Cycle 1
Health 2024-11-21 · Fire 2024-11-21
1 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Orange Park, FL
Vivo Healthcare Orange Park
5-star overall rating with 4-star inspections with 1 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
570 Wells Rd, Orange Park, FL
(904) 264-3912
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
120
Certified beds
Average residents
114
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Vivo Healthcare
Operator or chain grouping
Approved since
1990-04-26
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
0.36
Registered nurse staffing
LPN hours / resident day
0.89
Licensed practical nurse staffing
Aide hours / resident day
2.13
Nurse aide staffing
Weekend hours
3.20
Weekend nurse staffing
RN turnover
38%
Annual RN turnover
Total nurse turnover
60%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.7 |
2.1
0.4 pts better
|
1.9
0.2 pts better
|
Long Stay · 20240701-20250630 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.4 |
1.2
0.8 pts better
|
1.8
1.4 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 | 1.7% |
2.6%
0.9 pts better
|
3.3%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 12.8% |
3.7%
9.1 pts worse
|
11.4%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 5.1% |
5.9%
0.8 pts better
|
5.4%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 22.4% |
15.7%
6.7 pts worse
|
19.6%
2.8 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 10.4% |
9.8%
0.6 pts worse
|
16.7%
6.3 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 | 5.5% |
11.7%
6.2 pts better
|
16.3%
10.8 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 3.6% |
9.8%
6.2 pts better
|
14.9%
11.3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.3% |
0.4%
0.1 pts better
|
1.0%
0.7 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 | 7.9% |
12.5%
4.6 pts better
|
19.8%
11.9 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 5.9% |
5.1%
0.8 pts worse
|
5.1%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 97.2% |
94.3%
2.9 pts better
|
81.7%
15.5 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 4.0% |
9.3%
5.3 pts better
|
12.0%
8 pts better
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.9% |
1.5%
0.6 pts better
|
1.6%
0.7 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 98.7% |
94.7%
4 pts better
|
79.7%
19 pts better
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 12.7% |
26.2%
13.5 pts better
|
23.9%
11.2 pts better
|
Short Stay · 20240701-20250630 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-01-06 · Fire 2023-01-06
8 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Cycle 3
Health 2021-05-27 · Fire 2021-05-27
10 health deficiencies
Top issue: Pharmacy Service (5 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2024-11-21
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-11-22
D · Potential for more than minimal harm
2023-01-06
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-02-06
D · Potential for more than minimal harm
2023-01-06
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2023-02-06
Inspection history
Recent health citations
D · Potential for more than minimal harm
2024-11-21
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-12-16
F · Potential for more than minimal harm
2023-01-06
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 2023-02-28
F · Potential for more than minimal harm
2023-01-06
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2023-02-28
D · Potential for more than minimal harm
2023-01-06
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-02-06
D · Potential for more than minimal harm
2023-01-06
F676 · Quality of Life and Care Deficiencies
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2023-02-06
D · Potential for more than minimal harm
2023-01-06
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-02-06
D · Potential for more than minimal harm
2023-01-06
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-02-06
D · Potential for more than minimal harm
2023-01-06
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-02-06
D · Potential for more than minimal harm
2023-01-06
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-03-06
G · Actual harm
2021-05-27
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2021-07-07
E · Potential for more than minimal harm
2021-05-27
F758 · Pharmacy Service Deficiencies
Health
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.
Corrected 2021-07-05
D · Potential for more than minimal harm
2021-05-27
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2021-07-05
D · Potential for more than minimal harm
2021-05-27
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2021-07-06
D · Potential for more than minimal harm
2021-05-27
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2021-07-06
D · Potential for more than minimal harm
2021-05-27
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 2021-07-05
D · Potential for more than minimal harm
2021-05-27
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2021-07-05
D · Potential for more than minimal harm
2021-05-27
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2021-07-12
D · Potential for more than minimal harm
2021-05-27
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2021-07-07
D · Potential for more than minimal harm
2021-05-27
F761 · Pharmacy Service Deficiencies
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 2021-07-06
Penalties and ownership
What sits behind the stars
Ownership
Jacksonville 3 Orange Park Opco Holdings LLC
5% Or Greater Direct Ownership Interest · Organization
Jek Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Jek Irrv Tr Ii
5% Or Greater Indirect Ownership Interest · Organization
Nmj Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Nmj Irrv Tr Ii
5% Or Greater Indirect Ownership Interest · Organization
Cukier, Brocha
5% Or Greater Indirect Ownership Interest · Individual
Cukier, Josef
5% Or Greater Indirect Ownership Interest · Individual
Sf Irrevocable Trust
5% Or Greater Indirect Ownership Interest · Organization
Ab Marbec Realty Group
5% Or Greater Indirect Ownership Interest · Organization
Gluck, Benjamin
5% Or Greater Indirect Ownership Interest · Individual
Jacobowitz, Judah
5% Or Greater Indirect Ownership Interest · Individual
Cukier, Josef
Operational/Managerial Control · Individual
Cukier, Josef
Corporate Officer · Individual
Friedland, Shalom
Operational/Managerial Control · Individual
Gluck, Benjamin
Operational/Managerial Control · Individual
Jacksonville 3 Propco Holdings LLC
5% Or Greater Mortgage Interest · Organization
Orange Park Propco LLC
5% Or Greater Mortgage Interest · Organization
Sf Irrevocable Trust
Operational/Managerial Control · Organization
Nearby options
Other facilities in reach
#1
Life Care Center At Wells Crossing
Orange Park, FL
5-star overall rating with 4-star inspections with 3 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#2
Moosehaven
Orange Park, FL
5-star overall rating with 5-star inspections
#3
Oak View Health And Rehabilitation Center
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
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