Orange Park Rehabilitation and Nursing Center

In the surveyor’s words

From the most serious findings on record at Orange Park Rehabilitation and Nursing Center, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF695Oct 8, 2021

  Based on observation, interviews, record review and policy and procedure review, the facility failed to ensure that two (Resident #228 and #229) of three residents on oxygen therapy, received the correct number of liters of oxygen ordered by the physician and failed to ensure one (Resident #17) of one resident reviewed for tracheostomies, received [CONDITION(S)] care as ordered by the physician, from a total sample of 34 residents. This could result in the resident not receiving appropriate care and/or clinical complications. The findings include: 1. A review of Resident #228's medical record revealed an admitted [DATE] with a primary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the physician's orders revealed, oxygen at 2-3L/min continuous via nasal cannula. […]

• No harm, potential for more than minimal, patternF755Oct 8, 2021

  Based on observations, interviews, record review and facility policy and procedure review, the facility failed to ensure appropriate administration of medication for one (Resident #33) resident, failed to ensure accurate records of receipt and disposition of all controlled drugs for one (Resident #2) resident, and failed to assure accurate storage of eyedrops during medication storage review for two of two carts reviewed, from a total of four carts in the facility. The findings include: On 10/05/21 at 12:00 PM, medication for Resident #33 was observed at her bedside. (Photographic evidence obtained) A record review for Resident #33 revealed an admitted [DATE]. […]

• No harm, potential for more than minimal, isolatedF644May 15, 2025

  Based on a staff interview, record review, and a review of the facility's policies and procedures, the facility failed to update a resident's Pre-Admission Screening and Resident Review (PASRR) to include the resident's mental illness diagnosis for one (Resident #11) of two residents reviewed for PASRR completion from a total survey sample of 31 residents. The findings include: A review of the medical record revealed that Resident #11 was admitted to the facility on [DATE] with diagnoses including schizoaffective disorder - bipolar type and unspecified mood [affective] disorder. […]

• No harm, potential for more than minimal, isolatedF645May 15, 2025

  Based on staff interviews, record review, and a review of the facility's policies and procedures, the facility failed to provide one (Resident #25) of two residents reviewed for Preadmission Screening and Resident Review (PASRR) who had diagnoses indicating a serious mental illness (SMI) on admission, with a Level II PASRR screening. The findings include: A review of Resident #25's electronic medical record (EMR) revealed that the resident was admitted to the facility on [DATE] with a completed PASRR Level I dated 10/18/2024, which was located in the miscellaneous section of the EMR. The 10/18/2024 Level I PASRR indicated the need for a Level II screening to be conducted. No Level II screening was found in the record. […]

• No harm, potential for more than minimal, isolatedF656May 15, 2025

  Based on record review, a staff interview, and a review of the facility's policies and procedures, the facility failed to develop a comprehensive care plan to address anticoagulant therapy for one (Resident #65) of 25 residents whose care plans were reviewed, from total survey sample of 31 residents. The findings include: A review of the medical record revealed that Resident #65 was admitted to the facility on [DATE] with diagnoses including COPD (chronic obstructive pulmonary disease), traumatic amputation of the left great toe, PVD (peripheral vascular disease), bipolar disorder, major depressive disorder, partial traumatic amputation of the left 5th toe, chronic pain syndrome, and unspecified heart failure. […]