Health inspection·May 12, 2022

F 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Based on observation, record review, and interview, the facility failed to implement appropriate plans of action to correct identified quality deficiencies regarding hand hygiene standards of practice during medication administration. Findings include: During an observation of medication administration on 5/11/2022 at 7:45 AM, Staff A, Licensed Practical Nurse (LPN), did not perform hand hygiene, poured medications for Resident #14, entered the resident's room, did not perform hand hygiene, and handed the medication cup to the resident. Resident # 14 took the medication cup to her mouth, took the medications, and handed the medication cup back to the Staff A. Staff A disposed of the medication cup, did not perform hand hygiene, exited Resident #14's room, walked down the hallway, entered the room containing the Pyxis machine, removed a medication, put the medication into a medication cup, returned to Resident #14's room, did not perform hand hygiene, and handed the medication cup to the resident. Resident #14 took the medication, and gave the medication cup to Staff A. Staff A disposed of the medication cup, did not perform hand hygiene, exited the room, and returned to the medication cart. Staff A did not perform hand hygiene, opened the computer, and began preparing medications for the next resident. During an observation of medication administration on 5/11/2022 at 8:00 AM, Staff B, LPN, did not perform hand hygiene prior to preparing Resident #23's medications. Staff B knocked on the resident's door, entered the resident's room, did not perform hand hygiene, handed the medication cup to the resident. The resident took the cup to his mouth, took the medications, and handed the medication cup back to Staff B. Staff B disposed of the medication cup, did not perform hand hygiene, returned to the medication cart, and began preparing medications for the next resident. During an interview on 5/12/2022 at 10:04 AM, the Administrator stated the facility's Director of Nursing identified a concern regarding hand hygiene and initiated a performance improvement project in September of 2021. A request was made to review the performance improvement plan and all related documentation to verify the implementation of the performance improvement. No performance improvement plan was provided. Review of the Hand Hygiene and Contact Precautions Observations dated 3/4/2022 and 4/19/2022 documented two nurses with no staff identification were observed for hand hygiene during medication administration. No additional documentation was provided. Review of the policy and procedure titled, 2021 Quality Assurance & Performance Improvement (QAPI) Plan, dated 11/21/2017 and reviewed on 7/20/2021 read, The QAPI Steering Committee analyzes (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 3 Event ID: 105401 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 105401 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/12/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ayers Health and Rehabilitation Center 606 NE 7th St Trenton, FL 32693 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)