Port Orange Nursing and Rehab Center

In the surveyor’s words

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

• Immediate jeopardy, isolatedF600Feb 6, 2026

  Based on interviews and record review, the facility failed to ensure the residents' right to be free from neglect by failing to implement sufficient safeguards and supervision to prevent one (Resident #1) of four residents reviewed for Activities of Daily Living (ADL) care from an avoidable fall with a subsequent right hip fracture. The facility failed to ensure that staff implemented care plan interventions specifying two-person assistance with ADLs for Resident #1. On January 10, 2026, Resident #1's ADL care was provided by one Certified Nursing Assistant (CNA) rather than by two CNAs as indicated in the resident's care plan. The resident fell out of bed during ADL care and sustained a right hip fracture.Any resident requiring two-person staff assistance was at risk. […]

• Immediate jeopardy, isolatedF689Feb 6, 2026

  Based on interviews and record review, the facility failed implement sufficient safeguards and supervision to prevent one (Resident #1) of four residents reviewed for Activities of Daily Living (ADL) care from an avoidable fall with a subsequent right hip fracture. The facility failed to ensure that staff implemented care plan interventions specifying two-person assistance with ADLs for Resident #1. On January 10, 2026, Resident #1's ADL care was provided by one Certified Nursing Assistant (CNA) rather than by two CNAs as indicated in the resident's care plan. The resident fell out of bed during ADL care and sustained a right hip fracture.Any resident requiring two-person staff assistance was at risk. […]

• No harm, potential for more than minimal, patternF688Apr 1, 2026

  Based on observations, interviews, record review, and facility policy and procedure review, the facility failed to ensure that two (Resident #3 and Resident #113) of three residents reviewed for limited range of motion (ROM) received appropriate treatment and services to increase range of motion, and/or to prevent further decrease in range of motion, in a total survey sample of 36 residents. The findings include:1. During the initial tour on 3/29/26 at 1:51 PM, Resident #3 was observed in bed. Her right arm was contracted to the elbow, and her left-hand fingers were also contracted. She did not have any splints on her elbow or hand. When she was asked if she had any concerns, she stated she wanted to have more range of motion. […]

• No harm, potential for more than minimal, isolatedF677Apr 1, 2026

  Based on observations, interviews, and record review, the facility failed to ensure that two (Resident #28 and Resident #43) of three residents, who were reviewed for inability to carry out activities of daily living (ADLs), from a total of 36 residents in the sample, received necessary assistance to maintain good grooming and personal hygiene. The findings include: 1. Review of Resident #28's clinical record revealed she was admitted to the facility on [DATE] with diagnoses that included type 1 diabetes mellitus with diabetic chronic kidney disease, acquired absence of left leg above knee, occlusion and stenosis of bilateral carotid arteries, and major depressive disorder. […]

• No harm, potential for more than minimal, isolatedF695Apr 1, 2026

  Based on observations, interviews, record reviews, and facility policy and procedure review, the facility failed to ensure that one (Resident #131) of two residents reviewed for oxygen therapy, received the correct number of liters of oxygen ordered by the physician, in a total sample of 36 residents. This could result in the resident not receiving appropriate care and/or clinical complications. The findings include:On 3/29/26 at 11:13 AM, Resident #131 was observed lying in bed with oxygen (O2) via nasal canula (NC). An observation of her oxygen concentrator revealed the oxygen flow was set at 1.5 liters per minute (LPM). (Photographic evidence obtained) When the resident was asked if she adjusted the flow of the oxygen concentrator, she replied, No, I don't touch it. […]