Cycle 1
Health 2025-05-22 · Fire 2025-05-22
4 health deficiencies
Top issue: Resident Rights (3 deficiencies)
5 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Orange Park, FL
Isle Healthcare & Rehabilitation Center
3-star overall rating with 2-star inspections with $43,664 in total fines with 4 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
1125 Fleming Plantation Blvd, Orange Park, FL
(904) 213-8338
Overall
3 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
108
Certified beds
Average residents
102
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Gold Fl Trust Ii
Operator or chain grouping
Approved since
2005-03-11
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
46 facilities
Chain averages 3 overall / 3 health / 3 staffing / 5 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.55
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.76
Licensed practical nurse staffing · state 0.79 · national 0.87
Aide hours / resident day
2.16
Nurse aide staffing · state 2.34 · national 2.35
Total nurse hours
3.48
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.32
RN + LPN hours · state 1.52 · national 1.54
Weekend hours
3.29
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.41
Weekend registered nurse coverage · state 0.53 · national 0.47
Physical therapist
0.18
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.57
CMS adjusted RN staffing hours
Adjusted total hours
3.56
CMS adjusted total nurse staffing hours
Case-mix index
1.34
Higher values indicate more complex resident acuity
RN turnover
60%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
49%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Value-based purchasing
Program rank
7,914
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
28.40
Composite VBP score used to determine payment impact.
Payment multiplier
0.9850
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.46
Baseline 19.96% · Performance 19.83% · Measure score 3.46 · Achievement 3.46 · Improvement 0
Healthcare-associated infections
3.77
Baseline 6.64% · Performance 6.71% · Measure score 3.77 · Achievement 3.77 · Improvement 0
Total nurse turnover
2.65
Baseline 63.48% · Performance 52.83% · Measure score 2.65 · Achievement 2.65 · Improvement 2.26
Adjusted total nurse staffing
1.47
Baseline 3.8 hours · Performance 3.50 hours · Measure score 1.47 · Achievement 1.47 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.42% |
10.72%
1.7 pts worse
|
No Different than the National Rate · Eligible stays 182 · Observed rate 14.29% · Lower 95% interval 9.07% |
| Discharge to community | 50.77% |
50.57%
0.2 pts better
|
No Different than the National Rate · Eligible stays 155 · Observed rate 45.81% · Lower 95% interval 41.15% |
| Medicare spending per beneficiary | 1.19 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 166 · Denominator 166 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 166 |
| Discharge self-care score | 35.16% |
53.69%
18.5 pts worse
|
Numerator 32 · Denominator 91 |
| Discharge mobility score | 43.96% |
50.94%
7 pts worse
|
Numerator 40 · Denominator 91 |
| Pressure ulcers or injuries, new or worsened | 4.22% |
2.29%
1.9 pts worse
|
Numerator 7 · Denominator 166 · Adjusted rate 3.95% |
| Healthcare-associated infections requiring hospitalization | 6.71% |
7.12%
0.4 pts better
|
No Different than the National Rate · Eligible stays 120 · Observed rate 6.67% · Lower 95% interval 3.99% |
| Staff COVID-19 vaccination coverage | 2.01% |
8.2%
6.2 pts worse
|
Numerator 3 · Denominator 149 |
| Staff flu vaccination coverage | 23.26% |
42%
18.7 pts worse
|
Numerator 40 · Denominator 172 |
| Discharge function score | 39.56% |
56.45%
16.9 pts worse
|
Numerator 36 · Denominator 91 |
| Transfer of health information to provider | 86.15% |
95.95%
9.8 pts worse
|
Numerator 56 · Denominator 65 |
| Transfer of health information to patient | 95.65% |
96.28%
0.6 pts worse
|
Numerator 66 · Denominator 69 |
| Resident COVID-19 vaccinations up to date | 21.95% |
25.2%
3.2 pts worse
|
Numerator 18 · Denominator 82 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.2 |
2.1
0.9 pts better
|
1.9
0.7 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 1.2 · Expected 1.9 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.6 |
1.2
0.6 pts better
|
1.8
1.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.6 · Observed 0.5 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
97.8%
2.2 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
99.2%
0.8 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.3% |
2.6%
1.3 pts better
|
3.3%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 0.0% · Q3 1.2% · Q4 2.4% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 10.3% |
3.7%
6.6 pts worse
|
11.4%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 14.7% · Q3 18.2% · Q4 7.0% · 4Q avg 10.3% |
| Percentage of long-stay residents who lose too much weight | 1.0% |
5.9%
4.9 pts better
|
5.4%
4.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.4% · Q3 2.7% · Q4 0.0% · 4Q avg 1.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 0.7% |
15.7%
15 pts better
|
19.6%
18.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 1.4% · Q3 0.0% · Q4 0.0% · 4Q avg 0.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 5.1% |
9.8%
4.7 pts better
|
16.7%
11.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.4% · Q2 3.6% · Q3 5.0% · Q4 6.2% · 4Q avg 5.1% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 4.2% |
11.7%
7.5 pts better
|
16.3%
12.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.1% · Q2 0.0% · Q3 2.2% · Q4 0.0% · 4Q avg 4.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 2.6% |
9.8%
7.2 pts better
|
14.9%
12.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.9% · Q2 1.4% · Q3 2.8% · Q4 1.4% · 4Q avg 2.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.4%
0.4 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
0.8%
0.8 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 3.1% |
12.5%
9.4 pts better
|
19.8%
16.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.0% · Q2 3.4% · Q3 3.2% · Q4 1.1% · 4Q avg 3.1% |
| Percentage of long-stay residents with pressure ulcers | 2.3% |
5.1%
2.8 pts better
|
5.1%
2.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.0% · Q2 3.0% · Q3 4.1% · Q4 1.0% · 4Q avg 2.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.9% |
94.3%
4.6 pts better
|
81.7%
17.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 96.9% · Q2 99.4% · Q3 100.0% · Q4 100.0% · 4Q avg 98.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 4.3% |
9.3%
5 pts better
|
12.0%
7.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 4.3% · Observed 4.4% · Expected 11.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.5% |
1.5%
1 pts better
|
1.6%
1.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.8% · Q2 0.0% · Q3 0.0% · Q4 1.1% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 98.9% |
94.7%
4.2 pts better
|
79.7%
19.2 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 98.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.0% |
26.2%
2.2 pts better
|
23.9%
0.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.0% · Observed 25.3% · Expected 25.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-06-29 · Fire 2023-06-29
2 health deficiencies
Top issue: Infection Control (1 deficiency)
2 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Cycle 3
Health 2021-10-14 · Fire 2021-10-14
4 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2025-05-22
E42 · Emergency Preparedness Deficiencies
Fire Safety
Meet the requirements of an integrated health system.
Corrected 2025-06-29
D · Potential for more than minimal harm
2025-05-22
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2025-06-29
D · Potential for more than minimal harm
2025-05-22
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2025-06-29
D · Potential for more than minimal harm
2025-05-22
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2025-06-29
D · Potential for more than minimal harm
2025-05-22
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-06-29
D · Potential for more than minimal harm
2023-06-29
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2023-07-29
D · Potential for more than minimal harm
2023-06-29
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-07-29
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-05-22
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-06-29
J · Immediate jeopardy
2025-03-14
F578 · Resident Rights Deficiencies
Health
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.
Corrected 2025-04-04
F · Potential for more than minimal harm
2025-03-14
F568 · Resident Rights Deficiencies
Health
Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
Corrected 2025-04-04
D · Potential for more than minimal harm
2025-03-14
F569 · Resident Rights Deficiencies
Health
Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
Corrected 2025-04-04
D · Potential for more than minimal harm
2023-06-29
F687 · Quality of Life and Care Deficiencies
Health
Provide appropriate foot care.
Corrected 2023-07-29
D · Potential for more than minimal harm
2023-06-29
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-07-29
F · Potential for more than minimal harm
2021-10-14
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2021-11-18
D · Potential for more than minimal harm
2021-10-14
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2021-11-18
D · Potential for more than minimal harm
2021-10-14
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2021-11-18
D · Potential for more than minimal harm
2021-10-14
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2021-11-18
Penalties and ownership
What sits behind the stars
$43,664
2025-03-14
Fine
Fine · fine $43,664
Fine
Ownership
Isle SNF Holdco LLC
5% Or Greater Direct Ownership Interest · Organization
Copper Fl Trust Ii
5% Or Greater Indirect Ownership Interest · Organization
Fl Master Opco Holdco LLC
5% Or Greater Indirect Ownership Interest · Organization
Fuentes, Jose
W-2 Managing Employee · Individual
Gold Fl Trust Ii
5% Or Greater Indirect Ownership Interest · Organization
Shelby, Jack
Corporate Officer · Individual
Silver Fl Trust Ii
5% Or Greater Indirect Ownership Interest · Organization
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#2
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3-star overall rating with 2-star inspections with 3 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
#3
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5-star overall rating with 5-star inspections with 1 fire-safety deficiencies in the latest cycle
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