Inspection·August 19, 2025

F 0628 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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. The findings include:Clinical record review indicated that Resident #1 was admitted to the facility on [DATE], re- entry on 9/7/22 and discharged on 7/31/25. His diagnoses included aftercare following joint replacement, type 2 diabetes mellitus, dementia without behavior, metabolic encephalopathy, anxiety disorder, need assistance with personal care, heart failure and neurogenic arthritis.Review of the Quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 5/19/25, indicated that the resident had a Brief Interview for Mental status score of 11 out of 15 possible points, indicating moderate cognitive impairment. Review of the physician's orders dated 7/31/25 for Resident #1 revealed he was discharged to Blue Palms Health and Rehab of Daytona. Review of the care plan with a close date of 8/5/25 revealed that resident had impaired cognitive function/dementia or impaired thought process. Intervention included to communicate with the resident/family/caregiver regarding resident capabilities and needs. Discuss concerns about confusion disease process, nursing home placement with resident/family/caregivers. The care plan also indicated that the resident wished to remain in the facility for long term care, intervention included, to discuss feeling and concerns with impending discharge and monitor for and address episodes of anxiety, fear or distress. Review of the Discharge summary dated [DATE] noted the reason for discharge as transfer to skilled nursing facility. The Discharge MDS with ARD of 7/31/25 revealed that the type of discharge was planned. During interview with the administrator on 8/18/25 at 1:45 pm, she stated that Resident #1 was discharged to another skilled nursing facility with a memory care unit after an elopement incident on 6/28/25. When asked about the discharge planning and notification she stated that the discharge was an emergency due to safety concerns. She stated she consulted the ombudsman's office and was notified that they could proceed with the discharge. When asked if the resident responsible party was notified, she stated that the resident did not have a responsible party. She stated that the responsible party had passed away a year ago. The administrator was asked for information of the ombudsman's notification, which she mentioned that the discussion was verbal, and she did not have any paperwork. She was asked to notify the ombudsman that she spoke with to contact surveyor. During a follow up interview with the Administrator was conducted on 8/19/25 at 12:00 pm, she confirmed that the Agency of Health Care Administration (AHCA) transfer - discharge forms were not completed. She added that she could not get ahold of the ombudsman. In an interview with the Director of Social Services (SSD) on 8/19/25 at 12:56 pm, she stated that she had been working in the facility for 4 months. She stated that she was involved with the discharge planning. She explained that discharge planning starts on admission, and the plan may change depending on the resident's progress. She stated that she is (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 105458 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105458 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/19/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ormond Rehabilitation and Nursing Center 103 Clyde Morris Blvd Ormond Beach, FL 32174 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)