Ayers Health and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Ayers Health and Rehabilitation Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Aug 13, 2025

  Based on interview and record review, the facility failed to ensure residents were free from accidents and hazards by failing to ensure wound cleanser containing chemicals were secure when not in use for 1 (Resident #1) of 5 residents with wound care needs.On August 3 and 4, 2025, [Brand Name] Wound Care Cleanser was observed unattended in Resident #1's room at different times by three staff members. The wound cleanser was not removed. Resident #1 consumed the wound cleanser, complained of burning to his mouth and stomach resulting in Resident #1 being transferred to a higher level of care.The facility failed to ensure residents were free from accidents and hazards by failing to ensure wound cleanser containing chemicals were secure when not in use led to the determination of Immediate… […]

• No harm, potential for more than minimal, patternF880May 12, 2022

  Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program to help prevent the possible development and transmission of communicable diseases and infections during direct contact with the residents for medication administration for 2 of 3 nurses observed 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. […]

• No harm, potential for more than minimal, isolatedF641Jul 10, 2026

  Based on observation, interview, and record review the facility failed to provide an accurate assessment for 3 (Resident #22, #44, and #109) of 7 residents reviewed for respiratory services.Findings include:1)Review of Resident #22's physician ordered dated 4/12/2026 read, Oxygen: Administer Oxygen @ (at) _3_L [liters] via nasal cannula, face mask, CONTINUOUS.Review of Resident #22's Minimum Data Set (MDS) titled Quarterly dated 6/13/2026 Section O Special Treatments, Procedures, and Programs did not document the use of oxygen.Review of Resident #22's Weights and Vitals Summary documented on 6/13/2026 at 01:05 oxygen saturation was 93 % (Oxygen Via Nasal Cannula), 6/12/2026 at 19:39 oxygen saturation was 93% (Oxygen via Nasal Cannula) through 6/7/2026 at 02:30 oxygen saturation was 98%… […]

• No harm, potential for more than minimal, isolatedF644Jul 10, 2026

  Based on interview and record review the facility failed to update the State of Florida Agency of Health Care Administration Preadmission Screening and Resident Review (PASRR) for 1 (Resident #22) of 4 residents reviewed for behavioral services. Findings include:Review of Resident #22's admission Record resident was first admitted on [DATE] and has diagnosis including but not limited to Major Depressive Disorder [onset date 5/20/2026].Review of Resident #22's State of Florida Agency for Health Care Administration Preadmission Screening and Resident Review (PASRR) dated 8/28/2025 did not documented any mental or suspect mental illness.Review of Resident #22 Balance Wellbeing Psychology Evaluation Note dated 5/6/2026 read, Chief Complaint. Depression. History of Presenting Illness. […]

• No harm, potential for more than minimal, isolatedF656Jul 10, 2026

  Based on interview and record review the facility failed to develop and implement a comprehensive care plan for 1 (Resident #22) of 4 residents reviewed for behavioral services. Findings include:Review of Resident #22's admission Record resident was first admitted on [DATE] and has diagnoses including but not limited to Major Depressive Disorder [onset date 5/20/2026].Review of Resident #22's Balance Wellbeing Psychology Evaluation Note dated 5/6/2026 read, Chief Complaint. Depression. History of Presenting Illness. The patient presents today for evaluation of major depressive disorder, recurrent, moderate. […]