Health inspection·June 9, 2022

F 0554 Allow residents to self-administer drugs if determined clinically appropriate. 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 monitor over the counter medications in a resident's room, as evidenced, an over-the-counter medication found on the side table of Resident # 110. There were 55 residents residing in the facility at the time of this survey. Residents Affected - Few the findings included: Observation on 06/06/22 at 2:15 PM revealed Resident #110 was not in the room; A sealed box labelled Natural Health Product High Performance Antioxidant , Norwegian Spruce Extract, Fountain of Life (an over the counter medication) was observed on the bed table. (Photographic evidence) Review of Resident #10's Face Sheet revealed the resident was admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Clinical diagnoses included but not limited to Unspecified sequelae of Cerebral Infarction; Hypothyroidism, Unspecified; Nutritional Deficiency, Unspecified. Review of the physician's order revealed no orders for the above medication/supplement and no orders for self-administration or to have medication in room. Record review of Care Plan revealed no care plan for self-administration of medications. Review of Resident #110's clinical records indicated a care plan for Cognitive Impaired/Dementia with start date 07/29/2021 and revised on 04/24/2022; documented that the resident upon admission to the facility on [DATE] was awake, alert, oriented times one (AAOX1) to name. Resident is severely impaired in cognition. She is severely impaired to make informed decisions for daily living and healthcare decisions. Resident rarely and or never is able to make self-understood. She sometimes is able to understand others but responds adequately to simple, direct communication only. Resident is at risk for further decline in cognition as disease process progress to deterioration. Diagnosis (DX): Acute Ischemic left middle cerebral artery (MCA) stroke. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] section C for Cognitive Pattern indicated a score of 99 meaning the resident was unable to complete the interview. The Quarterly MDS Section C dated 04/30/2022 revealed the resident cognitive skills for daily decision making was severely impaired. Review of Section G -Functional status dated 04/30/2022 revealed the resident needed limited assistance with one-person physical assistance for bed mobility. the resident needed total dependence with two persons physical assistance for transfer, toilet use and locomotion. The resident needed extensive assistance with one person physical assistance for locomotion, dressing and personal hygiene. The resident is independent with set up only for eating. Page 1 of 2 105252 105252 06/09/2022 Jackson Memorial Perdue Medical Center 19590 Old Cutler Road Cutler Bay, FL 33157

F 0554 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 06/09/22 at 11:34 AM, during an interview Registered Nurse (RN) Staff A, stated the resident is alert and oriented times 3 but she is not verbal. She uses a board to communicate with the nurse. Resident has speech therapy. Resident has over the counter medication and following doctor's orders. Staff A revealed there was no order for the medication observed in the resident's room. On 06/09/22 at 11:40 AM, the Unit Manager (Staff B) reported that the family brought the medication over the weekend, and on Monday staff informed her of the medication on top of the side table and she picked the medication up, stored it in her office and she called the family to take the medication back because medications had to be ordered by a doctor. Further inspection at the time of this interview revealed the medication was sealed and identified with the resident's name.(Photographic evidence) 105252 Page 2 of 2