Health inspection·January 16, 2025

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure each resident received an accurate assessment reflective of the resident status for one resident (Resident #109) of four reviewed for discharge. Residents Affected - Few Findings include: Review of Resident #109's admission record documented the resident was admitted to the facility on [DATE] and discharged on 10/15/24. Diagnoses included pneumonia, sepsis, acute respiratory failure, chronic obstructive pulmonary disease, hypertension and atrial fibrillation. Review of the Minimum Data Set (MDS), Assessment Return Not Anticipated, Section A ,dated 10/21/24 documented Resident #109 was discharged to a hospital. Review of Resident #109's progress notes dated 10/21/24 read, Pt (patient) and family decided that they wanted pt transferred to [Name of Nursing Home] said that was the facility originally chosen for pt however they didn't have any available beds at time of discharge from hospital so, pt decided until a bed became available that she would come to this facility. Bed became available pt was transferred to [Name of Nursing Home] sent all documentation needed. [Name of Nursing Home] arranged transport. no DME (Durable Medical Equipment) or HH (home health) established due to transfer of facility. During an interview on 1/14/25 at 2:05 PM. the MDS Director confirmed the 10/15/24 assessment was inaccurate due to Resident #109 being transferred to a skilled nursing facility and not sent to the hospital. Page 1 of 5 105602 105602 01/16/2025 Hawthorne Center for Rehabilitation and Healing Of 4100 SW 33rd Ave Ocala, FL 34474

F 0656 Level of Harm - Minimal harm or potential for actual harm Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Based on observations, interviews, and record reviews, the facility failed to ensure a comprehensive care plan was developed for 4 (Resident #4, 49, 77, and 79) of 10 residents reviewed for oxygen therapy. Residents Affected - Few Findings include: 1) Review of Resident #79's admission record documented an admission date of 5/17/2024 with diagnosis that included heart failure, hypertensive heart disease, and COPD (chronic obstructive pulmonary disease). Review of Resident #79's physician order dated 9/1/2024 read, Oxygen @ 2 L/Min (at 2 liters per minute) via nasal cannula inhalation as needed as needed {sic} for COPD. Review of Resident #79's comprehensive care plan did not document focus for respiratory services. 2) Review of Resident #77's admission record documented an admission date of 11/15/2024 with diagnosis that included acute and chronic respiratory failure with hypercapnia and pneumonia. Review of Resident #77's physician order dated 1/14/2025 read, Oxygen tubing, cannula/mask change weekly and PRN (as needed) every night shift every Sat [Saturday] AND as needed. Review of Resident #77's physician order dated 1/14/2025 read, Oxygen @ 2L/Min via NC (at 2 liters per minute via nasal cannula) inhalation as needed as needed [sic]. Review of Resident #77's physician's order dated 12/5/2024 read, Oxygen tubing, cannula/mask change weekly and PRN Discontinued on 01/5/2025. Review of Resident #77's physician's order dated 12/5/2024 read, Oxygen @ 4L/Min via nasal cannula inhalation as needed as needed Discontinued on 1/5/2025. Review of Resident #77's comprehensive care plan did not reveal a focus for respiratory services. During an interview on 1/15/2025 at 12:07 PM, Staff E, MDS Coordinator, stated, [Resident #77's name] and [Resident #79's name] do have orders for oxygen. I do not see a focus of respiratory services [on the comprehensive care plan]. During an interview on 1/15/2025 at 2:03 PM, the Director of Nursing (DON) stated, Residents should have a focus [on the comprehensive care plan] of services they need. If they have oxygen orders they should have a respiratory focus. Review of the policy and procedure title Resident Assessment Instrument Comprehensive Care Plan Policy with a last review date of 12/19/2024 read, Policy Statement: Purpose: To ensure that each resident in the facility receives individualized and appropriate care based on a thorough assessment using the Resident Assessment Instrument (RAI) and to comply with state and federal regulations. Policy statement: The facility will utilize the RAI process to assess residents' needs, develop individualized care plans, and ensure the delivery of quality care. This process will involve interdisciplinary 105602 Page 2 of 5 105602 01/16/2025 Hawthorne Center for Rehabilitation and Healing Of 4100 SW 33rd Ave Ocala, FL 34474

F 0656 team members and be revised to reflect resident condition changes. Level of Harm - Minimal harm or potential for actual harm 3) During an observation on 1/13/2025 at 10:10 AM, Resident #4's oxygen concentrator was set at 3.5 L/Min (liters per minute). Photographic evidence obtained. Residents Affected - Few During an observation on 1/14/2025 at 2:50 PM, Resident #4's oxygen concentrator was set at 1.5 L/Min per nasal cannula. Photographic evidence obtained. During an observation on 1/16/2025 at 9:42 AM, Resident #4's oxygen concentrator was set at 1.5 L/Min and the resident was asleep in the bed. Review of Resident #4's physicians order for oxygen read, Oxygen @ 2_L/Min (2 liters per minute) via nasal cannula inhalation as needed every shift for SOB (shortness of breath). During an interview on 1/16/2025 at 9:45 AM, Staff A, Registered Nurse (RN), Supervisor, stated, It looks like the 02 [oxygen] is set at 1.75 L/Min. Sometimes the residents change their setting. When Staff A, RN was asked if it [resident self-adjusting oxygen setting] was addressed in the care plan, Staff A, RN did not respond. Review of Resident #4's comprehensive care plan did not document a focus for respiratory care services or the resident self-adjusting of the oxygen concentrator settings. 4) During an observation on 1/13/25 at 10:00 AM, Resident #49's oxygen concentrator was set at 3 L /min (liters per minute) per nasal cannula. Photographic evidence obtained. Review of Resident #49's physicians order dated 7/31/2024 read, Oxygen @ 2L/min per continuous inhalation via NC (nasal cannula) every shift. Review of Resident #49's comprehensive care plan did not include self-adjusting of the oxygen concentrator settings. During an interview on 1/16/2025 at 10:10 AM, Staff C, RN, [the nurse caring for Resident #4 and #49] stated that two of her residents [Resident #4 and #49] complains of breathing problems. I have identified that the settings are changed frequently, and I change the setting back to 2L/Min. They are [Resident #4 and #49] not care-planned to address changing the O2 settings. During an interview on 1/16/2025 at 10:43 AM the Director of Nursing (DON), stated, If a resident is manipulating their O2 (oxygen) setting, we would revise the behavioral and O2 care plan to include resident manipulation of setting for O2. I was not aware of [Resident #4's Name] or [Resident #49's Name] manipulating their O2 settings. During an interview on 1/16/2025 at 10:50 AM, Staff D, Minimum Data Set (MDS) Coordinator, License Practical Nurse (LPN) stated the MDS coordinator checks orders daily to revise care plans for O2 order revisions from the day before and on Monday, to check for order revisions from the weekend. I am not aware of [Resident #4's Name and Resident #49' Name] changing the O2 settings. 105602 Page 3 of 5 105602 01/16/2025 Hawthorne Center for Rehabilitation and Healing Of 4100 SW 33rd Ave Ocala, FL 34474

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 record reviews and interviews, the facility failed to accurately document notifications of medication parameters for 1 (Resident #39) of 6 residents reviewed for medication administration. Findings include: Review of Resident #39's physicians order dated 9/10/24 read, Insulin NPH (Neutral Protamine [NAME]) Isophane & Regular Subcutaneous Suspension (70-30) [70% Isophane and 30% regular or short acting insulin] 100 unit /ml (Insulin NPH Isophane & Reg (Human)) Inject 10 unit subcutaneously in the evening for DM [Diabetes Mellitus] Hold for BG <150 [Blood Glucose less than 150]. Review of Resident #39's Medication Administration Record (MAR) for the month of January 2025 documented Insulin NPH Isophane & Regular Subcutaneous Suspension Insulin was administer on 1/10/2025 at 2100 [9:00PM] when blood glucose level was 126 and on 1/14/2025 at 2100 for a blood glucose level of 123. Review of Resident #39's MAR for the month of December 2024 documented Insulin NPH Isophane & Regular Subcutaneous Suspension was administered on 12/15/2024 at 2100 for blood glucose of 145, on 12/17/2024 at 2100 for blood glucose of 143, on 12/18/2024 at 2100 for blood glucose of 133, 12/23/2024 at 2100 for blood glucose of 145, 12/24/2024 at 2100 for blood glucose of 144, 12/26/2024 at 2100 for blood glucose of 143, and on 12/30/2024 at 2100 for blood glucose of 145. Review of Resident #39's physicians order dated 12/9/2024 read, Midodrine HCI Oral Tablet 10 mg (milligrams) give 10 mg by mouth three times a day for hypotension hold if SBP >135 [systolic blood pressure is greater than 135]. Review of Resident #39's MAR for the month of January 2025 documented Midodrine was administered on 1/12/2025 at 0600 [6:00 AM] for a systolic blood pressure of 162. Review of Resident #39's MAR for the month of December 2024 documented Midodrine was administered on 12/14/2024 at 2200 for systolic blood pressure of 148, on 12/15/2024 at 0600 for systolic blood pressure of 148, on 12/18/2024 at 2200 for systolic blood pressure of 140 and on 12/19/2024 at 0600 for systolic blood pressure of 140. During an interview on 1/15/2025 at 12:31PM the attending provider stated, It is more of an issue with the nurses not documenting our conversations because the staff will contact me and act accordingly. They follow what I tell them but do not document our conversation. During an interview on 1/15/2025 at 2:00 PM, the Director of Nursing stated, Any conversation with a provider should be documented in the system. Review of the policy and procedure titled Documentation with a last review date of 12/19/2024 read, Purpose: The facility clinical staff will document the provision of care and services according to nursing standards and regulatory requirements. When completed, documentation will accurately reflect the clinical area and other services provided to the resident and ensure that the appropriate information is available to all interdisciplinary team members. 105602 Page 4 of 5 105602 01/16/2025 Hawthorne Center for Rehabilitation and Healing Of 4100 SW 33rd Ave Ocala, FL 34474

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews, and record reviews, the facility failed to follow infection control standards of practice during 1 of 5 medication administration observations and 2 (Resident #4 and #20) of 10 residents reviewed for oxygen therapy. Residents Affected - Few Findings include: 1). During a medication administration observation on 1/15/25 at 8:40 AM for Resident #39, Staff B, Registered Nurse (RN) removed the cap to a vial of Ceftriaxone sodium injection solution 1 gram and removed the cap to a vial of sterile water. Staff B, RN opened a sterile needle with syringe and inserted the needle into the vial of sterile water without wiping the rubber of the vial with an alcohol wipe. Staff B, RN withdrew 2.1 ml [milliliters] of sterile water and inserted the needle of the syringe with sterile water into the vial of Ceftriaxone sodium injection solution 1 gram without wiping the rubber top of the Ceftriaxone vial with an alcohol wipe. Staff B, RN left the needle in the vial of Ceftriaxone and shook the vial. Staff B, RN then attempted to withdraw the solution using the syringe still attached, but had difficulty removing the solution. Staff B, RN pushed the solution in the syringe back into the vial and removed the needle. Staff B, RN opened a new sterile needle with syringe and inserted it into the vial of Ceftriaxone without wiping the rubber stopper of the vial with an alcohol wipe. During an interview on 1/15/25 at 8:48 AM, Staff B, RN stated, I am old school and the vial top [rubber stopper] is clean when I remove the caps to the vials. During an interview on 1/15/25 at 10:53 AM, the Director of Nursing (DON) stated, When a vial cap is removed, the top of the cap should be wiped with an alcohol wipe before inserting a needle. Review of the National Library of Medicine website (https://www.mcbi.nlm.nih.gov) related to general safety practices for injections read, Procedure for septum vials. Wipe the access diaphragm (septum) with 70% alcohol (isopropyl alcohol or ethanol) on a swab or cotton-wool ball before piercing the vial, and allow to air dry before inserting a device into the bottle. 2) During an observation on 1/13/25 at 10:03 PM, Resident #4 room was observed to have a nebulizer mask on the bedside table and not bagged. During an observation on 01/13/25 10:08 AM, Resident #20 asleep in bed; nebulizer mask was on the bedside table and was not bagged. Photographic evidence obtained. During an interview on 1/13/25 at 12:30 PM, the DON stated, nebulizer mask should be placed in a bag and not on the bedside table. Review of the policy titled, Respiratory Therapy Equipment, last reviewed on 12/19/24, read Purpose: The purpose of this procedure is to provide guidelines to help prevent nosocomial infections associated with respiratory therapy equipment, including ventilators, and to prevent transmission of infections to resident and staff. Procedure. Oxygen Administration. 5. Keep oxygen cannula and tubing used PRN in a plastic bag when not in use. 105602 Page 5 of 5