Ormsby Post Acute Rehabilitation

In the surveyor’s words

From the most serious findings on record at Ormsby Post Acute Rehabilitation, in the surveyor’s own words.

• Immediate jeopardy, isolatedF610May 29, 2024

  Based on observation, interview, clinical record review, and document review, the facility failed to ensure a potential incidence of misappropriation of a resident's prescribed narcotic pain medication was investigated for misappropriation of property for 1 of 2 residents reviewed for potential narcotic diversion (Resident #44). This deficient practice could lead to undetected narcotic diversion from residents causing increased pain and diminished quality of life. Additionally, the facility failed to thoroughly investigate a resident's allegation of abuse and ensure a suspended employee did not continue to work in the facility until an investigation was completed for 1 of 19 sampled residents (Resident #19). […]

• Immediate jeopardy, isolatedF684Jul 5, 2023

  Based on observation, interview, clinical record review, and document review, the facility failed to ensure a head-to-toe assessment was completed by a licensed qualified professional when a resident with an injury to the left side of the head and at high risk for intracranial hemorrhage was found on the floor after a fall and was reported timely to a physician for 1 of 19 sampled residents (Resident #16), and a wound was identified and reported to the appropriate staff, treated, and documented for 1 of 19 sampled residents (Resident #4). Finding include: Resident #16 Resident #16 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including muscle weakness, dementia, and lack of coordination. […]

• No harm, potential for more than minimal, widespreadF812May 14, 2026

  Based on observation, interview, and document review, the facility failed to ensure 1) proper hand hygiene was performed by dietary staff, 2) refrigerated food was stored properly, 3) food was discarded by the expiration date, and 4) the outside propane gas grill (Barbecue) was cleaned appropriately. This deficient practice had the potential to affect all residents in the facility by increasing the risk of infection and foodborne illnesses. Findings include: Hand Washing On 05/11/2026 at 8:31 AM, a Dietary [NAME] was holding a baking pan containing potatoes. The Dietary [NAME] was not wearing gloves. The Dietary [NAME] place the baking pan onto the food preparation surface and donned gloves without performing hand hygiene. […]

• No harm, potential for more than minimal, widespreadF812Mar 27, 2025

  Based on observation, interview, and document review, the facility failed to obtain cooking temperatures and holding temperatures of chicken prior to plating the chicken to serve to residents for lunch service. This deficient practice posed a potential risk to safety and health standards which could lead to contamination and place residents at risk of foodborne illness. Findings include: On 03/26/2025 at 11:30 AM, dietary staff had removed three large trays of chicken breasts from the oven. The chicken was transferred to a holding tray and placed in the steam table. The chicken was then placed on a plate and ready to be placed in a steam cart to deliver to residents. […]

• No harm, potential for more than minimal, widespreadF726May 29, 2024

  Based on observation, interview, clinical record review, and document review, the facility failed to ensure 1) the Infection Preventionist (IP) had the skills necessary to review lab results to determine the appropriateness of implementing transmission-based precautions (TBP) 2) a nurse administering medications had completed a competency for medication administration. This deficient practice could lead to residents not being placed on transmission-based precautions when necessary, causing other residents to be exposed to communicable diseases and residents not receiving medications as prescribed, creating increased potential for adverse medication reactions 3) the Infection Preventionist (IP) had the knowledge necessary to ensure the appropriate selection and administration of… […]