1 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
9 fire-safety deficiencies
Top issue: Emergency Preparedness (5 deficiencies)
Orange Park, FL
5-star overall rating with 5-star inspections with 1 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
833 Kingsley Ave, Orange Park, FL
(904) 269-2610
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Beds
120
Certified beds
Average residents
107
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Robert Schoenfeld
Operator or chain grouping
Approved since
1987-11-03
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
RN hours / resident day
0.45
Registered nurse staffing
LPN hours / resident day
0.86
Licensed practical nurse staffing
Aide hours / resident day
2.21
Nurse aide staffing
Weekend hours
3.11
Weekend nurse staffing
RN turnover
0%
Annual RN turnover
Total nurse turnover
46%
Annual nurse turnover
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.4 |
2.1
0.7 pts better
|
1.9
0.5 pts better
|
Long Stay · 20240701-20250630 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.8 |
1.2
0.4 pts better
|
1.8
1 pts better
|
Long Stay · 20240701-20250630 |
| 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 |
| 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 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.5% |
2.6%
2.1 pts better
|
3.3%
2.8 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 6.6% |
3.7%
2.9 pts worse
|
11.4%
4.8 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 3.6% |
5.9%
2.3 pts better
|
5.4%
1.8 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 14.1% |
15.7%
1.6 pts better
|
19.6%
5.5 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 7.3% |
9.8%
2.5 pts better
|
16.7%
9.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents whose ability to walk independently worsened | 3.2% |
11.7%
8.5 pts better
|
16.3%
13.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 1.9% |
9.8%
7.9 pts better
|
14.9%
13 pts better
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| 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 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 2.9% |
12.5%
9.6 pts better
|
19.8%
16.9 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 10.5% |
5.1%
5.4 pts worse
|
5.1%
5.4 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 97.3% |
94.3%
3 pts better
|
81.7%
15.6 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 8.2% |
9.3%
1.1 pts better
|
12.0%
3.8 pts better
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 3.3% |
1.5%
1.8 pts worse
|
1.6%
1.7 pts worse
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 100.0% |
94.7%
5.3 pts better
|
79.7%
20.3 pts better
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 21.1% |
26.2%
5.1 pts better
|
23.9%
2.8 pts better
|
Short Stay · 20240701-20250630 |
Survey summary
Top issue: Quality of Life and Care (1 deficiency)
9 fire-safety deficiencies
Top issue: Emergency Preparedness (5 deficiencies)
Top issue: Quality of Life and Care (2 deficiencies)
3 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Top issue: Resident Rights (3 deficiencies)
1 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire Safety
Have exits that are accessible at all times.
Corrected 2025-03-27
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2025-03-27
Fire Safety
Create arrangements with other facilities to receive patients.
Corrected 2025-03-27
Fire Safety
List the names and contact information of those in the facility.
Corrected 2025-03-27
Fire Safety
Conduct testing and exercise requirements.
Corrected 2025-03-27
Fire Safety
Meet the requirements of an integrated health system.
Corrected 2025-03-27
Fire Safety
Include a process for Emergency Preparedness collaboration.
Corrected 2025-03-27
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-03-27
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-03-27
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-05-20
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2023-05-20
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-05-20
Fire Safety
Have exits that are accessible at all times.
Corrected 2021-10-24
Inspection history
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-03-27
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-05-20
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-05-20
Health
Provide routine and 24-hour emergency dental care for each resident.
Corrected 2023-05-20
Health
Keep all essential equipment working safely.
Corrected 2023-05-20
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2021-10-24
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2021-10-24
Health
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.
Corrected 2021-10-24
Health
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Corrected 2021-10-24
Health
Keep residents' personal and medical records private and confidential.
Corrected 2021-10-24
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2021-10-24
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2021-10-24
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2021-10-24
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2021-10-24
Penalties and ownership
Operational/Managerial Control · Organization
W-2 Managing Employee · Individual
Operational/Managerial Control · Individual
Corporate Officer · Individual
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