Ormond Rehabilitation and Nursing Center

Inspectors wroteBased on interview and record review, the facility failed to ensure a refund was issued to the resident or resident representative within 30 days from the resident's date of discharge from the facility for 1 resident sampled for refunds, Resident #2.

Inspectors wroteBased on interviews, record review, and facility policy review, the facility failed to ensure a peripherally intravenous (IV) used for the administration of intravenous fluids was removed in accordance with professional standards following the discontinuation of the IV for one (Resident #1) of three residents reviewed for intravenous care. Resident #1 was discharged home with the peripheral IV remaining in her arm.

Inspectors wroteBased on the kitchen food service observations, staff interviews, and a review of facility records and policies and procedures, the facility failed to maintain dietary equipment in safe and sanitary condition to prevent the outbreak of foodborne illness, with the potential to affect any resident who consumed ice from the facility's kitchen, by failing to maintain and clean the ice machine to prevent contamination/biological growth. Food safety and sanitation are important in health care settings serving nursing home residents. Kitchen equipment shall be maintained and kept free of waterborne microorganisms to avoid a potential source of pathogen exposure.

Inspectors wroteBased on observations, record review, interviews, and a review of the facility's policy and procedure for Falls and other facility documentation, the facility failed to implement a comprehensive person-centered care plan for one (Resident #10) of 27 residents whose care plans were reviewed for falls. Fall mats were ordered for Resident #10 but were not in place, which could result in fall injuries.

Inspectors wroteBased on interviews, record review, and a review of the facility's policies and procedures, the facility failed to ensure treatment and care were provided in accordance with professional standards of practice and the comprehensive person-centered care plan for one (Resident #28) of 27 residents in the survey sample whose care plans were reviewed. Resident #28, with a Brief Interview for Mental Status (BIMS) score indicating intact cognition, stated he was not receiving his medications as ordered, and a review of his medical record for August 2025 revealed that on numerous dates, five medications were not signed off by nursing as having been administered. Failure to administer medications as ordered by the physician has the potential to cause a negative outcome to the resident's physical, mental, or psychosocial health and well-being.

Inspectors wroteBased on interviews, record review, and a review of the facility's policies and procedures, the facility failed to ensure residents' medical records were complete and accurately documented, in accordance with accepted professional standards and practices, for one (Resident #28) of a total survey sample of 27 residents whose records were reviewed. Resident #28, with a Brief Interview for Mental Status (BIMS) score indicating intact cognition, stated he was not receiving his medications as ordered, and a review of his medical record for August 2025 revealed that on numerous dates, five medications were not signed off by nursing as having been administered. The resident's record must reflect the care and services provided to the resident.

Inspectors wroteBased on resident record review, interviews, and review of the facility's transfer/discharge policy, the facility failed to ensure required documentation was completed prior to transfer/discharge for 1 (Resident #1) of 3 residents reviewed for transfer/discharge, from a total sample of 7 residents.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 2 of 2 observations conducted in the central kitchen.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to dispose of refuse in a sanitary manner for two of two observations conducted in the main dumpster area.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to treat residents in a dignified manner while providing care and services for 3 of 22 sampled residents (Residents #15, #38, and #247).

Inspectors wroteBased on observation, interviews, policy and record review, the facility failed to provide showers per resident preference for 1 of 3 residents sampled for shower choices (Resident #146).

Inspectors wroteBased on observations, interviews, and record review, the facility failed to maintain a safe, sanitary, and homelike environment for two (one across from room [ROOM NUMBER] and the other across from room [ROOM NUMBER]) of two shower rooms and 5 of 38 resident rooms, affecting Residents #12, #146, #248, #247, and #197.

Inspectors wroteBased on interviews and record reviews, the facility failed to 1) Implement a smoking care plan for two (Residents #7 and #28) of 22 sampled residents, and 2) Implement an Enhanced Barrier Precaution (EBP) care plan for one (Resident #247) of 22 sampled residents.

Inspectors wroteBased on interviews and record reviews the facility failed to identify a pressure ulcer on admission for 1 of 1 residents sampled for pressure ulcers (Resident #247).

Inspectors wroteBased on interviews and record reviews the facility failed to identify and evaluate residents who smoke for 2 out of 55 residents who were identified for smoking (Residents #7 and #28).

Inspectors wroteBased on observation, interviews, record review and policy review, the facility failed to provide an anchor for catheter tubing for 1 of 1 resident observed for catheter care (Resident #25).

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to identify a significant weight loss and provide nutritional interventions in a timely manner for 2 of 5 residents reviewed for nutrition (Resident #10 and Resident #199).

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that each Resident received care and services for the provision of hemodialysis consistent with professional standards of practice for two of the two residents reviewed for Dialysis (Resident #196 and Resident #201).

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide the correct diet order per the physician's orders for one (1) of 5 sampled residents, Resident #200, reviewed for nutrition.

Inspectors wroteBased on observation, interviews, policy and record review, the facility failed to obtain a physician order for Occupational Therapy (OT) prior to commencing OT for 1 of 1 sampled resident reviewed for rehabilitation (Rehab) services, Resident #146.

Inspectors wroteBased on observation, interviews, policy and record review, the facility failed to ensure accuracy of records for a resident with a PICC (peripherally inserted central catheter) line dressing for 1 of 1 sampled resident sampled for PICC line, Resident #247; and failed to document a resident-to-resident interaction for 2 of 3 sampled residents reviewed for accidents, Resident #26 and #28.

Inspectors wroteBased on the observations, interviews, and record review, the facility failed to ensure staff were made aware of residents on Enhance Barrier Precautions (EBP) for 1 of 11 sampled residents on EBP (Resident #247); failed to use appropriate Personal Protective Equipment (PPE) for 1 of 11 sampled residents on EBP (Resident #247); and failed to maintain Contact Isolation Precautions as ordered for 1 of 3 sampled residents on Transmission Based Precautions (TBP) (Resident #199).

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure that each resident's drug regimen was free from unnecessary drugs for three (Residents #26, #38, and #11) of 23 residents in the sample. An unnecessary drug is any drug, when used without adequate monitoring.