Health inspection·March 6, 2025

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm Based on record review and interview, the facility failed to ensure the minimum data set (MDS) was completed accurately for 1 of 3 residents, Resident #104 reviewed for hospitalization. Residents Affected - Few Findings include: Review of Resident #104's medical record revealed a form titled Release of Responsibility on Leave of Absence which documented the resident signed herself out on a leave of absence on 2/2/25 at 12:35 PM. Review of Resident #104's MDS (Minimum Data Set) Resident Assessment and Care Screening Nursing Home discharge date d 2/11/25 read, Section A - Identification Information A2105, Discharge Status Enter Code 04. 04. Short-Term General Hospital. Review of the Skilled Note dated 2/2/25 at 5:37 pm for Resident #104 read, Comments/Narrative Section . Resident left with family at 12:30 to retrieve clothes from home and has yet to come back. She took all belongings with her when she left. Resident advised to be back to facility by 11 pm and verbalized positive understanding. I called and informed resident's daughter, [Daughter's name], that resident was signing out of facility, and she verbalized positive understanding. Review of the Action Summary report read, [Resident #104's name] Discharge Status: discharged to home or self care. Eff [Effective] Date 2/2/2025. Time: 12:00 PM. During an interview on 3/4/25 at 1:15 PM, the Minimum Data Set (MDS) Coordinator verified the information documented on the MDS Resident Assessment and Care Screening Nursing Home discharge date d 02/11/2025 was inaccurate. Page 1 of 6 105401 105401 03/06/2025 Ayers Health and Rehabilitation Center 606 NE 7th St Trenton, FL 32693

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 record review and interview, the facility failed to develop for implementation a comprehensive care plan to meet the needs for respiratory care services for 2 of 7 residents, Residents #50 and #33, reviewed for respiratory care services. Findings include: 1) During an observation on 3/3/25 at 9:40 AM there was a continuous positive airway pressure (CPAP) machine on Resident #50's bedside table, there was tubing and a mask attached. There were two 1-gallon bottles of sterile water observed on the floor next to Resident #50's bed. (Photographic evidence obtained). During an observation on 3/4/25 at 3:15 PM there was a CPAP machine on the bedside table in Resident #50's room. The face mask was attached to the tubing on the machine. (Photographic evidence obtained). During an interview on 3/4/25 at 3:40 PM, Resident #50 stated, I wear that [CPAP machine] every night. The staff do not help me with it. I believe they knew about it when I brought it in. Review of Resident #50's medical record documented the resident was admitted into the facility on [DATE] with medical diagnosis to include obstructive sleep apnea (a sleep disorder characterized by recurrent episodes of complete or partial blockage of the upper airway during sleep, leading to interrupted breathing), Type 2 diabetes mellitus with other specified complication; essential (primary) hypertension. Review of Resident #50's physician orders did not contain an order for the CPAP machine or respiratory therapy services. Review of Resident #50's MDS [Minimum Data Set] admission Evaluation, dated 2/7/25 read, Section I: Additional active ICD diagnosis 2: G47.33 Obstructive Sleep Apnea (Adult). Section O: C1. Oxygen Therapy - No. Review of Resident #50's care plan, dated 2/12/25, did not contain a focus pertaining to Resident #50's diagnosis of obstructive sleep apnea, and nightly use of a CPAP machine. 2) During an observation on 03/04/2025 at 12:28 PM of Resident #33 it showed she was sitting in bed eating lunch with oxygen being administered at 3 liters per minute via nasal cannula. Review of the physician order dated 12/17/2024 for Resident #33 read, Administer oxygen at 3 Liters per minute (humidified) via nasal cannula continuously. Review of Resident #33 care plan dated 02/19/2025 did not contain a focus pertaining to the resident's respiratory care need for continuous oxygen. During an interview conducted on 03/06/2025 at 10:05 AM the Director of Nursing (DON) stated, My expectations would be that residents with respiratory needs would have that included on their 105401 Page 2 of 6 105401 03/06/2025 Ayers Health and Rehabilitation Center 606 NE 7th St Trenton, FL 32693

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few comprehensive care plan. The DON reviewed Resident #50 and Resident #33's comprehensive care plans and verified the care plans did not contain a focus related to Resident #50 and Resident #33's respiratory needs. Review of the policy and procedure titled Comprehensive Care Plans, last reviewed on 2/19/25, read, Policy: It is the policy of this facility to develop and implement a comprehensive person-centered plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and ALL services that are identified in the resident's comprehensive assessment and meet professional standards of quality . Policy Explanation and Compliance Guidelines: . 3. The comprehensive care plan will describe, at minimum, the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. 105401 Page 3 of 6 105401 03/06/2025 Ayers Health and Rehabilitation Center 606 NE 7th St Trenton, FL 32693

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure oxygen was administered as ordered by the physician for 1 of 7 residents, Resident #89 Residents Affected - Few Findings include: Review of Resident #89's admission record dated 3/1/24 documented diagnoses that included other disorders of lung, gastrointestinal hemorrhage, unspecified systolic (congestive) heart failure unspecified atrial fibrillation, and dependence on supplemental oxygen. Review of Resident #89's physician orders dated 5/17/24 read, Observation: oxygen therapy observe for signs and symptoms of cyanosis, hypoxia, and oxygen toxicity: oxygen: administer oxygen at 2L/min. [2 liters per minute] During an observation on 03/03/25 at 10:56 AM Resident #89 was observed resting in bed with oxygen being administered at 4 liters per minute via nasal cannula. The oxygen concentrator was at the head of the bed on the resident's right side, outside of the reach of the resident. During an observation on 03/03/25 at 1:30 PM Resident #89 was observed resting in bed with oxygen being administered at 4 liters per minute. The oxygen concentrator was at the head of the bed on the resident's right side, outside of the reach of the resident. During an observation of Resident #89 on 3/4/25 at 10:15 AM with Staff B, Certified Nursing Assistant (CNA). Staff B verified the oxygen was being administered at 4 liters per minute. During an interview on 3/5/25 at 10:12 AM Resident #89 stated, I do not know how to change the levels [oxygen]. During an interview on 3/4/25 at 10:16 AM Staff C, Registered Nurse (RN) stated, That is not correct [the oxygen administration]. It should not be on 4 liters it is ordered for 2 liters. [Resident 89's name] does not change the levels. The oxygen level should be checked at the beginning of every shift, I just have not checked it yet. Review of Resident #89's medical record progress notes for the period of 2/19/25 through 3/5/25, did not provide for documentation for the need to increase the resident's oxygen or a change in the resident's respiratory status. Review of Resident #89's care plan dated 3/4/24 read, [Resident #89's name] receives oxygen therapy, oxygen settings : O2 [oxygen] at 2L via nasal cannula. Interventions: Administer oxygen as ordered. Review of the policy and procedure titled, Oxygen Administration with an implementation date of 12/2024 read, Policy: Oxygen is administered to residents who need it, consistent with professional standards of practice 1. Oxygen is administered under order of a physician, except in the case of an emergency. 105401 Page 4 of 6 105401 03/06/2025 Ayers Health and Rehabilitation Center 606 NE 7th St Trenton, FL 32693

F 0710 Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review the facility failed to enusre physician supervision of medical care for 1 of 7 residents, Resident #50, reviewed for respiratory care. Residents Affected - Few Findings include: During an observation on 3/3/25 at 9:40 AM there was a continuous positive airway pressure (CPAP) machine on Resident #50's bedside table, there was tubing and a mask attached. There were two 1-gallon bottles of sterile water observed on the floor next to Resident #50's bed. (Photographic evidence obtained). During an observation on 3/4/25 at 3:15 PM there was a CPAP machine on the bedside table in Resident #50's room. The face mask was attached to the tubing on the machine. (Photographic evidence obtained). During an interview on 3/4/25 at 3:40 PM, Resident #50 stated, I wear that [CPAP machine] every night. The staff do not help me with it. I believe they knew about it when I brought it in. Review of Resident #50's physician orders did not contain an order for the CPAP machine or respiratory therapy services. Review of Resident #50's medical record documented the resident was admitted into the facility on [DATE] with medical diagnosis to include obstructive sleep apnea (a sleep disorder characterized by recurrent episodes of complete or partial blockage of the upper airway during sleep, leading to interrupted breathing), Type 2 diabetes mellitus with other specified complication; essential (primary) hypertension. During an interview on 3/4/25 at 1:45 PM, Staff D, Registered Nurse (RN) stated, We don't currently have any residents on CPAP. I would confirm the order before putting it on. If a resident came in with a CPAP machine, we need to confirm the order with the physician. [Resident #50's name] is super independent. I don't see an order [for the CPAP machine]. During an interview on 3/4/25 at 1:48 PM, Staff E, Licensed Practical Nurse (LPN) - Unit Manager, stated, I don't remember being told she [Resident #50] had one [a CPAP machine]. She does not have an order [for a CPA machine]. She is diagnosed with sleep apnea. We will call the doctor to confirm he wants it and get an order. During an interview on 3/4/25 at 1:52 PM, the DON stated, For residents on CPAP, Respiratory follows them and we have orders. The nurse ensures they [residents] are wearing them or refusing. Review of Resident #50's MDS [Minimum Data Set] admission Evaluation, dated 2/7/25 read, Section I: Additional active ICD diagnosis 2: G47.33 Obstructive Sleep Apnea (Adult). Section O: C1. Oxygen Therapy - No. Review of the policy and procedure titled Oxygen Administration, implemented on 12/24, and last reviewed on 2/19/25, read Policy: Oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's 105401 Page 5 of 6 105401 03/06/2025 Ayers Health and Rehabilitation Center 606 NE 7th St Trenton, FL 32693

F 0710 Level of Harm - Minimal harm or potential for actual harm goals and preferences . Policy Explanation and Compliance Guidelines: 1. Oxygen is administered under orders of a physician . Types of delivery systems include: . d. CPAP Mask - This mask is part of a system that allows a resident to receive continuous positive airway pressure (CPAP), with or without an artificial airway. The system is comprised of a mask, tubing, and a machine that generates a constant flow of air pressure. Machines have different settings. Residents Affected - Few 105401 Page 6 of 6