Inspection visit
Inspection
5 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 5 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0661
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure necessary information is communicated to the resident, and receiving health care provider at the
time of a planned discharge.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observations, interviews and record review, the facility failed to provide a complete and appropriate
discharge summary by failing to reconcile pre-discharge and post-discharge medications for one (Resident
#199) of three residents reviewed for discharges, from a total sample of 24 residents.
The findings include:
A review of Resident #199's medical record revealed an admission date of 11/1/2021, and the resident was
discharged home on [DATE]. The resident's medical diagnoses included adrenal insufficiency and
hypotension. An admission Minimum Data Set (MDS) assessment, dated 11/6/2021, revealed a Brief
Interview for Mental Status (BIMS) score of 15 out of a possible 15 points, indicating intact cognition.
Resident #199 required extensive to total assistance with activities of daily living (ADLs).
A review of a provider progress note dated 11/20/2021, authored by the resident's attending physician,
indicated the resident's blood pressure log was reviewed and persistent hypotension (low blood pressure)
was noted. The note further indicated the resident's metoprolol and furosemide medications were
discontinued. (Photographic Evidence Obtained)
A review of the resident's pre-discharge medication list revealed the orders for metoprolol and furosemide
were discontinued on 11/12/2021 due to the resident's recurring hypotensive episodes. (Photographic
Evidence Obtained)
A review of the resident's post-discharge medication list, provided to the resident at the time of discharge,
revealed orders for furosemide and metoprolol. (Photographic Evidence Obtained)
On 12/01/2021 at 3:35 p.m., an interview was conducted with Licensed Practical Nurse (LPN) B. She was
asked to review the post-discharge medication list. She confirmed that the list was the one given to the
resident's wife at the time of discharge. The nurse was asked to review the resident's pre-discharge
medication orders and compare them to the medications on the post-discharge list provided to Resident
#199's wife at the time of discharge. LPN B explained that she had not reconciled the medication lists prior
to the resident discharging, and that upon further review, she found that the metoprolol and furosemide
should have been removed from the post-discharge medication list.
On 12/02/2021 at 1:30 p.m., an interview was conducted with the Unit Manager. She was asked to explain
the facility's process for reconciliation of pre-discharge and post-discharge medications to ensure a safe
discharge. She acknowledged that LPN B failed to reconcile the medications, and stated she wasn't sure
why the nurse had failed to carry out the task. The Unit Manager explained that the
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 10
Event ID:
105962
Printed: 05/28/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
105962
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/02/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Life Care Center at Wells Crossing
355 Crossing Blvd
Orange Park, FL 32073
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0661
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
medication list provided to the resident at the time of discharge should only include medications that were
active up to the point of discharge, in addition to any new orders the provider may have written with the
discharge orders.
The facility's policy for discharges, titled Discharge Summary (last reviewed on 8/10/2021) defined
medication reconciliation as a process of comparing pre-discharge medications to post-discharge
medications by creating an accurate list of both prescription and over the counter medications that included
the drug name, dosage, frequency, route, and indication for use for the purpose of preventing unintended
changes or omissions at transition points in care. The policy directed staff to conduct a reconciliation of all
pre-discharge medications with the post-discharge medications and noted that any discrepancies or
differences found during the reconciliation must be assessed and resolved, and the resolution documented
in the discharge summary, along with a rationale for any changes. (Photographic Evidence Obtained)
According to WebMD (accessed on 12/2/2021 at 4 p.m.) at
https://www.webmd.com/heart/understanding-low-blood-pressure-basics), hypotension is the medical term
for low blood pressure (less than 90/60). A blood pressure reading appears as two numbers. The first and
higher of the two is a measure of systolic pressure, or the pressure in the arteries when the heart beats and
fills them with blood. The second number measures diastolic pressure, or the pressure in the arteries when
the heart rests between beats.
According to MedlinePlus (accessed on 12/2/2021 at 4:10 p.m.) at
https://medlineplus.gov/druginfo/meds/a682864.html), metoprolol is a medication that is used to treat high
blood pressure. It works by relaxing blood vessels and slowing heart rate to improve blood flow and
decrease blood pressure.
According to MedlinePlus (accessed on 12/2/2021 at 4:15 p.m.) at
https://medlineplus.gov/druginfo/meds/a682858.html), furosemide is a medication that is used to treat high
blood pressure. It works by causing the kidneys to get rid of unneeded water and salt from the body into the
urine.
.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105962
If continuation sheet
Page 2 of 10
Printed: 05/28/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
105962
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/02/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Life Care Center at Wells Crossing
355 Crossing Blvd
Orange Park, FL 32073
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0692
Provide enough food/fluids to maintain a resident's health.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observations, record review and interviews, the facility failed to ensure that one (Resident #41) of two
residents reviewed for nutritional risk, out of 24 sampled residents, was properly monitored for acceptable
parameters of nutritional status. Specifically, the facility failed to ensure Resident #41 received appropriate
nutritional interventions as ordered by the physician.
Residents Affected - Few
The findings include:
A review of Resident #41's medical record revealed she was admitted to the facility on [DATE]. Her primary
diagnosis was unspecified dementia without behavioral disturbance. Additional diagnoses included muscle
weakness, difficulty walking, a need for assistance with personal care, hypothyroidism, anxiety disorder,
hyperlipidemia, gastroesophageal reflux disease without esophagitis, and dysphagia. The 10/8/2021 MDS
(minimum data set) assessment documented a BIMS (brief interview for mental status) of 5 out of a
possible 15 points, indicating severe cognitive impairment. The resident was documented as requiring
supervision with one-person physical assistance for eating. She was documented as weighing 128 lbs., and
was noted to have had a weight loss of 5% or more in the last month, or a loss of 10% or more in the last 6
months.
Further review of the record revealed the the following documented weights:
5/15/2021 137 lbs.
6/5/2021 140 lbs.
7/3/2021 135 lbs.
8/8/2021 134 lbs.
9/24/2021 131 lbs.
10/2/2021 128 lbs.
11/23/2021 128 lbs.
The resident had no weight loss in the last 30 days, a 4.48% weight loss in the last 90 days, and a weight
loss of 6.57% in the last 6 months. This indicated a downward trend.
A care plan, initiated on 11/20/2021 with the last revision on 12/1/2021, documented that the resident
continued with significant weight loss, 10% over the past 6 months related to dementia. Despite
interventions of an appetite stimulant, nutrition supplements, liberalization of diet, and fortified foods, she
continued to lose weight. Her BMI (body mass index) was documented at 22.7, at the low end of the
desired range for her age. Interventions included administration of medications as ordered, to provide and
serve diet as ordered, and for the RD (registered dietitian) to evaluate and make diet change
recommendations PRN (as needed).
A physician's order was documented in the electronic medication administration record (eMAR) for October
and November 2021 that indicated a 5/21/2021 order for Megestrol Acetate Suspension 400 mg
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105962
If continuation sheet
Page 3 of 10
Printed: 05/28/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
105962
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/02/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Life Care Center at Wells Crossing
355 Crossing Blvd
Orange Park, FL 32073
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0692
(milligrams)/10 ml (milliliters), give 10 milliliter by mouth one time a day for appetite stimulant.
Level of Harm - Minimal harm
or potential for actual harm
A telephone physician's order was documented in the resident's chart for 10/11/2021 to increase Megace to
400 mg twice a day. This physician's order was not transcribed to the resident's active record.
Residents Affected - Few
A physician's progress note on 11/17/2021 documented that the resident had been ordered an increase of
Megace to twice daily.
An interview was conducted with the RD (registered dietitian) on 12/2/2021 at 2:25 p.m. She said she came
into the facility three days a week as a consultant and participated in the weekly Nutritional At Risk
meetings. She looked to see if a resident was continuing to lose weight, or if interventions were not
working. Any recommendations, including requests for a medication for appetite stimulant, were sent to the
physician. The RD said Registered Nurse (RN) A would give the order recommendations to the physician,
and she would then review the records to ensure the order was implemented in the resident's record. She
said she had spoken to Resident #41 on 11/1/2021 about her nutritional needs. The resident told her she
liked ice cream, but not the house shakes. The RD said the resident had a physician's order for Megace,
but upon review of the resident record, she was not aware there had been a new physician's order in
October to double the administration of the medication in October. She said she was not working at the
facility then, but would follow-up.
An interview was conducted with Registered Nurse (RN) A on 12/2/2021 at 2:51 p.m. She said the facility's
process was that the RD would give her nutritional recommendations that she would then put in the
computer. She said the physician told her that she could put supplements into the resident's record. The
physician would give medication orders to the nurse on duty, who would be the one responsible for putting
the information in the resident's record. She said an RD communication to the physician, as a telephone
order, would get flagged so the nurse could see it. The night nurse would also follow-up with flagged orders
to make sure they were documented.
An interview was conducted with the Director of Nursing (DON) on 12/2/2021 at 3:28 p.m. She said the RD
had informed her that there was a physician's order to increase the Megace for Resident #41 that had not
been put into the resident's active orders. She said she was not aware that there was a telephone order
that had not been transcribed. She said she told the nursing staff that they would start doing 24 hour night
checks for the physician orders.
.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105962
If continuation sheet
Page 4 of 10
Printed: 05/28/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
105962
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/02/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Life Care Center at Wells Crossing
355 Crossing Blvd
Orange Park, FL 32073
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0694
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Level of Harm - Minimal harm
or potential for actual harm
Based on observations, interviews, and record review, the facility failed to administer intravenous fluids to
improve low blood pressure for one (Resident #199) of one resident reviewed for intravenous fluids from a
total sample of 24 residents.
Residents Affected - Few
The findings include:
A review of Resident #199's medical record revealed an admission date of 11/1/2021. The resident's
medical diagnoses included adrenal insufficiency, atrial fibrillation, and hypotension. An admission Minimum
Data Set (MDS) assessment, dated 11/6/2021, revealed a Brief Interview for Mental Status (BIMS) score of
15 out of a possible 15 points, indicating intact cognition. Resident #199 required extensive to total
assistance with activities of daily living (ADLs).
A review of a provider progress note, dated 11/20/2021, authored by the resident's attending physician,
indicated the resident's blood pressure log was reviewed and persistent hypotension (low blood pressure)
was noted. The resident's metoprolol and furosemide were discontinued, and the resident reported that
intravenous fluids made him feel better. The diagnosis, assessment, and plan directed staff to start normal
saline intravenously at 70 milliliters per hour for 2 liters and to continue monitoring vital signs every shift.
Staff were also directed to notify the physician for a systolic blood pressure of less than 100 mmHg
(millimeters of mercury). (Photographic Evidence Obtained)
A nursing progress note dated 11/23/2021 at 11:12 a.m., indicated the resident was noted with
hypotension. The physician was notified. Orders were obtained for intravenous fluids and to transfer the
resident to the hospital. Resident #199 requested not to be transferred to the hospital, and additional orders
were received to continue treatment at the facility. (Photographic Evidence Obtained)
A review of the physician's orders revealed an order dated 11/23/2021 at 11:11 a.m., which directed staff to
monitor the resident's blood pressure every 8 hours and administer 2 liters of normal saline as needed for a
systolic blood pressure (SBP) of less than 100. (Photographic Evidence Obtained)
A review of Resident #199's blood pressures revealed the following entries:
11/24/2021 at 12:41 p.m. 95/50
11/28/2021 at 2:23 p.m. 82/52
11/29/2021 at 12:02 p.m. 98/60
11/30/2021 2:03 p.m. 94/54
(Photographic Evidence Obtained)
On 11/30/2021 at 3:34 p.m., an observation of Resident #199 revealed he was not receiving intravenous
fluids. His wife was at the bedside.
A review of Resident #199's medication administration record (MAR) for November 2021, revealed no
documented administration of the ordered normal saline on 11/24/2021, 11/28/2021, 11/29/2021, or
11/30/2021. (Photographic Evidence Obtained)
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105962
If continuation sheet
Page 5 of 10
Printed: 05/28/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
105962
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/02/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Life Care Center at Wells Crossing
355 Crossing Blvd
Orange Park, FL 32073
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0694
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Further review of the resident's nursing progress notes revealed no notes referencing the episodes of low
blood pressure or notifications of the physician on 11/24/2021, 11/28/2021, 11/29/2021, or 11/30/2021.
A review of the resident's comprehensive care plans revealed a focus area for the potential for fluid deficit
related to diuretic use. Interventions included administration of medications as ordered, enteral feeding and
water flushes as ordered, and labs and diagnostics as ordered.
On 12/01/2021 at 10:22 a.m., an interview was conducted with Licensed Practical Nurse (LPN) B. She
acknowledged that she was caring for Resident #199. She reviewed the resident's electronic physician's
orders, confirmed the order for normal saline, and that it was to be given for systolic blood pressures of less
than 100 mmHg. The nurse then reviewed the MAR for November 2021 and confirmed that the normal
saline had not been administered on 11/24/2021, 11/28/2021, 11/29/2021, or 11/30/2021. She stated she
had been off for a week and she wasn't sure why the resident had not received the normal saline as it was
ordered.
On 12/01/2021 at 1:51 p.m., an interview was conducted with the Director of Nursing (DON). She was
asked to review Resident #199's medical record. The DON confirmed the order for monitoring the resident's
blood pressure and administration of normal saline for an SBP <100 (systolic blood pressure of less than
100). The DON was asked how the facility monitored physician's orders to ensure they were being carried
out. She stated she would look into it. No additional information was received.
A review of the facility's process for management of low blood pressure titled Blood Pressure Decrease,
directed nursing staff to check vital signs frequently and to administer IV (intravenous) fluids as prescribed.
(Photographic Evidence Obtained)
According to WebMD (accessed on 12/2/2021 at 4 p.m.) at
https://www.webmd.com/heart/understanding-low-blood-pressure-basics, Hypotension is the medical term
for low blood pressure (less than 90/60). A blood pressure reading appears as two numbers. The first and
higher of the two is a measure of systolic pressure, or the pressure in the arteries when the heart beats and
fills them with blood. The second number measures diastolic pressure, or the pressure in the arteries when
the heart rests between beats.
.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105962
If continuation sheet
Page 6 of 10
Printed: 05/28/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
105962
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/02/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Life Care Center at Wells Crossing
355 Crossing Blvd
Orange Park, FL 32073
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0695
Provide safe and appropriate respiratory care for a resident when needed.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review, the facility failed ensure that one (Resident #8) resident who
required respiratory care, from 22 residents receiving respiratory care and a total of 24 residents in the
sample, received oxygen therapy as ordered.
Residents Affected - Few
The findings include:
On 11/29/21 at 12:29 PM, Resident #8's oxygen cannula was dated 11/16/21 and the oxygen setting was at
2.5 liters per minute (L/min). (Photographic evidence obtained)
On 11/30/21 at 10:32 AM, Resident #8's oxygen cannula was dated 11/16/21 and the oxygen setting was at
3.0 L/min. (Photographic evidence obtained)
A review of the clinical record indicated that Resident#8 was admitted to the facility on [DATE] and again on
8/19/20. Her diagnoses included chronic obstructive pulmonary disease (COPD), paranoid schizophrenia,
dependent on supplemental oxygen, chronic respiratory failure with hypoxia or hypercapnia, lack of
coordination, and muscle weakness.
A review of the the Physician's Order Sheets for November 2021, revealed the resident's current orders
included oxygen via nasal canula at 2 L/min continuously, change oxygen water and tubing every Tuesday,
check oxygen saturation every shift and notify the physician if less than 92%, pulmonary consult dated
11/4/21, Advair discus 100-50 mcg (micrograms), one inhalation orally every 12 hours, Combivent
Respimat aerosol 20-100mcg/ACT, 1 puff every 6 hours for COPD, Tiotropium bromide monohydrate 18
mcg, 1 capsule, inhale one time a day for COPD and rinse mouth after use, loratadine 10 mg (milligrams),
one tablet one time a day for allergy, guaifenesin 400 mg q12 hours (every 12 hours) for COPD.
A review of the quarterly Minimum Data Set (MDS) assessment, dated 11/16/21, revealed that the resident
had a brief interview for mental status (BIMS) score of 15 out of a possible 15 points, indicating intact
cognition. She required extensive assistance for bed mobility, transfers did not occur, she was totally
dependent for toilet use, she required supervision for eating and she was on oxygen therapy.
A review of the Care Plan indicated the resident was at risk for a respiratory infection related to COPD,
cardiac disease, and COVID-19 (recovered). Interventions included oxygen as ordered. Observe and notify
the physician if the resident experiences cough, fever, low oxygen saturation and shortness of breath.
A review of a health care note, dated 11/28/21 at 12:22 AM read, Resident alert and oriented, respirations
even and unlabored, oxygen continuous at 4 L/min.
A review of a health status note, dated 11/29/21 at 12:41 AM read, Resident alert and oriented, respirations
even and unlabored, oxygen continuous at 4 L/min.
An observation of Resident #8 on 12/01/21 at 10:45 AM, revealed that the oxygen setting was at 3 L/min.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105962
If continuation sheet
Page 7 of 10
Printed: 05/28/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
105962
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/02/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Life Care Center at Wells Crossing
355 Crossing Blvd
Orange Park, FL 32073
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0695
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
On 12/01/21 at 11:45 AM, Licensed Practical Nurse (LPN) E confirmed that Resident #8's oxygen setting
was at 3 L/min. She stated the resident should be at 4 L/min and adjusted the setting to 4 L/min. When
asked what the physician's orders stated about the flow rate for Resident #8's oxygen, LPN E stated, 4
liters. She continued to state that the resident was previously on a higher flow rate but it was decreased to 4
liters. When asked to verify the physician's orders, LPN E reviewed the orders and stated Resident #8's
oxygen flow rate was ordered at 2 L/min continuously.
On 12/01/21 at 02:47 PM, Registered Nurse (RN) G confirmed that Resident #8's oxygen orders were for
2L/min. He also stated the oxygen tubing should be changed weekly on Tuesdays and labeled. He
confirmed that Resident #8's oxygen tubing had not been changed per the protocol. He added that he
would have an in-service for the nursing staff to ensure that all residents with oxygen orders were receiving
the ordered amount of oxygen every shift.
A review of the facility's policy and procedure titled, Oxygen Administration/ Safety/ Storage/Maintenance
(Revised 08/02/21) revealed, Purpose: To ensure that oxygen is administered and stored safely within the
healthcare centers or in an outside storage area. Infection Control practices included:
1) Change oxygen supplies weekly and when visibly soiled. Equipment should be labeled with patient name
and dated when setup or changed out.
2) Humidifier/Aerosol bottles should be dated and replaced every 7 days regardless of water level.
.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105962
If continuation sheet
Page 8 of 10
Printed: 05/28/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
105962
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/02/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Life Care Center at Wells Crossing
355 Crossing Blvd
Orange Park, FL 32073
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0758
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
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.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
record review and interview, the facility failed to ensure that 1) A resident received antipsychotic medication
as prescribed, and 2) As needed (PRN) antipsychotic medication had a stop date, for one (Resident #53) of
five residents reviewed for unnecessary medications from a total sample of 24 residents.
The findings include:
On 12/01/21 at 10:59 AM, Resident #53 was observed lying in bed on her back with her eyes closed. She
was difficult to awaken with verbal commands.
A review of the clinical record indicated that Resident#53 was admitted to the facility on [DATE]. Her
diagnoses included sepsis, type II diabetes mellitus, dementia with behavioral disturbance, and major
depressive disorder.
A review of the physician's orders, revealed an 11/16/21 order for lorazepam (Ativan), 1 mg (milligram)
every eight hours for anxiety, and lorazepam (Ativan) 1 mg every four hours as needed for anxiety, and
depakote 125 mg at bedtime (HS). There was no stop date for the as needed lorazepam order. (Copy
obtained)
A review of the Significant Change Minimum Data Set (MDS) assessment, dated 11/15/21, revealed that
Resident #53 had a Brief Interview for Mental Status (BIMS) score of 9 out of a possible 15 points,
indicating moderate cognitive impairment. She required extensive assistance for bed mobility, transfers,
eating and toilet use.
A review of the Care Plan indicated the resident had: Behavior problems related to dementia. She is noted
to yell out frequently, change needs during conversation and at times response is not relevant to the
situation; has impaired cognitive ability/impaired thought process related dementia with history of cerebral
infarction; is at risk for change in mood or behavior due to diagnosis of depression and risk for becoming
withdrawn and depressed (resident receives escitalopram for depression); uses antianxiety medication
related to anxiety disorder, uses antidepressant medication related depression. Interventions included to
observe for and report as needed any adverse reactions to antidepressant and antianxiety medications.
A review of the physician's progress notes dated 10/05/21, 10/07/21, 10/20/21, 10/22/21, 10/26/21 and
11/2/21, revealed that the resident was on escitalopram oxalate (Lexapro), 10 mg, 2 tablets orally once a
day for depression. (Copies obtained)
A review of the Medication Administration Records (MARs) for October and November 2021 revealed that
Resident #53 had not received escitalopram oxalate (Lexapro) since 10/20/21. (Copies obtained)
In a 12/01/21 at 2:47 PM, Registered Nurse (RN) G confirmed that the as needed Ativan had no stop date.
He added that he would follow up with the hospice provider to get a stop date. When asked about the
resident's escitalopram oxalate (Lexapro), RN G stated he was not aware that the resident had an order for
the medication. He reviewd the physician's orders and confirmed that Resident #53 was on the medication.
He added that the nurses who received the orders had not transcribed them to the
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105962
If continuation sheet
Page 9 of 10
Printed: 05/28/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
105962
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/02/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Life Care Center at Wells Crossing
355 Crossing Blvd
Orange Park, FL 32073
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0758
MAR.
Level of Harm - Minimal harm
or potential for actual harm
On 12/02/21 at 10:00 AM and 2:00 PM, Resident #53 was observed lying in bed on her back with her eyes
closed. She did not open her eyes following verbal commands.
Residents Affected - Few
On 12/02/21at 4:27 PM, the Director of Nursing (DON) stated Resident #53 had previously been
transferred to an acute-care facility, and upon return to this facility on 10/20/21, the nurse did not transcribe
the medication to the MAR. The DON added that the physician would be notified, and she would initiate
in-service training for the nursing staff to review physicians' orders for accuracy and completeness.
A review of the facility's policy and procedure titled, Psychotropic Medication Use (last revised on
11/28/16), revealed that PRN (as needed) orders for psychotropic drugs should be limited to 14 days. If the
attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be
extended beyond 14 days, he or she should document their rationale in the resident's medical record and
indicate the duration of the PRN order. PRN orders for antipsychotic drugs should be limited to 14 days and
should not be renewed unless the attending physician or prescribing practitioner evaluates the resident for
the appropriateness of that medication. The facility should not extend PRN antipsychotic orders beyond 14
days. All medications used to treat behaviors must have a clinical indication and be used in the lowest
possible dose to achieve the desired therapeutic effect. All medications used to treat behaviors should be
monitored for: Efficacy, risks, benefits and harm or adverse consequences.
.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105962
If continuation sheet
Page 10 of 10
Reading this as a family member? Your long-term care ombudsman is a free advocate for residents and families.
Back to topCitations
5 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F661 - Quality of life
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
F692 - Assisted nutrition and hydration
Provide enough food/fluids to maintain a resident's health.
F694 - Parenteral Fluids
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
F695 - Respiratory care, including tracheostomy care and tracheal suctioning
Provide safe and appropriate respiratory care for a resident when needed.
F758 - Medication Errors
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.
FAQ · About this visit
Common questions about this visit
What happened during the December 2, 2021 survey of LIFE CARE CENTER AT WELLS CROSSING?
This was a inspection survey of LIFE CARE CENTER AT WELLS CROSSING on December 2, 2021. The surveyor cited 5 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at LIFE CARE CENTER AT WELLS CROSSING on December 2, 2021?
Yes, 5 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planne..."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.