Health 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 Page 1 of 2 105458 105458 08/19/2025 Ormond Rehabilitation and Nursing Center 103 Clyde Morris Blvd Ormond Beach, FL 32174

F 0628 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few notified of the residents plans during the Patient-Driven Payment Model (PDPM) meeting, quarterly assessment and care planning. She was involved with Resident #1 discharge and that the discharge notification came from the administrator. When asked if Resident #1 was provided prior notification for discharge, she stated that the Administrator told her that she had communicated with the ombudsman about it. Therefore, she proceeded to secure placement and resident was moved out. During a phone interview with the Ombudsman on 8/19/25 at 2:30 pm, she confirmed that their office does not make any discharge recommendation, and they were not consulted of any discharge from the facility. She also stated that the facility had not sent any Transfer/Discharge notices since January 2025. Review of the facility's Transfer/Discharge Policy Dated April 2022 revealed that the Center provide a resident/resident representative with thirty days written notice of impending discharge.Policy Interpretation and Implementation: Except as specified below, a resident/his or her representative will be given a thirty (30)-day advance notice of an impending transferor discharge from the Center: a. The transfer is necessary for the resident's welfare and the resident's needs cannot be met in the Center.b. The transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the Center;c. The safety of individuals in the Center is endangered; d. The health of individuals in the Center would otherwise be endangered;e. The resident has failed, after reasonable and appropriate notice, to pay for (or to have paid under Medicare or Medicaid) a stay at the Center.f. An immediate transfer or discharge is required by the resident's urgent medical needs. g. The resident is transferred for other than medical reasons.h. The resident has not resided in the Center for thirty (30) days; and/[NAME]. The Center ceases to operate.The resident/representative will be provided with the following information:a. The reason for the transfer or discharge. b. The effective date of the transfer or discharge.c. The location to which the resident is being transferred or discharged .d. The name, address, and telephone number of the state long-term care Ombudsman. e. The name, address, and telephone number of each individual or agency responsible for the protection and advocacy of mentally ill or developmental disabled individuals (as applies); and f. The name address and telephone number of the state health department agency that has been designated to handle appeals of transfers and discharge notices. 105458 Page 2 of 2