Health inspection·April 7, 2022

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents received necessary respiratory care and services in accordance with professional standards of practice for 5 or 9 residents reviewed for respiratory care, Residents #36, #281, #12, #282 and #55. (Photographic evidence obtained) Residents Affected - Some Findings: An observation on 4/5/22 at 07:54 AM of Resident #36 showed the resident's oxygen nasal cannula are lying on the bed and extra tubing lying on the floor with no date on the tubing to verify when it was changed. An observation on 4/5/2022 at 2:55 PM of Resident #36 showed the resident's oxygen tubing and nasal cannula are lying on the floor. There is no date on the oxygen tubing to verify when the oxygen tubing was changed. An observation on 4/6/2022 at 8:40 AM of Resident #36 showed the resident's oxygen tubing and nasal canula are lying on the floor and there is no date on the oxygen tubing to verify when the oxygen tubing was changed. Review of Resident #36's physician orders dated 2/2/2022 read, Oxygen @ 2Liters minute via nasal cannula inhalation as needed. Oxygen tubing, cannula/mask change weekly and PRN [as needed] every night shift every Thursday. An interview was conducted on 4/6/2022 at 8:38 AM with Staff C, License Practical Nurse (LPN) Unit Manager. The LPN Unit Manager stated there is no Respiratory Therapist in the facility and the nurses handled any treatments related to oxygen, or respiratory therapy. She stated that every Thursday night the nurses on night shift are to change all the oxygen tubing and sterile water. Dates are placed on the supplies when they are put out for use; per facility protocol. The staff should have dated the tubing when they put the supplies out. Staff C, LPN, Unit Manager confirmed the tubing was not dated and should not be lying on the floor. An interview conducted on 4/6/2022 at 10:05 AM with the Director of Nursing (DON), the DON stated her expectations are that the tubing is changed and dated. An observation of Resident #281 on 4/4/2022 at 11:42 AM showed the resident's oxygen tubing lying on the bed and the nebulizer mask hanging on the nebulizer machine. There is no date documented on the tubing for the oxygen or the nebulizer mask and tubing to verify when it was changed. (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: 105602 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 105602 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/07/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hawthorne Center for Rehabilitation and Healing Of 4100 SW 33rd Ave Ocala, FL 34474 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)