Inspection visit
Inspection
16 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 16 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0656
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Develop and implement a complete care plan that meets all the resident's needs, with timetables and
actions that can be measured.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observations, record review, interviews, and a review of the facility's policy and procedure for Falls and
other facility documentation, the facility failed to implement a comprehensive person-centered care plan for
one (Resident #10) of 27 residents whose care plans were reviewed for falls. Fall mats were ordered for
Resident #10 but were not in place, which could result in fall injuries. The findings include:
On 8/24/25 at 11:30 a.m., Resident #10 was observed lying in a high bed with an air mattress and 1/4 side
rails. The resident was asked if he had fallen and he replied yes. He reported several falls and having gone
to the hospital after one fall. He could not remember the date, only that the fall was recent.
On 8/25/25 at 9:30 a.m., the facility's matrix was reviewed. The matrix revealed that the resident had fallen
with a major injury.
On 8/25/25 at 2:30 p.m., Resident #10 was observed lying in bed. No fall mats were at bedside. His room
and bathroom were checked, but there were no fall mats in his room. He reported that he did not need the
mats when he was asked about them. The bed was in high position. A record review revealed that the
resident had episodes of confusion.
On 8/26/25 at 9:00 a.m., Resident #10 was observed lying in bed watching TV and eating his breakfast. Fall
mats were not observed at bedside. His bed was in high position.
On 8/27/25 at 9:30 a.m., the resident was observed in bed with his eyes closed. The bed was in high
position, and no fall mats were observed.
On 8/27/25 at 11:00 a.m., Resident #10 was observed in bed watching TV. The bed was in high position,
and no fall mats were observed.
A review of Resident #10's medical record revealed that he had a re-entry on 7/18/25 with an initial
admission on [DATE]. His diagnoses included osteomyelitis of the ankle and foot, chronic obstructive
pulmonary disease (COPD), mild protein calorie malnutrition, and anemia. The five-day Minimum Data Set
(MDS) assessment dated [DATE] revealed a prior fall and that the resident needed substantial, maximum
assistance with toileting, partial, moderate assistance with bed mobility, and for transfers, he required
substantial maximal assistance. Resident #10 had a Brief Interview for Mental Status (BIMS) score of 8 out
of 15 possible points, indicating moderate cognitive impairment.
A review of the Care Plan dated 7/10/25 revealed that the resident was at risk for falls and had a
(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 7
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
08/27/2025
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)
F 0656
Level of Harm - Minimal harm
or potential for actual harm
history of falls. Interventions included that the bed be in low position (initiated 7/23/25) and fall mats (two)
beside the bed (initiated 7/11/25). (Copy obtained) The medical record documented a fall on 7/11/25 with a
small abrasion under the left knee where the resident slid out of his wheelchair, and on 7/16/25, he was
found lying prone on the side of the bed. Resident #10 hit his head and suffered skin tears to his right elbow
and was transferred to the hospital.
Residents Affected - Few
An interview was conducted with Registered Nurse (RN) E on 8/27/25 at 11:00 a.m. who said she had
worked in the facility for two years. She reported that the resident had a fall and was sent to the hospital last
month. He returned to the facility. When she was asked what interventions were used for fall prevention, she
reviewed the resident's care plan and reported that he had a low bed and fall mats at bedside. RN E was
accompanied to Resident #10's room. After entering the room, RN E confirmed that the resident had no fall
mats, and his bed was not low. She started lowering the bed and told the resident she was going to get him
some fall mats.
An interview was conducted on 8/27/25 at 11:32 a.m. with the Assistant Director of Nursing (ADON). She
reported that the resident had a fall on 7/11/25 where he slid out of his wheelchair trying to reach the call
light. The Unit Manager arrived and reported that the resident suffered a small abrasion under his left knee
and a Dycem cushion to the wheelchair was implemented on 7/16/25. The Unit Manager/Licensed Practical
Nurse (LPN) also reported that two fall mats at bedside were added to the care plan on 7/11/25. The ADON
reported that on 7/16/25 the resident was transported to the hospital due to oa change in condition. He had
fallen and stated his head hurt. He had slid out of bed. The fall risk evaluation revealed a high risk for falls
(12) on 7/18/25. The Unit Manager confirmed that there were no fall mats at bedside. She went to get
some. She stated the resident had fall mats, but his room was deep cleaned, and the mats were removed.
The Unit Manager confirmed that there had been no fall mats in room since 8/24/25.
A review of the facility's policy and procedure titled Falls (dated April 2022) revealed:
It is the policy of this center to determine fall risk, provide interventions to prevent/reduce falls, and update
interventions as needed to prevent and/or reduce falls and injury.
1.Fall risk screen within 24 hours of admission, quarterly and PRN (as needed).
2.Care plan in place for fall reduction.
3.Update the plan of care. (Copy obtained)
A review of the facility's Performance Improvement Plans (PIPs) revealed that Falls was one of seven PIPs
in in place for this facility. It had a start date of 8/25/25, one day after the survey began on 8/24/25. The
Falls PIP was implemented due to notification of family, no timely interventions and documentation.
Resident #10 did have a Fall care plan documented but did not have his fall mats or low bed implemented.
The concern was not following the care plan.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105458
If continuation sheet
Page 2 of 7
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
08/27/2025
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)
F 0684
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interviews, record review, and a review of the facility's policies and procedures, the facility failed to ensure
treatment and care were provided in accordance with professional standards of practice and the
comprehensive person-centered care plan for one (Resident #28) of 27 residents in the survey sample
whose care plans were reviewed. Resident #28, with a Brief Interview for Mental Status (BIMS) score
indicating intact cognition, stated he was not receiving his medications as ordered, and a review of his
medical record for August 2025 revealed that on numerous dates, five medications were not signed off by
nursing as having been administered. Failure to administer medications as ordered by the physician has the
potential to cause a negative outcome to the resident's physical, mental, or psychosocial health and
well-being. The findings include: On 08/24/2025 at 1:33 PM, Resident #28 stated he believed some of his
medications were missed. He stated they were sometimes late or not provided at all. Resident #28 could
not identify a particular medication that was late or missed. A review of the resident's active physician's
orders revealed:Ferrous Sulfate oral tablet 325 (65 Fe (iron) mg, give 1 tablet by mouth in the morning for
anemia (08/07/2025)Plavix oral tablet 75 mg (Clopidogrel Bisulfate), give 1 tablet by mouth at bedtime for
antiplatelet (06/13/2025)Vitamin C oral tablet (Ascorbic Acid), give 500 mg by mouth in the morning for iron
absorption (08/07/2025)Risperidone oral tablet 2 mg, give 1 tablet by mouth every morning and at bedtime
for schizophrenia (06/13/2025)Amlactin Daily External Lotion 12% (Lactic Acid (Ammonium Lactate), apply
to bilateral (both) feet topically every morning and at bedtime for dry skin. Wash feet with soap and water
before applying lotion (07/20/2025) A review of Resident #28's August 2025 Medication Administration
Record (MAR) and Treatment Administration Record (TAR) revealed missing documentation used to verify
that the following medications were administered:Ferrous Sulfate oral tablet 325 (65 Fe) mg for anemia was
missing signatures on 8/10/2025 and 8/13/2025 verifying that the medication was administered.Plavix oral
tablet 75 mg for antiplatelet was missing a signature on 8/9/2025 verifying that the medication was
administered.Vitamin C oral tablet (Ascorbic Acid) for iron absorption was missing signatures on 8/10/2025
and 8/13/2025 verifying that the medication was administered.Risperidone Oral Tablet 2 mg for
schizophrenia was missing a signature on 8/9/2025 verifying that the medication was
administered.Amlactin Daily External Lotion 12 % (Lactic Acid (Ammonium Lactate) was missing signatures
on 8/9/2025 and 8/12/2025 verifying that the medication was administered. (Copy obtained) Further review
of the medical record revealed that Resident #28 was admitted to the facility on [DATE]. Primary diagnoses
included, but were not limited to, Parkinson's disease without dyskinesia, anemia, dementia in other
diseases classified elsewhere with other behavioral disturbance; schizoaffective disorder - bipolar type,
persistent mood disorder; dementia with psychotic disturbance. A review of the 5-day minimum data set
(MDS) assessment dated [DATE] revealed that the resident was receiving antipsychotic and antiplatelet
medications. He had a Brief Interview for Mental Status (BIMS) score of 13 out of 15 possible points,
indicating intact cognition. A review of the resident's Care Plan, dated 07/01/2025, revealed impaired
cognitive function/or impaired thought processes related to dementia; at risk for adverse reaction related to
Doxycycline, Seroquel allergies; use of psychotropic medications related to schizophrenia; antiplatelet
therapy related to history of cerebral infarction; Parkinson's disease, anemia, dementia, and risk for
alteration in skin integrity related to Parkinson's disease, wasting syndrome and malnutrition. Interventions
included administration of medications as ordered by the physician. Monitor/document for side effects and
effectiveness; monitor weight/weight changes; administer medications as ordered by the physician; monitor
for side effects and effectiveness every shift; provide and serve
Residents Affected - Few
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105458
If continuation sheet
Page 3 of 7
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
08/27/2025
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)
F 0684
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
supplements as ordered: see current orders; and keep skin clean and dry, use lotion on dry skin. (Copies
obtained) On 08/27/2025 at 10:20 AM, Certified Nursing Assistant (CNA) G was asked if the resident had
complained about not receiving his medications at all or receiving his medications late. CNA G replied, no.
On 08/27/2025 at 10:29 AM, Licensed Practical Nurse (LPN) H was asked if the resident complained about
not receiving his medications at all or receiving his medications late. LPN H replied, No, I give it to him on
time. LPN H was asked about the following medications that were missing the documentation to verify that
they were administered: Ferrous Sulfate oral tablet 325 (65 Fe) mg for anemia missing signatures on
8/10/2025 and 8/13/2025. She replied, I'm not sure what happened. It was 5:00 AM medication in the
morning. I was not at the facility. Plavix oral tablet 75 mg for antiplatelet, missing a signature on 8/9/2025.
She replied, That's night shift. Vitamin C oral tablet (Ascorbic Acid) for iron absorption, missing signatures
on 8/10/2025 and 8/13/2025. She replied, That's an AM medication. I'm not sure. Risperidone oral tablet 2
mg for schizophrenia, missing a signature on 8/9/2025. She replied, Night shift. Amlactin Daily External
Lotion 12 % (Lactic Acid (Ammonium Lactate), missing signatures on 8/9/2025 and 8/12/2025 to verify that
the medication was administered. She replied, Night shift. On 08/27/2025 at 11:52 AM, the Assistant
Director of Nursing (ADON) was asked to verify that the following medications, missing signatures on the
MAR to verify administration, were provided: Ferrous Sulfate oral tablet 325 (65 Fe) mg for anemia, missing
signatures on 8/10/2025 and 8/13/2025; Plavix oral tablet 75 mg for antiplatelet, missing a signature on
8/9/2025; Vitamin C oral tablet (Ascorbic Acid) for iron absorption, missing signatures on 8/10/2025 and
8/13/2025; Risperidone oral tablet 2 mg for schizophrenia, missing a signature on 8/9/2025; and Amlactin
Daily External Lotion 12 % (Lactic Acid (Ammonium Lactate), missing signatures on 8/9/2025 and
8/12/2025. She confirmed that these medications were not documented as having been administered on
the dates noted above. A review of the facility's policy and procedure titled Administration of Drugs (dated
04/2022), revealed:Policy: Drugs will be administered in a timely manner and as prescribed by the
resident's attending physician or the Center's Medical Director. Policy Interpretation and Implementation . 2.
Drugs must be administered in accordance with the written orders of the attending physician. 3. All current
drugs and dosage schedules must be recorded on the resident's Electronic Medication Administration
Record (eMAR). 4. Topical drugs used in treatments should be recorded on the resident's treatment record .
9. The nurse administering the drug must record such information on the resident's eMAR before
administering the next resident's drug. 10. The nurse administering the drugs must electronically sign the
resident's eMAR . 12. Should a drug be withheld, refused, or given other than at the scheduled time, the
nurse should give the appropriate chart code inside the eMAR that states the reason for not administering
that particular drug. 13. The nurse should enter an explanatory note in the progress notes for the eMAR
when drugs are withheld, refused, or given other than at scheduled times. The physician should be notified
of drugs that are withheld and/or repeated refusal of drugs. (Copy obtained)
Event ID:
Facility ID:
105458
If continuation sheet
Page 4 of 7
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
08/27/2025
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)
F 0842
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in
accordance with accepted professional standards.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interviews, record review, and a review of the facility's policies and procedures, the facility failed to ensure
residents' medical records were complete and accurately documented, in accordance with accepted
professional standards and practices, for one (Resident #28) of a total survey sample of 27 residents
whose records were reviewed. Resident #28, with a Brief Interview for Mental Status (BIMS) score
indicating intact cognition, stated he was not receiving his medications as ordered, and a review of his
medical record for August 2025 revealed that on numerous dates, five medications were not signed off by
nursing as having been administered. The resident's record must reflect the care and services provided to
the resident.The findings include: On 08/24/2025 at 1:33 PM, Resident #28 stated he believed some of his
medications were missed. He stated they were sometimes late or not provided at all. Resident #28 could
not identify a particular medication that was late or missed. A review of the resident's active physician's
orders revealed:Ferrous Sulfate oral tablet 325 (65 Fe (iron) mg, give 1 tablet by mouth in the morning for
anemia (08/07/2025)Plavix oral tablet 75 mg (Clopidogrel Bisulfate), give 1 tablet by mouth at bedtime for
antiplatelet (06/13/2025)Vitamin C oral tablet (Ascorbic Acid), give 500 mg by mouth in the morning for iron
absorption (08/07/2025)Risperidone oral tablet 2 mg, give 1 tablet by mouth every morning and at bedtime
for schizophrenia (06/13/2025)Amlactin Daily External Lotion 12% (Lactic Acid (Ammonium Lactate), apply
to bilateral (both) feet topically every morning and at bedtime for dry skin. Wash feet with soap and water
before applying lotion (07/20/2025) A review of Resident #28's August 2025 Medication Administration
Record (MAR) and Treatment Administration Record (TAR) revealed missing documentation used to verify
that the following medications were administered:Ferrous Sulfate oral tablet 325 (65 Fe) mg for anemia was
missing signatures on 8/10/2025 and 8/13/2025 verifying that the medication was administered.Plavix oral
tablet 75 mg for antiplatelet was missing a signature on 8/9/2025 verifying that the medication was
administered.Vitamin C oral tablet (Ascorbic Acid) for iron absorption was missing signatures on 8/10/2025
and 8/13/2025 verifying that the medication was administered.Risperidone Oral Tablet 2 mg for
schizophrenia was missing a signature on 8/9/2025 verifying that the medication was
administered.Amlactin Daily External Lotion 12 % (Lactic Acid (Ammonium Lactate) was missing signatures
on 8/9/2025 and 8/12/2025 verifying that the medication was administered. (Copy obtained) A review of the
5-day minimum data set (MDS) assessment dated [DATE] revealed that the resident was receiving
antipsychotic and antiplatelet medications. He had a Brief Interview for Mental Status (BIMS) score of 13
out of 15 possible points, indicating intact cognition. On 08/27/2025 at 10:29 AM, Licensed Practical Nurse
(LPN) H was asked if the resident complained about not receiving his medications at all or receiving his
medications late. LPN H replied, No, I give it to him on time. LPN H was asked about the following
medications that were missing the documentation to verify that they were administered: Ferrous Sulfate oral
tablet 325 (65 Fe) mg for anemia missing signatures on 8/10/2025 and 8/13/2025. She replied, I'm not sure
what happened. It was 5:00 AM medication in the morning. I was not at the facility. Plavix oral tablet 75 mg
for antiplatelet, missing a signature on 8/9/2025. She replied, That's night shift. Vitamin C oral tablet
(Ascorbic Acid) for iron absorption, missing signatures on 8/10/2025 and 8/13/2025. She replied, That's an
AM medication. I'm not sure. Risperidone oral tablet 2 mg for schizophrenia, missing a signature on
8/9/2025. She replied, Night shift. Amlactin Daily External Lotion 12 % (Lactic Acid (Ammonium Lactate),
missing signatures on 8/9/2025 and 8/12/2025 to verify that the medication was administered. She replied,
Night shift. On 08/27/2025 at 11:52 AM, the Assistant Director of Nursing (ADON) was asked to verify that
the
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105458
If continuation sheet
Page 5 of 7
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
08/27/2025
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)
F 0842
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
following medications, missing signatures on the MAR to verify administration, were provided: Ferrous
Sulfate oral tablet 325 (65 Fe) mg for anemia, missing signatures on 8/10/2025 and 8/13/2025; Plavix oral
tablet 75 mg for antiplatelet, missing a signature on 8/9/2025; Vitamin C oral tablet (Ascorbic Acid) for iron
absorption, missing signatures on 8/10/2025 and 8/13/2025; Risperidone oral tablet 2 mg for schizophrenia,
missing a signature on 8/9/2025; and Amlactin Daily External Lotion 12 % (Lactic Acid (Ammonium
Lactate), missing signatures on 8/9/2025 and 8/12/2025. She confirmed that these medications were not
documented as having been administered on the dates noted above. A review of the facility's policy and
procedure titled Administration of Drugs (dated 04/2022), revealed:3. All current drugs and dosage
schedules must be recorded on the resident's Electronic Medication Administration Record (eMAR). 4.
Topical drugs used in treatments should be recorded on the resident's treatment record . 9. The nurse
administering the drug must record such information on the resident's eMAR before administering the next
resident's drug. 10. The nurse administering the drugs must electronically sign the resident's eMAR . 12.
Should a drug be withheld, refused, or given other than at the scheduled time, the nurse should give the
appropriate chart code inside the eMAR that states the reason for not administering that particular drug. 13.
The nurse should enter an explanatory note in the progress notes for the eMAR when drugs are withheld,
refused, or given other than at scheduled times. The physician should be notified of drugs that are withheld
and/or repeated refusal of drugs. (Copy obtained)
Event ID:
Facility ID:
105458
If continuation sheet
Page 6 of 7
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
08/27/2025
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)
F 0908
Keep all essential equipment working safely.
Level of Harm - Minimal harm
or potential for actual harm
Based on the kitchen food service observations, staff interviews, and a review of facility records and
policies and procedures, the facility failed to maintain dietary equipment in safe and sanitary condition to
prevent the outbreak of foodborne illness, with the potential to affect any resident who consumed ice from
the facility's kitchen, by failing to maintain and clean the ice machine to prevent contamination/biological
growth. Food safety and sanitation are important in health care settings serving nursing home residents.
Kitchen equipment shall be maintained and kept free of waterborne microorganisms to avoid a potential
source of pathogen exposure.The findings include: During a follow up visit to the kitchen on 08/26/2025 at
11:20 AM, the ice machine located outside the kitchen's main door's ice diverter was covered with a slimy,
pink substance. The 2025 ice machine cleaning log hanging on the side of the ice machine documented
cleaning on 08/24/2025. (Photographic evidence obtained) During this follow up visit, the Regional Food
Service Director verified with his personal cell phone a document showing that the ice machine was
cleaned by Maintenance on 07/31/2025. He stated the ice machine would be shut down, all ice removed
and cleaned today. (Photographic evidence obtained). On 08/27/2025 at 8:29 AM, Dietary Aide A was
asked who was responsible for cleaning the ice machine and how often. She replied, At one time we were
told it was Maintenance, then they said it was Dietary. We were told last that it was Maintenance's
responsibility. Dietary is currently cleaning the outside, and inside edges around the open area of the door
one time per week. On 08/27/2025 at 8:42 AM, [NAME] B was asked who was responsible for cleaning the
ice machine and how often. She replied, As far as I know it's Maintenance; I don't know their cleaning
schedule. Dietary does not clean it at all. On 08/27/2025 at 9:03 AM, the Certified Dietary Manager was
asked who was responsible for cleaning the ice machine and how often. She replied, The kitchen staff. It's
an ongoing issue with Dietary and Maintenance. We wipe down the outside and run the scoop through the
dish machine every week. On 08/27/2025 at 9:49 AM, the Maintenance Director was asked who was
responsible for cleaning the ice machine and how often. He replied, Dietary and Maintenance. Maintenance
cleans the ice machine quarterly. The top and bottom of the ice machine including the fan, condenser, the
tray and diverter area is cleaned. A review of the facility's Work History Report, Direct Supply TELS
(electronic maintenance program) indicated:Task Description: Ice machines/ice bins: Verify ice machine and
ice cart scoops and scoop bins are cleaned and sanitized; marked done on-time by the Maintenance
Director on 7/21/2025. A review of the facility's policy and procedure titled Ice Machines and Ice Storage
Chest (revised 01/2012), revealed:Policy Statement: Ice machines and ice storage/distribution containers
will be used and maintained to assure a safe and sanitary supply of ice . 3. Our facility has established
procedures for cleaning and disinfecting ice machines and storage chests which adhere to the
manufacturer's instructions. The infection Preventionist (or designee) maintains a copy of these procedures.
A review of the facility's policy and procedure titled Ice Machine and Ice Storage Chests (revised
8/27/2025), revealed:Policy: Ice machine and ice storage chest/containers must be maintained in a safe
and sanitary condition . 3. The ice machine will be cleaned monthly per manufacturers' recommendation
and as needed by Maintenance. 4. The Dietitian will check the ice machine for cleanliness monthly during
facility visits and will report need for additional cleaning to the Administrator. (Copies obtained)
Residents Affected - Some
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105458
If continuation sheet
Page 7 of 7
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Back to topCitations
16 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F908 - Maintain all mechanical, electrical, and patient care equipment in safe
Keep all essential equipment working safely.
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
F842 - Resident-identifiable information
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
F656 - Comprehensive Care Plans
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- 0004GeneralS&S Dpotential for harm
Develop and maintain an Emergency Preparedness Program (EP).
- 0006GeneralS&S Dpotential for harm
Conduct risk assessment and an All-Hazards approach.
- 0025GeneralS&S Dpotential for harm
Create arrangements with other facilities to receive patients.
- 0026GeneralS&S Dpotential for harm
Establish roles under a Waiver declared by secretary.
- 0030GeneralS&S Dpotential for harm
List the names and contact information of those in the facility.
- 0036GeneralS&S Dpotential for harm
Establish emergency prep training and testing.
- 0037GeneralS&S Dpotential for harm
Establish staff and initial training requirements.
- 0039GeneralS&S Dpotential for harm
Conduct testing and exercise requirements.
F711 - Physician Visits
Provide a written emergency evacuation plan.
F761 - Labeling of Drugs and Biologicals
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
- 0900GeneralS&S Dpotential for harm
Meet Health Care Facilities Code mechanical requirements.
F917 - Private closet space in each resident room, as specified in §483
Ensure electrical receptacles or cover plates have distinctive color or marking.
FAQ · About this visit
Common questions about this visit
What happened during the August 27, 2025 survey of ORMOND REHABILITATION AND NURSING CENTER?
This was a inspection survey of ORMOND REHABILITATION AND NURSING CENTER on August 27, 2025. The surveyor cited 16 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at ORMOND REHABILITATION AND NURSING CENTER on August 27, 2025?
Yes, 16 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Keep all essential equipment working safely."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.