Ormond Nursing & Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to ensure a care plan was developed for a resident with exit seeking behaviors to decrease the risk of elopement (an individual who was incapable of adequately protecting themselves who left a health care facility undetected and unsupervised) for 1 (Resident #12) of 6 (Resident #4, Resident #12, Resident #58, Resident #72, Resident #80, and Resident #90) sampled residents reviewed for accidents hazards.Findings: Review of the facility's Care Plan Process policy and procedure, dated 06/2015 and revised on 12/2024, revealed, in part, the care plan was driven by a resident's unique needs. Further review revealed a well-developed and executed care plan would provide information regarding how the causes and risks associated with issues and/or conditions were addressed to provide for a resident's highest practicable level of well-being. Further review revealed the facility would re-evaluate the resident's status annually and then modify the individualized…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interviews, and record reviews, the facility failed to ensure residents did not have cigarette lighters in their possession per facility policy for 1 (Resident #90) of 6 (Resident #4, Resident #12, Resident #58, Resident #72, Resident #80, Resident #90) sampled residents investigated for accident hazards.Findings:Review of the facility's Smoking Policy and regulations, dated 04/2006 and revised on 10/2024, revealed, in part, cigarette lighters and matches were not permitted in a resident's room and would be kept at the nursing station. Visitors were not permitted to smoke in the facility, nor were they permitted to give or leave matches or lighters with any resident.Review of Resident #90's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/09/2025 revealed, in part, Resident #90 was a current tobacco user. Review of Resident #90's Care Plan initiated on 05/28/2025, with a goal date of 09/05/2025, revealed, in part, residents smoking supplies were stored per the facility policy. Observation on 07/22/2025 at 10:12AM, of the smoker's patio,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on Interviews and record reviews the facility failed to administer a medication as ordered for 1 (Resident#1) of 3 (Resident#1, Resident#2, Resident #3) sampled residents reviewed for unnecessary medications. Findings: Review of the facility's policy and procedure on Medication Administration with an effective date of 10/04/2024, revealed, in part, nursing personnel shall ensure the safe and effective administration of medications. Further review revealed, prior to administration, the nursing staff member administering the medication shall ensure medications match the physician's orders and label, and that the proper dose was administered. Review of Resident #1's medical record revealed, in part, an admission date of 11/18/2024. Further review revealed Resident #1 had the following diagnoses, in part, chronic obstructive pulmonary disease (COPD) gastric esophageal reflux disease (GERD) and unspecified psychosis. Review of Resident #1's physician orders revealed, in part, an order dated 01/31/2025 for Ondansetron 4 milligrams (mg) by mouth p.o. every 6 hours for 3 days. In an…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to ensure a resident and the resident's representative was issued a written notice of discharge prior to discharging a resident. This deficient practice was identified for 1 (Resident #1) of 2 (Resident #1 and Resident #2) sampled residents reviewed for discharge requirements. Findings: Review of Resident #1's clinical record revealed Resident #1 was admitted to the facility on [DATE]. Further review revealed Resident #1 was discharged from the facility on 05/27/2024 because Resident #1's representative was unable to make the bed hold payments. In an interview on 07/31/2024 at 10:30 a.m., S2Assistant Director of Nursing (ADON) indicated the cost of the facility's bed hold price and amount was given and explained at length to Resident #1's representative. S2ADON further indicated Resident #1's representative knew the cost to hold Resident #1's bed, and Resident #1's representative did not make payments to the facility. There was no documented evidence and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record reviews, observations, and interviews, the facility failed to assess a resident for self-administration of medications for 2 (Resident #22 and Resident #97) of 20 (Resident #2, Resident #13, Resident #16, Resident #17, Resident #22, Resident #25, Resident #26, Resident #39, Resident #44, Resident #61, Resident #64, Resident #67, Resident #69, Resident #70, Resident #79, Resident #77, Resident #80, Resident #88, Resident #95, and Resident #97) sampled residents reviewed. Findings: Review of the facility's Self-Administration of Medications policy with a revision date of 11/2017 revealed, in part, residents would be allowed to self-administer medications only if a physician order was obtained allowing residents to keep a medication at bedside for the purpose of self-administration, and the interdisciplinary team deemed resident to be clinically appropriate to self-administer medications. Review of the facility's Drug Administration and Documentation policy with a revision date of 12/2023 revealed, in part, under no circumstances is medication to be left at the bedside…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure a resident with a mental illness had an accurate PASARR (Preadmission Screening and Resident Review) for 1 (Resident #67) of 2 (Resident #17, Resident #67) residents reviewed for PASARR. Findings: Review of Resident #67's Medical Record review revealed, in part, Resident #67 was admitted to the facility on [DATE] with a diagnosis of PTSD (Post-Traumatic Stress Disorder). Review of Resident #67's Quarterly MDS (Minimum Data Set) dated 05/30/2024 revealed, in part, Resident #67 had a diagnosis of Post-Traumatic Stress Disorder (PTSD). Review of Resident #67's Level I PASARR dated 10/07/2020 revealed, in part, Resident #67's diagnosis of PTSD was not selected on Section III as a mental illness. In an interview on 07/17/2024 at 10:03 a.m., S3Social Service Director indicated Resident #67 did not have a Level II PASARR, and the facility could not produce any documented evidence that a Level II PASARR for a diagnosis of PTSD was completed and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure staff implemented their Policy & Procedure for abuse for 1 (Resident #2) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents reviewed for abuse. Findings: Review of the facility's Elder Justice Act policy with a revision date of 04/2022 revealed, in part, it is the facility's policy to comply with the Elder Justice Act (EJA) about reporting a reasonable suspicion of a crime, under Section 1150B of the Social Security Act, as established by the Patient Protection and Affordable Care Act. Further review revealed staff must report the suspicion of an incident to the administrator. Resident #2 Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/12/2023 revealed, in part, Resident #2 had a Brief Interview for Mental Status (BIMS) score of 14 which indicated she was cognitively intact. In an interview on 11/06/2023 at 9:08 a.m., S2Housekeeper asked the state surveyor to talk Resident #2 stating the resident wanted to report something. In an interview on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews, and record reviews the facility failed to: 1.) Ensure resident's interventions were updated after a fall for 1 (Resident #44) of 3 (Resident #19, Resident #44, and Resident #78); and, 2.) Ensure a resident's intervention listed in the Comprehensive Care Plan was implemented for 1 (Resident #78) of 3 (Resident #19, Resident #44, and Resident #78) sampled residents reviewed for falls. Findings: 1. Resident #44 Review of Resident #44's Minimum Data Set (MDS) with and Assessment Reference Date (ARD) revealed, in part, Resident #44 had a Brief Interview of Mental Status (BIMS) of 8 (a score of 8-12 indicated a resident had moderately impaired cognition). Review of Resident #44's care plan with a target date of 09/30/2023 revealed Resident #44 was at risk for falls with a fall on 06/02/2023. Review revealed a new intervention for the fall on 06/02/2023 was not initiated. In an interview on 08/29/2023 at 3:04 p.m., S8Liscensed Practical Nurse (LPN) stated Resident #44 had a fall last week. S8LPN stated Resident #44 was recently moved to this room and was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and record review, the facility failed to monitor the oral intake of 2 (Resident #63 and Resident #106) of 2 residents investigated for nutrition. Findings: Review of the facility's Food Intake Records policy revealed, in part, the intake of each resident should be documented at each meal. Resident #63 Review of Resident #63's Registered Dietician (RD) Nutrition assessment dated [DATE] revealed, in part, to monitor Resident #63's oral intake. Review of Resident #63's log of percentage of meals eaten revealed, in part, no documentation of the percentage of breakfast eaten 08/17/2023, 08/22/2023, 08/23/2023, 08/24/2023, 08/26/2023, and 08/27/2023, no documentation of the percentage of lunch eaten on 08/17/2023, 08/22/2023, 08/23/2023, 08/24/2023, and 08/27/2023 and no documentation of the percentage of dinner eaten on 08/15/2023, 08/17/2023, 08/19/2023, 08/21/2023, 08/22/2023, 08/24/2023, 08/25/2023, 08/26/2023, 08/27/2023, and 08/29/2023. In an interview on 08/31/2023 at 10:13…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to notify the physician and responsible party of a resident's onset of loose stools and bilateral buttock wounds for 1 (Resident #79) of 1 (Resident #79) sampled residents reviewed for skin conditions. Findings: Review of Resident #79's departmental notes, revealed, in part, the following: 1. 08/19/2023 the Certified Nurse Assistant (CNA) reported one episode of loose stool; and, 2. 08/30/2023 the CNA reported loose stools this shift; and, 3. 08/31/2023 the CNA reported one episode of loose stool. Further review revealed no documented evidence the physician or responsible party was notified of Resident #79's loose stools. Review of Resident #79's August 2023 Physician's orders revealed, in part, orders dated 08/24/2023 to cleanse left and right buttock moisture associated skin damage (MASD) with normal saline, pat dry and apply calmoseptine ointment (moisture barrier that protects and helps heal skin irritations) daily until resolved. Review of Resident #79's departmental notes, revealed, in part, no documented…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to: 1) Ensure a residents wounds were assessed; and, 2) Ensure a resident was provided treatment for loose stools for 1 (Resident #79) of 1 (Resident #79) sampled residents reviewed for skin conditions. Findings: Review of the facility's prevention and treatment of skin issues policy revealed, in part, the facility should properly identify and assess residents whose clinical conditions increase the risk for impaired skin integrity to implement preventative measures and to provide appropriate treatment. Further review revealed, for newly identified skin issues staff should implement weekly wound documentation in the Wound Assessment Manager (WAM) to include: type of wound, location, date, length, width, depth, wound base description, and wound edge description. 1. Review of Resident #79's August 2023 Physician's orders revealed, in part, an order dated 08/24/2023 to cleanse left and right buttock moisture associated skin damage (MASD) with normal saline, pat dry and apply calmoseptine ointment (moisture barrier…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.