Inspection·September 2, 2021

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, staff interview, clinical record review and facility policy and procedure review, the facility failed to safely secure medications by leaving them unattended at bedside for 1 (Resident #266) of 1 resident observed. The findings included: Review of facility policy titled, Storage and Expiration Dating of Medications, Biologicals, Syringes, and Needles revised 10/28/2019 which stated, Facility should ensure that all medications and biologicals, including treatment items, are securely stored in a locked cabinet/cart or locked medication room that is inaccessible by residents and visitors. On 8/30/21 at 11:16 a.m., Resident #266 was observed in her room and lying in bed. Observed in her room at this time were two boxes of medication, respiratory inhalers, on the resident's bedside table. Medications at bedside were Wixela 250/50(generic form of Advair), a respiratory inhalation medication used to treat asthma, opened on 8/24/21. Dose one puff inhaled orally two times a day. The second medication at the bedside was Incruse 62.5 micrograms (mcg), a respiratory inhalation medication used to treat chronic obstructive pulmonary disease (COPD), opened on 8/26/21. Dose one inhalation one time a day for COPD. Resident interviewed said she did not know where they came from and was not on any inhalers and not aware of what medications she was taking. On 8/30/21 at 11:19 a.m., interviewed Unit manager Licensed Practical Nurse (LPN) Staff B. She confirmed Resident #266 did not have an order or assessment for self-administering medications. Unit Manager LPN Staff B confirmed there was no reason for medication to be there at the bedside and confirmed resident was confused. Unit Manager LPN Staff B went into resident's room and confirmed two boxes of medication inhalers were on the bedside table next to the resident's bed. Unit Manager LPN Staff B removed the medications. On 8/30/21 at 11:24 a.m., interviewed LPN Staff A who said she gave resident #266 her medications that morning around 8:30 a.m. LPN Staff A confirmed she documented on Medication Administration Record (MAR) the exact time she administered medication was at 8:33 a.m. LPN Staff A said she did not realize she left the inhalers at the resident's bedside. LPN Staff A said the resident was very confused. Clinical record review for Resident #266 included a diagnosis of dementia, and Resident #266's Brief Interview for Mental Status (BIMS) score of 10 on the Minimum Data Set (MDS) admission assessment indicated moderate cognitive impairment increasing risk of self-medicating incorrectly. (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 2 Event ID: 105289 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 105289 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/02/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Life Care Center of Punta Gorda 450 Shreve Street Punta Gorda, FL 33950 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)