Average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Ormond Rehabilitation And Nursing Center during CMS and state inspections, most recent first.
A resident with cardiovascular diagnoses received a physician-ordered peripheral IV for a one-time 0.9% NS infusion for low blood pressure, but there were no MAR/TAR entries or care plan details for IV care or flushes, and a nursing assessment documented no IVs shortly before discharge. After discharge, the resident’s daughter reported that the IV remained in the resident’s arm. Staff interviews revealed that RNs relied on standing orders for IV care, did not consistently document IV site condition on skin assessments, and one RN who completed the IV therapy could not recall removing the IV and stated she documented discontinuation only if she remembered. The DON stated RNs were responsible for ongoing IV care and documentation, including documenting discontinuation, and facility policy required documentation of IV removal, which was not done.
Ice Machine Not Maintained in Safe and Sanitary Condition: The ice machine was observed with a slimy, pink substance on the ice diverter area, and records showed inconsistent cleaning documentation. Staff gave conflicting accounts of whether Dietary or Maintenance was responsible, with cleaning described as weekly wiping of the outside by Dietary and quarterly cleaning by Maintenance, while facility policies also conflicted on the required cleaning schedule.
Failure to Implement Fall Prevention Interventions: A resident with a history of falls, moderate cognitive impairment, and significant assistance needs had a care plan calling for a low bed and two fall mats, but repeated observations showed the bed in a high position with no mats at bedside. Staff reviewed the care plan and then confirmed the missing mats and non-low bed, despite prior falls that included injury and a hospital transfer.
Missing medication administration documentation was identified for a resident with intact cognition who said some meds were late or not given. The MAR/TAR lacked signatures for ordered meds including an iron supplement, antiplatelet therapy, vitamin C, an antipsychotic, and a topical lotion. An LPN could not explain the omissions, and the ADON confirmed the meds were not documented as administered.
Incomplete medication administration documentation was identified for a resident with intact cognition who said some medications were missed or late. The MAR/TAR lacked signatures for ordered Ferrous Sulfate, Plavix, Vitamin C, Risperidone, and Amlactin lotion on multiple occasions, and the ADON confirmed the medications were not documented as administered. Facility policy required nurses to record and electronically sign medication and topical treatment administration on the eMAR/TAR.
Failure to complete required transfer/discharge notice and related documentation for a resident with dementia and moderate cognitive impairment. The resident was discharged after an elopement incident and the admin described it as an emergency for safety reasons, but AHCA transfer-discharge forms were not completed. The SSD said discharge planning was based on the admin’s report of speaking with the ombudsman, while the ombudsman later stated no discharge was reviewed or recommended and that no transfer/discharge notices had been sent for months.
The facility failed to maintain proper sanitation and food safety standards in the central kitchen. Observations included dirty floors, grease-coated skillets, uncovered garbage, and undated food items. Additionally, cold salads were stored at temperatures above the recommended levels. The Food Service Director and Corporate Food Service Manager acknowledged these deficiencies.
The facility failed to dispose of refuse in a sanitary manner, with observations revealing a large roll-off dumpster containing various debris and garbage, an open patio area with used utensils and food wraps, and four gray dumpsters with dirty standing water and trash. The Maintenance Director admitted to not noticing the unsanitary conditions, and the Administrator was informed of the findings.
The facility failed to treat residents with dignity during care and medication administration. An LPN and an RN were observed administering medications in the hallway to two residents with cognitive impairments, which is against the facility's policy. Additionally, an RN improperly signed and dated a dressing directly on a resident's abdomen instead of using a piece of tape as required.
A resident, who is cognitively intact, reported not being given a choice regarding the number and timing of showers. The resident was assigned specific shower days and was not given the option for more frequent showers, despite expressing a desire for them. The facility's policy on resident schedule choices was not followed.
The facility failed to maintain a safe, sanitary, and homelike environment for several residents and common areas. Observations revealed issues such as peeling paint, non-functional light bulbs, debris, and biological growth in shower rooms. Interviews with staff confirmed these issues and acknowledged the need for repairs and cleaning.
The facility failed to implement smoking care plans for two residents and an Enhanced Barrier Precaution (EBP) care plan for another resident. Despite being a non-smoking facility, residents were found smoking off-property without proper care plans. Additionally, a resident with multiple diagnoses did not have EBP interventions included in their care plan, indicating a failure to meet medical and nursing needs.
A facility failed to identify a pressure ulcer on admission for a resident with sepsis and liver abscess. Initial assessments did not document any pressure ulcers, but a stage II pressure ulcer on the coccyx was identified shortly after admission. The DON acknowledged the lack of documentation, leading to delayed care and intervention.
The facility failed to identify and evaluate two residents who smoke, despite having a policy for a smoke-free environment. Both residents admitted to smoking and keeping smoking materials, but the facility did not enforce its smoking policy or conduct necessary evaluations.
The facility failed to provide an anchor for catheter tubing for a resident with a BIMS score of 15 and diagnoses including a thoracic vertebra fracture, hypertension, and neuromuscular bladder dysfunction. During catheter care, a CNA did not use an anchor, contrary to facility policy and physician's orders.
The facility failed to identify significant weight loss and provide timely nutritional interventions for two residents. One resident experienced a severe weight loss of 13.5% within four days, and another resident experienced a 6.9% weight loss within three days. Both residents' nutritional needs were not adequately monitored or addressed, and the Registered Dietitian was unaware of their conditions due to a failure in the clinical dashboard system.
The facility failed to provide appropriate dialysis care for two residents, resulting in missed and improperly timed medication doses. Communication between the facility and the dialysis center was inadequate, leading to a lack of necessary documentation and coordination.
A resident with protein-calorie malnutrition, dysphagia, and type 2 diabetes did not receive the correct diet order as prescribed. Observations showed discrepancies between the diet orders and the meals provided, with the resident receiving improperly prepared food. Interviews revealed communication and implementation issues among staff, leading to the incorrect diet being served.
A resident began receiving OT without a physician order, contrary to the facility's policy. The resident, admitted with multiple diagnoses and cognitively intact, received OT on four occasions before a late clarification order was entered.
The facility failed to document a PICC line dressing change for a resident and did not record a verbal altercation between two residents. The DON confirmed the lack of documentation for the dressing change, and staff members were aware of the resident interaction but did not document it in the EHR.
The facility failed to ensure staff were aware of and used appropriate PPE for a resident on Enhanced Barrier Precautions (EBP) and did not maintain Contact Isolation Precautions for another resident. This led to non-compliance with infection control policies and CDC guidelines.
Failure to Remove Peripheral IV Prior to Resident Discharge
Penalty
Summary
The deficiency involves the facility’s failure to remove a peripheral IV catheter in accordance with professional standards and facility policy after IV fluid therapy was completed, resulting in a resident being discharged home with the IV still in place. The resident, who had diagnoses including essential hypertension, unspecified atrial fibrillation, and supraventricular tachycardia, was admitted on 1/23/26 and discharged on 2/13/26. A physician’s order dated 1/31/26 authorized peripheral IV placement for fluids and a one-time 1 liter 0.9% sodium chloride infusion at 75 mL/hr for low blood pressure, with an end date of 2/1/26. Review of the MAR and TAR for January and February 2026 showed no orders for IV care or flushes, and the resident’s care plan contained no mention of IV care. A nursing assessment dated 2/12/26 documented no IVs, no skin conditions, and no areas of concern, despite the subsequent report that the IV remained in place at discharge. The resident’s daughter later called the facility on 2/16/26 and reported that the IV had not been removed when the resident was discharged home. In interviews, RN A stated that IV dressing changes and flushes were handled via standing orders and documented on the MAR and TAR, but she did not document IV site condition on skin assessments, focusing instead on skin breakdown or redness. The DON reported that an outside company initiated IVs, but facility RNs were responsible for ongoing IV care and documentation, including documenting IV discontinuation in progress notes and noting the IV on skin checks if present. RN B, who completed the IV therapy for this resident, stated she did not remember whether she had discontinued the IV and said she would document IV discontinuation “if I remember to.” Review of the facility’s “Intravenous (IV) Therapy (Peripheral)” policy dated 11/2025 showed that it required documentation of IV removal, which did not occur in this case.
Ice Machine Not Maintained in Safe and Sanitary Condition
Penalty
Summary
The facility failed to maintain dietary equipment in a safe and sanitary condition when the ice machine outside the kitchen main door was observed covered with a slimy, pink substance during a follow-up kitchen visit. The ice machine cleaning log posted on the machine documented cleaning on 08/24/2025, and the Regional Food Service Director verified a document on his personal cell phone showing the ice machine had been cleaned by Maintenance on 07/31/2025. He stated the ice machine would be shut down, all ice removed, and cleaned that day. Staff interviews showed confusion about who was responsible for cleaning the ice machine and how often it was to be cleaned. A Dietary Aide stated that responsibility had shifted between Maintenance and Dietary and that Dietary was currently cleaning only the outside and inside edges around the open area of the door once per week. Another staff member stated she believed Maintenance was responsible but did not know the schedule. The Certified Dietary Manager stated kitchen staff were responsible and that Dietary wiped down the outside and ran the scoop through the dish machine weekly, while the Maintenance Director stated both Dietary and Maintenance were responsible and that Maintenance cleaned the ice machine quarterly, including the top and bottom, fan, condenser, tray, and diverter area. Facility records and policies showed conflicting expectations, including a policy revised 01/2012 stating ice machines would be maintained to assure a safe and sanitary supply of ice and cleaned according to manufacturer instructions, and a revised 08/27/2025 policy stating the ice machine would be cleaned monthly per manufacturer recommendation and as needed by Maintenance, with the Dietitian checking cleanliness monthly.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to implement a comprehensive person-centered care plan for a resident with a history of falls. Resident #10 had diagnoses including osteomyelitis of the ankle and foot, COPD, mild protein calorie malnutrition, and anemia, and his MDS showed a prior fall, moderate cognitive impairment with a BIMS score of 8 out of 15, and need for substantial assistance with toileting and transfers. His care plan identified him as at risk for falls and included interventions for the bed to be in low position and for two fall mats to be beside the bed, with the fall mats initiated on 7/11/25 and the low bed initiated on 7/23/25. Record review showed falls on 7/11/25, when he slid out of his wheelchair and sustained a small abrasion under his left knee, and on 7/16/25, when he was found lying prone on the side of the bed, hit his head, sustained skin tears to his right elbow, and was transferred to the hospital. During observations on 8/24/25, 8/25/25, 8/26/25, and 8/27/25, the resident was repeatedly seen in bed with the bed in a high position and no fall mats at bedside. RN E reviewed the care plan and then confirmed in the room that no fall mats were present and the bed was not low. The ADON and Unit Manager also confirmed that the resident had no fall mats at bedside, and the Unit Manager stated there had been no fall mats in the room since 8/24/25.
Missing Medication Administration Documentation
Penalty
Summary
Treatment and care were not provided in accordance with physician orders and the resident’s care plan for one resident with intact cognition. The resident stated he believed some of his medications were missed and said they were sometimes late or not provided at all. A review of the resident’s August 2025 MAR and TAR showed missing signatures documenting administration of Ferrous Sulfate on 8/10/2025 and 8/13/2025, Plavix on 8/9/2025, Vitamin C on 8/10/2025 and 8/13/2025, Risperidone on 8/9/2025, and Amlactin Daily External Lotion on 8/9/2025 and 8/12/2025. The resident’s record showed diagnoses including Parkinson’s disease, anemia, dementia with behavioral disturbance, schizoaffective disorder, persistent mood disorder, and dementia with psychotic disturbance. The resident’s 5-day MDS indicated he was receiving antipsychotic and antiplatelet medications and had a BIMS score of 13 out of 15. His care plan dated 07/01/2025 included interventions for impaired cognition, psychotropic medication use, antiplatelet therapy, anemia, Parkinson’s disease, and risk for altered skin integrity, with directions to administer medications as ordered and to keep skin clean and dry with lotion on dry skin. During interviews, CNA G stated the resident had not complained about medications being late or missed. LPN H stated she gave the medications on time but could not explain the missing documentation, saying some were morning medications and others were night shift medications. The ADON reviewed the MAR and confirmed the listed medications were not documented as having been administered on the dates noted. The facility policy required drugs to be administered as ordered, recorded on the eMAR or treatment record, and electronically signed by the nurse administering them, with charting required when a drug is withheld, refused, or given at a different time.
Incomplete Medication Administration Documentation
Penalty
Summary
The facility failed to ensure that Resident #28’s medical record was complete and accurately documented for medications and topical treatment administration. Resident #28 had a BIMS score of 13 out of 15, indicating intact cognition, and told the surveyor on 08/24/2025 that he believed some of his medications were missed and that they were sometimes late or not provided at all, although he could not identify a specific medication that was missed. A review of the resident’s active physician orders showed Ferrous Sulfate 325 mg daily for anemia, Plavix 75 mg at bedtime for antiplatelet therapy, Vitamin C 500 mg daily for iron absorption, Risperidone 2 mg twice daily for schizophrenia, and Amlactin Daily External Lotion 12% applied to both feet twice daily for dry skin. Review of the August 2025 MAR and TAR showed missing signatures documenting administration of Ferrous Sulfate on 8/10/2025 and 8/13/2025, Plavix on 8/9/2025, Vitamin C on 8/10/2025 and 8/13/2025, Risperidone on 8/9/2025, and Amlactin lotion on 8/9/2025 and 8/12/2025. During interviews, the LPN stated the missing entries were on shifts she was not working and could not explain the absent documentation. The ADON reviewed the MAR and confirmed that the listed medications were not documented as having been administered on the dates noted. The facility policy required current drugs and dosage schedules to be recorded on the eMAR, topical drugs to be recorded on the treatment record, and the administering nurse to electronically sign the eMAR before the next scheduled dose, with charting and progress notes required when medications were withheld, refused, or given at other than the scheduled time.
Failure to Complete Required Transfer/Discharge Notice
Penalty
Summary
The facility failed to ensure required transfer/discharge documentation was completed before the discharge of one resident. Resident #1 was admitted to the facility, later re-entered, and was discharged to another skilled nursing facility. His diagnoses included aftercare following joint replacement, type 2 diabetes mellitus, dementia without behavior, metabolic encephalopathy, anxiety disorder, heart failure, neurogenic arthritis, and need for assistance with personal care. A quarterly MDS assessment showed a BIMS score of 11 out of 15, indicating moderate cognitive impairment. The care plan identified impaired cognitive function/dementia and noted that the resident wished to remain in the facility for long-term care. The physician’s order dated 7/31/25 documented discharge to Blue Palms Health and Rehab of Daytona, and the discharge MDS identified the discharge as planned. The administrator stated the resident was discharged after an elopement incident and described the discharge as an emergency due to safety concerns. She stated she consulted the ombudsman’s office and was told the discharge could proceed, but she also stated the resident had no responsible party because the responsible party had died about a year earlier. The administrator later confirmed that the AHCA transfer-discharge forms were not completed and that she could not get ahold of the ombudsman. The Director of Social Services stated she was involved in discharge planning and that the discharge notification came from the administrator. She said she proceeded to secure placement after being told the administrator had communicated with the ombudsman. However, the ombudsman later stated that their office does not make discharge recommendations, was not consulted about any discharge from the facility, and that the facility had not sent any transfer/discharge notices since January 2025. The facility’s transfer/discharge policy required 30 days written notice to the resident or representative, along with specified information including the reason for discharge, effective date, destination, ombudsman contact information, advocacy agency information, and appeal contact information.
Failure to Maintain Sanitation and Food Safety Standards in Central Kitchen
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. During a tour of the central kitchen, several deficiencies were noted, including dirty floors, opened cardboard boxes on the floor, grease-coated skillets, an uncovered dumpster with exposed garbage, and dirty paper napkins on plate warmers. Additionally, several lights were not working or were broken, air vents were dirty, and a scoop was found sitting on top of canned peaches. The Food Service Director was observed using an incorrect Hydrion Chlorine meter, and a dietary aide admitted that a cleaning cloth in a red bucket contained only soap and water. Other issues included a dirty fryer basket, undated and unlabeled food items in the walk-in refrigerator, and a dirty rag on the kitchen counter. The dry storage area floor was also dirty, and used paper towels were found under the stove area. During a second visit, cold cottage cheese and ham salads were found to be stored at temperatures above the recommended 40 degrees Fahrenheit, with internal temperatures of 46 and 48.8 degrees Fahrenheit, respectively. The Corporate Food Service Manager acknowledged that these items had been recently taken out of the walk-in refrigerator for the tray line. In an interview with the facility's Administrator, she was informed of these findings. The observations and interviews indicate a failure to maintain proper sanitation and food safety standards in the central kitchen, which could potentially compromise the health and safety of the residents. The facility's policies on sanitation and food safety were not adhered to, leading to multiple instances of non-compliance with professional standards for food service safety.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to dispose of refuse in a sanitary manner, as observed in the main dumpster area. During observations, a large roll-off dumpster was found containing debris, cardboard boxes, soda boxes, furniture, a mattress, and unidentified garbage. This dumpster had no lid and was only secured on three sides. Additionally, a large open patio area near the kitchen backdoor was observed with used utensils, food wraps, and debris. Four gray round dumpsters were noted with dirty standing water, unidentified trash, and garbage bags, attracting insects and emitting a foul odor. These observations were documented with photographic evidence. In an interview, the Maintenance Director, who oversees the daily cleaning of the dumpster area, admitted to not noticing the large open patio area with the utensils, food wraps, and debris. The Administrator was informed of these findings during an interview. The facility's policy on garbage and rubbish disposal, dated April 2022, mandates that all garbage and rubbish containing food waste be kept in containers with tight-fitting lids, cleaned daily, and stored to be inaccessible to vermin. The facility failed to adhere to these guidelines, resulting in unsanitary conditions in the dumpster area.
Failure to Treat Residents with Dignity During Care and Medication Administration
Penalty
Summary
The facility failed to treat residents in a dignified manner while providing care and services. For Resident #15, who had severe cognitive impairment, an LPN was observed administering medications in the hallway, which is against the facility's policy. The LPN admitted that medications should not be administered in the hallway. Similarly, Resident #38, who had moderate cognitive impairment, was also administered medications in the hallway by an RN, which is also against the facility's policy. For Resident #247, who had moderate cognitive impairment and was being treated for sepsis and an abscess of the liver, an RN was observed changing the resident's abdominal dressing. The RN signed and dated the dressing directly on the resident with a marker, which is not the correct procedure according to the facility's policy. The RN acknowledged that the correct procedure is to sign and date a piece of tape and then apply it to the resident after the wound care is completed. These actions demonstrate a failure to treat residents with dignity and respect during personal care and medication administration.
Failure to Honor Resident's Shower Preferences
Penalty
Summary
The facility failed to honor a resident's right to self-determination by not providing showers according to the resident's preference. Resident #146, who is cognitively intact with a BIMS score of 15, reported that she was not given a choice regarding the number of showers she could receive. She was assigned shower days on Wednesdays and Saturdays during the 3-11 shift and was not given the option to choose morning or evening showers or to have more than two showers per week. The resident expressed a desire for more showers but was not given that option. A review of the resident's medical record showed that she was admitted with diagnoses including congestive heart failure, Type 2 diabetes, and hypertension. The electronic health record indicated that the resident received only one shower on 05/18/24. The Director of Nursing confirmed that all documentation was electronic and that CNAs charted showers in the task section of the EHR. The facility's policy on Activities of Daily Living (ADLS)/Maintain Abilities, dated 8/2022, states that residents have the right to choose their schedules, including bathing, consistent with their interests, assessments, and care plans. However, this policy was not followed in the case of Resident #146.
Failure to Maintain a Safe and Sanitary Environment
Penalty
Summary
The facility failed to maintain a safe, sanitary, and homelike environment for several residents and common areas. Observations revealed that Resident #12's room had peeling paint and a non-functional light bulb, while Resident #146's room had similar issues with peeling paint and two non-functional light bulbs. Resident #248's room had mismatched paint and a non-functional light bulb, and Resident #247's room also had a non-functional light bulb. Additionally, Resident #197's room was found to have debris and disposable food packaging around and behind the bed, despite the resident having reported the issue multiple times to the staff without resolution. The facility's shower rooms were also found to be in poor condition. One shower room had loose tiles and black biological growth on the floor, while the other had an overwhelming odor of urine, a hairbrush in the sink, a used brief in a plastic bag on the floor, and personal belongings and towels in a plastic bag on the shower floor. Both shower rooms had black biological growth on the tiles and walls, and one had a non-functional fluorescent light fixture and a lock that did not work. Interviews with the Director of Housekeeping and the Director of Maintenance confirmed these issues and acknowledged the need for repairs and cleaning.
Failure to Implement Smoking and EBP Care Plans
Penalty
Summary
The facility failed to implement a smoking care plan for two residents and an Enhanced Barrier Precaution (EBP) care plan for another resident. Resident #7, who has diagnoses including Synovitis, Tenosynovitis, and Generalized Anxiety Disorder, was found to be smoking on the property next door and storing cigarettes and a lighter in an unlocked closet. Despite being a non-smoking facility, the resident's care plan did not adequately address the risks associated with smoking, and the facility staff were unaware of where the smoking materials were kept. Similarly, Resident #28, with diagnoses including Hemiplegia, Hemiparesis, Chronic Obstructive Pulmonary Disease, and Major Depressive Disorder, was also found to be smoking off-property without a proper smoking care plan in place. The facility's staff, including the Administrator and Director of Nursing (DON), acknowledged that they did not conduct smoking evaluations because the facility is non-smoking, despite residents' smoking habits being known to them. Additionally, the facility failed to implement an EBP care plan for Resident #247, who has diagnoses including Sepsis and Abscess of the Liver. The resident's care plan included interventions for IV therapy and liver abscess infection but did not include EBP interventions for skin integrity impairment to the coccyx. The facility's policy requires comprehensive care plans to be developed and maintained for each resident, incorporating identified problem areas and risk factors. However, the care plan for Resident #247 lacked necessary EBP interventions, indicating a failure to meet the resident's medical and nursing needs. The facility's policy on comprehensive care plans mandates that they be developed within seven days of the resident's assessment or within twenty-one days after admission, whichever occurs first. Care plans are to be revised as changes in the resident's condition dictate and reviewed at least quarterly. The failure to implement appropriate care plans for smoking and EBP for the residents in question highlights a significant deficiency in the facility's adherence to its own policies and procedures, potentially compromising resident safety and care quality.
Failure to Identify Pressure Ulcer on Admission
Penalty
Summary
The facility failed to identify a pressure ulcer on admission for a resident, leading to a deficiency in pressure ulcer care. The resident was admitted with diagnoses including Other Gram-Negative Sepsis and Abscess of Liver. Initial assessments and documentation did not note any pressure ulcers, and the Minimum Data Set indicated no existing pressure ulcers. However, a physician's order for wound care on the coccyx area was placed shortly after admission, and a stage II pressure ulcer was identified by a Nurse Practitioner on the coccyx area. This discrepancy indicates that the pressure ulcer was either missed during the initial assessment or developed shortly after admission without timely identification and documentation by the facility staff. Further review of the resident's care plan and weekly skin integrity reviews showed that the pressure ulcer on the coccyx was not documented until several days after admission. The Director of Nursing acknowledged the lack of documentation for the coccyx wound on admission and confirmed that the pressure ulcer was identified post-admission. This failure to identify and document the pressure ulcer on admission led to a delay in appropriate care and intervention, which is a significant deficiency in the facility's pressure ulcer care protocol.
Failure to Identify and Evaluate Smoking Residents
Penalty
Summary
The facility failed to identify and evaluate residents who smoke, specifically for two residents. Resident #7 was admitted with diagnoses including Synovitis, Tenosynovitis, and Generalized Anxiety Disorder. Despite the facility's policy of maintaining a smoke-free environment, Resident #7 admitted to smoking and keeping cigarettes and a lighter in an unlocked closet in his room. The care plan for Resident #7 included interventions for safe smoking, but the facility did not enforce these measures effectively. Resident #28, admitted with diagnoses including Hemiplegia, Hemiparesis, Chronic Obstructive Pulmonary Disease, Major Depressive Disorder, and Tobacco Use, also admitted to smoking. Although the facility's policy required a smoking evaluation and proper storage of smoking materials, Resident #28 refused to disclose where he kept his cigarettes and lighter. The facility's staff, including the Administrator and Director of Nursing, acknowledged that they did not keep track of the residents' smoking materials and did not conduct smoking evaluations because they considered the facility to be non-smoking. Interviews with the Administrator and Director of Nursing revealed that the facility did not enforce its smoking policy effectively. Both residents were allowed to sign themselves out to smoke on the property of a neighboring Assisted Living Facility. The facility's failure to monitor and evaluate the residents' smoking habits and materials led to a deficiency in providing a safe environment free from accident hazards, as required by their policies.
Failure to Provide Catheter Anchor
Penalty
Summary
The facility failed to provide an anchor for catheter tubing for a resident who was observed for catheter care. The resident, who was cognitively intact with a BIMS score of 15, had diagnoses including an unspecified fracture of the second thoracic vertebra, hypertension, and neuromuscular dysfunction of the bladder. The facility's policy required the catheter to be secured with a leg strap to reduce friction and movement at the insertion site. During an observation of catheter care performed by a CNA, it was noted that there was no anchor for the catheter tubing either before or after the care. The CNA confirmed that she did not have an anchor for the catheter, which was contrary to the physician's orders and facility policy that mandated changing the catheter anchor and urine bag every night shift on Sundays.
Failure to Address Significant Weight Loss and Nutritional Needs
Penalty
Summary
The facility failed to identify significant weight loss and provide timely nutritional interventions for two residents. Resident #10 experienced a severe weight loss of 13.5% from 118 pounds to 102 pounds within four days and a further loss to 98.1 pounds over the next two weeks. Despite these significant changes, no additional nutritional assessments or interventions were documented after the initial evaluation. Observations showed that Resident #10 consistently consumed less than 65% of her meals, and the Registered Dietitian was unaware of the severe weight loss, indicating a failure in monitoring and addressing the resident's nutritional needs. Resident #199 also experienced a severe weight loss of 6.9% within three days, dropping from 161 pounds to 149.8 pounds. Despite being diagnosed with severe protein-calorie malnutrition and muscle wasting, there were no additional nutritional assessments or interventions documented after the initial evaluation. Observations revealed that Resident #199 consumed very little of his meals and frequently reported pain and nausea, which affected his appetite. The Registered Dietitian was unaware of Resident #199's poor intake and weight loss, as it did not appear on the clinical dashboard used for monitoring. Both cases highlight a failure in the facility's system for monitoring and addressing significant weight loss and poor nutritional intake. The Registered Dietitian's reliance on a clinical dashboard that did not capture these residents' issues contributed to the lack of timely interventions. Additionally, the facility's policy on weighing and weight at-risk protocol was not effectively implemented, leading to missed opportunities for early intervention and support for the affected residents.
Failure to Provide Appropriate Dialysis Care
Penalty
Summary
The facility failed to ensure that residents receiving hemodialysis received care and services consistent with professional standards of practice. Resident #196, who was admitted with end-stage renal disease and dependence on renal dialysis, did not receive his medication Sevelamer with meals as required. His wife reported that the medication was attempted to be given outside the facility on the way to dialysis, and there were no communication sheets between the facility and the dialysis center in the dialysis binder. Staff confirmed the absence of these communication sheets and admitted that they often had to call the dialysis center to request them. Resident #201, also diagnosed with end-stage renal disease and dependence on renal dialysis, did not receive his Sevelamer medication with meals as required. He returned from dialysis to find his dinner waiting but was unsure if the medication was given with his meal. The Medication Administration Record showed missed doses of Sevelamer and Humalog insulin due to his absence at dialysis. The Director of Nursing confirmed that medications should be scheduled around dialysis times and that the nursing team should review and address medication orders immediately upon admission.
Failure to Provide Correct Diet Order
Penalty
Summary
The facility failed to provide the correct diet order per the physician's orders for Resident #200, who was admitted with diagnoses of protein-calorie malnutrition, dysphagia, and type 2 diabetes. Observations revealed discrepancies between the diet orders and the meals provided. On one occasion, the resident received mechanically ground chicken and pieces of red potatoes that were not mechanically ground, contrary to the meal ticket. On another occasion, the resident received chopped broccoli florets instead of the mechanically ground diet specified. The resident expressed a poor appetite and consumed only a small portion of the meals provided. Interviews with the Director of Nursing (DON), Food Service Director (FSD), and Speech Language Pathologist (SLP) revealed inconsistencies in the communication and implementation of diet orders. The DON was unaware of why the meal tickets did not match the electronic system's diet orders. The FSD explained the process of inputting diet orders into the meal tracker but was unaware of the specific requirements for mechanically altered diets. The SLP noted that the resident preferred a pureed diet and was able to consume more food independently when provided with this texture. The facility's Administrator was informed of the findings and the importance of adhering to the correct diet orders for the resident.
Failure to Obtain Physician Order for Occupational Therapy
Penalty
Summary
The facility failed to obtain a physician order for Occupational Therapy (OT) prior to commencing OT for a resident. The facility's policy requires that therapy services must be ordered in writing by a licensed physician or nurse practitioner. However, Resident #146, who was admitted with diagnoses including Congestive Heart Failure, Type 2 Diabetes, and Hypertension, began receiving OT on 05/16/24 without a physician order. The resident, who was cognitively intact with a BIMS score of 15, expressed that she thought she should be getting more therapy during an interview on 05/20/24. Upon review, it was found that there was no physician order for OT in the resident's records. The Director of Therapy confirmed that the resident had received OT on four occasions without an order and subsequently entered a late clarification order on 05/22/24, effective from 05/16/24. This deficiency was identified during the survey process, highlighting the facility's failure to adhere to its own policy regarding therapy orders.
Failure to Document PICC Line Dressing Change and Resident Interaction
Penalty
Summary
The facility failed to ensure the accuracy of records for a resident with a PICC line dressing and did not document a resident-to-resident interaction. Resident #247, who has moderate cognitive impairment, had a PICC line dressing with a faded date of 05/13/24, but the Treatment Administration Record (TAR) did not document a dressing change on that date. The Director of Nursing (DON) confirmed the lack of documentation for the dressing change on 05/13/24, despite the physician's order to change the dressing weekly on the evening shift every Friday. Additionally, the facility did not document a verbal altercation between Resident #26 and Resident #28. Resident #26, who is cognitively intact, reported being yelled at by Resident #28 on 05/19/24. Staff F, the Admissions Coordinator, and Staff G, the psychiatrist, were aware of the incident but did not document it in the electronic health record (EHR). The DON and the Administrator were also informed of the argument but did not document the interaction, believing it was not an abuse situation. These deficiencies highlight the facility's failure to maintain accurate and complete medical records as per their policy. The lack of documentation for the PICC line dressing change and the resident-to-resident interaction indicates a lapse in following accepted professional standards for record-keeping and safeguarding resident-identifiable information.
Failure to Implement and Communicate Infection Control Precautions
Penalty
Summary
The facility failed to ensure staff were made aware of residents on Enhanced Barrier Precautions (EBP) and did not use appropriate Personal Protective Equipment (PPE) for a resident on EBP. Specifically, Resident #247, who had diagnoses including Other Gram-Negative Sepsis and Abscess of Liver, was not properly identified as requiring EBP. The resident had a PICC line, an abdominal drain, and a wound on the coccyx, all of which necessitated EBP. However, there was no EBP signage on the resident's door, no PPE cart outside the room, and staff did not wear the required gown and gloves while providing care. The Director of Nursing (DON) confirmed that the facility did not place signs on the doors for EBP and relied on care plans and electronic medical records to communicate EBP status to staff. This led to staff being unaware of the need for EBP and not following proper infection control procedures when caring for Resident #247. Additionally, the facility failed to maintain Contact Isolation Precautions for Resident #199, who was on contact isolation for ESBL in the urine. Despite having an order for contact precautions, there was no contact isolation sign posted on the resident's door, and no PPE cart was available outside the room during multiple observations. It was only after several hours and multiple observations that a PPE cart and isolation sign were placed outside the resident's door. The DON confirmed that Resident #199 had been on contact isolation since the initial order and emphasized that the facility follows CDC guidelines for contact isolation, which include placing signage and PPE carts outside the resident's room. These deficiencies indicate a failure in the facility's infection prevention and control program, specifically in communicating and implementing EBP and contact isolation precautions. The lack of proper signage, PPE availability, and staff awareness led to non-compliance with the facility's policies and CDC guidelines, potentially increasing the risk of infection transmission among residents and staff.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
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Nursing homes near Ormond Beach
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Coquina Center | 1.6 mi | ★★★★★ | 6 | 0 |
| Avante At Ormond Beach, Inc | 2.2 mi | ★★★★★ | 0 | 0 |
| Bridgeview Center | 2.6 mi | ★★★★★ | 1 | 0 |
| Terrace At Bishop's Glen, The | 3.2 mi | ★★★★★ | 0 | 0 |
| Emory L Bennett Memorial Veterans Nursing Home | 4.1 mi | ★★★★★ | 0 | 0 |
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