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🔎 Orange Park Health And Rehabilitation

Inspection Results


Inspection Overview

Orange Park Health And Rehabilitation has been cited for a total of 33 deficiencies since we began saving each survey.

In Florida, the average facility has **23.63 deficiencies** in our database. This profile shows the longer-term view.

Tip: Surveys happen throughout the year. Always check the official Medicare Care Compare site for the most recent data.



Understanding Deficiency Severity (A-L Scale)

The farther along in the alphabet (A through L) the Scope value is, the more severe the deficiency. **A through F means no actual harm has happened.**

Severity (Harm)Scope (Widespread?)Code Range
No Actual HarmIsolated to PatternA - C
No Actual HarmWidespreadD - F
**Actual Harm**IsolatedG
**Actual Harm**PatternH
**Actual Harm**WidespreadI
**Immediate Jeopardy**IsolatedJ
**Immediate Jeopardy**PatternK
**Immediate Jeopardy**WidespreadL


Detailed Deficiency List (Most Recent First)

Scope/Severity: F

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Survey Date: 2023-11-09
Correction Date: 2023-12-14
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: D

Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.

Survey Date: 2023-09-28
Correction Date: 2023-10-16
Category: Nursing and Physician Services Deficiencies
From Complaint: Y

Scope/Severity: D

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Survey Date: 2023-03-09
Correction Date: 2023-03-21
Category: Pharmacy Service Deficiencies
From Complaint: Y

Scope/Severity: D

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Survey Date: 2022-09-09
Correction Date: 2022-10-04
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: D

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Survey Date: 2022-06-10
Correction Date: 2022-07-01
Category: Nutrition and Dietary Deficiencies
From Complaint: Y

Scope/Severity: E

Honor the resident's right to organize and participate in resident/family groups in the facility.

Survey Date: 2022-01-21
Correction Date: 2022-03-01
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Survey Date: 2022-01-21
Correction Date: 2022-03-01
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Survey Date: 2022-01-21
Correction Date: 2022-03-01
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Provide safe and appropriate respiratory care for a resident when needed.

Survey Date: 2022-01-21
Correction Date: 2022-03-01
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Survey Date: 2022-01-21
Correction Date: 2022-03-01
Category: Pharmacy Service Deficiencies
From Complaint: Y

Scope/Severity: D

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Survey Date: 2021-05-05
Correction Date: 2021-05-28
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: J

Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

Survey Date: 2021-02-10
Correction Date: 2021-03-03
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: J

Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.

Survey Date: 2021-02-10
Correction Date: 2021-03-03
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: D

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Survey Date: 2021-02-10
Correction Date: 2021-03-03
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: Y

Scope/Severity: G

Ensure services provided by the nursing facility meet professional standards of quality.

Survey Date: 2020-08-17
Correction Date: 2020-11-16
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: Y

Scope/Severity: G

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Survey Date: 2020-08-17
Correction Date: 2020-11-16
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: G

Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.

Survey Date: 2020-08-17
Correction Date: 2020-11-05
Category: Nursing and Physician Services Deficiencies
From Complaint: Y

Scope/Severity: D

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Survey Date: 2020-08-17
Correction Date: 2020-11-05
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: Y

Scope/Severity: D

Provide care and assistance to perform activities of daily living for any resident who is unable.

Survey Date: 2020-02-06
Correction Date: 2020-03-06
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Provide enough food/fluids to maintain a resident's health.

Survey Date: 2020-02-06
Correction Date: 2020-03-06
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Provide safe and appropriate respiratory care for a resident when needed.

Survey Date: 2020-02-06
Correction Date: 2020-03-06
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

Survey Date: 2020-02-06
Correction Date: 2020-03-06
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: D

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Survey Date: 2020-02-06
Correction Date: 2020-03-06
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: D

Provide or obtain dental services for each resident.

Survey Date: 2020-02-06
Correction Date: 2020-03-06
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: E

Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

Survey Date: 2018-10-12
Correction Date: 2018-11-08
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.

Survey Date: 2018-10-12
Correction Date: 2019-01-20
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Provide safe and appropriate respiratory care for a resident when needed.

Survey Date: 2018-10-12
Correction Date: 2019-01-20
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: E

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

Survey Date: 2018-10-12
Correction Date: 2018-11-08
Category: Nursing and Physician Services Deficiencies
From Complaint: N

Scope/Severity: D

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Survey Date: 2018-10-12
Correction Date: 2019-01-20
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: E

Ensure each resident’s drug regimen must be free from unnecessary drugs.

Survey Date: 2018-10-12
Correction Date: 2018-11-08
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: D

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Survey Date: 2018-10-12
Correction Date: 2018-11-08
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: D

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Survey Date: 2018-10-12
Correction Date: 2019-01-20
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: J

Provide and implement an infection prevention and control program.

Survey Date: 2018-10-12
Correction Date: 2018-11-08
Category: Infection Control Deficiencies
From Complaint: N


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All deficiency data is sourced directly from the **Centers for Medicare & Medicaid Services (CMS)**.
Data Aggregation and Review provided by **The Nursing Home Site.**