs of irreversible death, which were not documented in this case. The resident was not revived and expired at the facility. The incident involved a resident with multiple medical diagnoses, including arthritis, urinary tract infection, severe malnutrition, congestive heart failure, Alzheimer's disease, COPD, hypotension, and diabetes with chronic kidney disease. The resident was alert and oriented earlier in the shift and had a care plan in place specifying Full Code status, with staff instructed to be aware of and follow the resident's wishes. On the night of the event, a CNA found the resident unresponsive and notified an LPN, who assessed the resident, verified the code status, and initiated CPR. However, the LPN did not call 911 or activate a Code Blue, and stopped CPR after approximately five minutes without further medical direction. Interviews and record reviews revealed that the LPN did not follow facility protocol, which required continuous CPR until EMS arrival and immediate notification of emergency services. The LPN also pronounced the resident's death, which was outside the scope of practice for an LPN, and failed to notify supervisory staff in a timely manner. The facility's policy and staff interviews confirmed that these actions were inconsistent with required procedures for responding to a Full Code resident in cardiac or respiratory arrest.
Failure to Investigate Resident Death and Ensure Staff Compliance with Code Protocols
Penalty
Summary
The facility failed to administer its operations in a manner that ensured effective and efficient use of resources, as evidenced by its response to the death of a resident with a Full Code status. The resident, who had multiple complex medical diagnoses including arthritis due to bacteria, severe protein-calorie malnutrition, congestive heart failure, Alzheimer's disease, COPD, hypotension, and diabetes with chronic kidney disease, was found unresponsive by a CNA. The LPN on duty assessed the resident, verified the code status, and initiated CPR for approximately five minutes before stopping. The LPN did not call 911 or initiate a Code Blue, which was contrary to facility protocol for Full Code residents. The LPN also pronounced the resident's death, which was outside the scope of practice for an LPN, and failed to notify the RN on duty or document the incident in a timely manner. The facility's administration did not immediately investigate the death or implement measures to ensure resident safety. There was a significant delay in reporting the incident to the appropriate agencies, with the event being reported five days after it occurred. The investigation was not thorough, as written witness statements were not obtained promptly, and the staff involved were not suspended pending investigation. The decision not to report the incident initially was based on the belief that it did not meet reporting requirements, despite evidence to the contrary. The facility also failed to ensure that all staff were aware of and followed the resident's advance directives and code status protocols. Additionally, the LPN involved in the incident was found to have an ineligible Level II background screening status, with expired fingerprints, yet continued to provide direct care to residents. The Human Resources Manager was unaware of the LPN's ineligible status until after the incident. These failures in administrative oversight and adherence to policy placed other residents with Full Code status at risk of avoidable and untimely deaths, as immediate and appropriate actions were not taken to investigate the event, ensure staff competency, or maintain regulatory compliance.
Failure to Timely Report Suspected Neglect and Delayed Emergency Response
Penalty
Summary
The facility failed to ensure that an alleged violation involving resident neglect was reported immediately, as required by state law and facility policy. A resident, who was admitted with a full code status, was found unresponsive by a CNA during a shift. The LPN on duty assessed the resident, found no pulse or respirations, verified the code status, and initiated CPR. However, the LPN did not call 911 or initiate a Code Blue, which was contrary to the facility's protocol. The LPN also pronounced the resident's death, which was outside his scope of practice, and did not provide a written statement regarding the event at the time. The CNA involved was not asked to provide a written statement until the date of the survey. The incident was not reported to the State Survey Agency or other appropriate authorities within the required two-hour timeframe. Instead, the event was reported five days after it occurred, following a determination by the corporate office that the incident was indeed reportable. Initial internal discussions among the Administrator, DHS, and corporate personnel led to the incorrect conclusion that the event was not reportable, based in part on undocumented statements that the resident was already deceased when found. There was no documentation or witness statement to support this claim at the time of the initial review. Interviews with staff revealed confusion and lack of adherence to the facility's abuse prevention and reporting policy. The LPN did not follow the established protocol for emergency response and reporting, and the facility's leadership did not immediately recognize the event as a reportable incident. The delay in reporting, lack of timely documentation, and failure to obtain witness statements contributed to the deficiency identified by surveyors.
Failure to Provide Adequate Fingernail Care for a Resident
Penalty
Summary
The facility failed to provide necessary services for a resident who was unable to perform activities of daily living, specifically in maintaining good grooming and personal hygiene. Resident #294, who required assistance with personal care due to cognitive and communication deficits and diabetes mellitus type II, was observed on two separate occasions with elongated, jagged fingernails and brown matter underneath. The resident confirmed that it had been a while since his fingernails were trimmed and that no staff had offered to trim or clean them, although he expressed willingness to have them trimmed. Interviews with facility staff revealed a lack of clarity regarding responsibility for fingernail care, particularly for diabetic residents. A CNA stated that CNAs were responsible for nail care, while an RN indicated that nurses should handle nail care for diabetic residents. Both staff members acknowledged the resident's need for fingernail care upon assessment. Additionally, the facility lacked a policy and procedure for ADL care, as confirmed by the Director of Nursing.
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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 Fleming Island
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Isle Healthcare & Rehabilitation Center | 1.1 mi | ★★★★★ | 0 | 0 |
| Middleburg Rehabilitation And Nursing Center | 5.5 mi | ★★★★★ | 5 | 0 |
| Aviata At Orange Park | 5.7 mi | ★★★★★ | 7 | 0 |
| Oak View Health And Rehabilitation Center | 5.8 mi | ★★★★★ | 0 | 0 |
| Life Care Center Of Orange Park | 5.9 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.