Ormond Nursing and Care Center

In the surveyor’s words

From the most serious findings on record at Ormond Nursing and Care Center, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF656Aug 31, 2023

  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). […]

• No harm, potential for more than minimal, patternF692Aug 31, 2023

  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… […]

• No harm, potential for more than minimal, isolatedF689Jul 22, 2026

  Based on observations, interviews, and record reviews, the facility failed to ensure a resident that had a risk of aspiration was supervised during meals for 1(Resident #31) of 1 sampled residents investigated for accidents hazards. Findings:Review of Resident #31's clinical record revealed, in part, Resident #31 was admitted to the facility on [DATE]. Further review revealed Resident #31's diagnoses included, myasthenia gravis (chronic autoimmune disease that causes weakness in the muscles you control voluntarily) generalized muscle weakness, gait impairment (difficulty walking), reduce mobility, and cognitive communication deficit (inability to focus, remember, organize thoughts, or follow conversations). […]

• No harm, potential for more than minimal, isolatedF880Jul 22, 2026

  Based on observation, interviews, and record reviews, the facility failed to ensure a resident with an increased risk for multidrug-resistant organisms (MDRO's) had Enhanced Barrier Precautions (EBP) implemented for 1(Resident #8) of 2 residents observed for wound care.Review of the facility's EBP policy and procedure, dated 01/2023 and revised 03/2024 revealed, in part, EBP are an infection control intervention designed to reduce transmission of MDRO's in nursing homes. EBP involve gown and glove use during high-contact resident care activities for residents at increased risk of MDRO acquisition (e.g., residents with wounds). EBP expand the use of gown and gloves beyond anticipated blood and body fluid exposure. […]

• No harm, potential for more than minimal, isolatedF656Jul 23, 2025

  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. […]