Ayers Nursing Home

In the surveyor’s words

From the most serious findings on record at Ayers Nursing Home, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF851Sep 19, 2024

  Based on record review and interview, the facility failed to submit payroll based staffing information to CMS as required for the 3rd quarter of 2024. The administrator identified 69 residents resided in the facility. Findings: A PBJ Staffing Data Report - FY Quarter 3 2024, documented there was no data submitted for the third quarter. On 09/17/24 at 11:51 a.m., the BOM stated the staffing report for the 3rd quarter of 2024 had not been submitted to CMS as required.

• No harm, potential for more than minimal, patternF600Jul 30, 2026

  Based on record review and interview, the facility failed to protect a resident from verbal abuse for 1 (#1) of 3 sampled residents reviewed for staff abuse. The DON identified 72 residents resided in the facility.Findings: A policy titled Resident Abuse and Neglect Policy and Procedure, dated 02/24/20, read in part, ensure all residents are free from mistreatment, neglect, abuse .reporting, recognizing, and free from reprisal .recognize burnout, frustration or stress related issues .how and whom they may report concerns to, such as incidents and grievances without fear of retribution .no staff member is exempt from being reported. A final incident report, dated 07/20/26, showed an abuse allegation against LPN #1. […]

• No harm, potential for more than minimal, patternF644Sep 19, 2024

  Based on record review and interview, the facility failed to ensure diagnosis of a serious mental illness was reported to the OHCA for a level II PASRR evaluation for two (#3 and #48) of three sampled residents reviewed for PASRR. The DON identified 69 residents resided in the facility. Findings: An undated facility PASRR policy, read in part, Upon the receipt of a referral the designated staff will review the diagnosis and medication of the possible admission .If it is determined the referral requires a Level II PASRR due to a diagnosis and/or use of anti-psych meds, a Level II PASRR is initiated and transmitted to OHCA to determine approval for admission to LTC . 1. […]

• No harm, potential for more than minimal, patternF698Sep 19, 2024

  Based on observation, record review, and interview, the facility failed to provide assessment and monitoring before and after dialysis treatments, and maintain ongoing communication with the dialysis center for one (#13) of one sampled resident reviewed for dialysis. The DON identified one resident who received dialysis treatments. A Policy for Care of Dialysis Residents in LTC Setting, dated September 2024, read in part, Purpose: To set a policy that will establish guidelines for best practices for End Stage Renal Disease and (ESRD)-Specific Resident care for dialysis residents. Our goal is to efficiently and effectively increase the quality of care of life for ESRD residents. […]

• No harm, potential for more than minimal, patternF759Sep 19, 2024

  Based on observation, record review, and interview, the facility failed to ensure a medication rate of less than 5%. A total of 31 opportunities were observed during the medication pass with two errors identified. The total medication error rate was 6.45% related to two medications crushed without physician orders to crush the medications for two (#23 and #62) of nine sampled residents reviewed for medications. The administrator identified 69 residents resided in the facility. Findings: An undated document titled Drugs that should not be chewed or crushed, read in part, .Potassium Chloride .Enteric coated tablet designed to pass through the stomach whole and then dissolve in the intestines .Reasons for this type of formulation include: 1a. […]