Inspection·February 8, 2023

F 0554 Allow residents to self-administer drugs if determined clinically appropriate. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure proper administration of medications for 1 resident assessed for self-administration of medications of a total sample of 33 residents (#84). Residents Affected - Few Findings Resident #84's medical record reflected an admission date of 3/20/22 and diagnoses including heart failure, cardiomyopathy, chronic obstructive pulmonary disease, rheumatoid arthritis, and anxiety. The resident's quarterly Minimum Data Set (MDS) assessment with Assessment Reference Date of 12/23/22 revealed the resident's cognition was intact with a Brief Interview for Mental Status (BIMS) score of 15/15. The assessment noted the resident required supervision with assistance of one person for toileting and bathing. On 2/07/23 at 9:08 AM, resident #84 sat on the side of her bed with her overbed table in front of her with medications spread out on the table. The resident stated her nurse left the medications there for her to take. The resident stated she had not taken any of the pills. There were nine pills on the table and one pill on the floor. The resident's nurse was not in the resident's room and was not seen outside the room in the hallway. On 2/07/23 at 9:09 AM, the Unit Manager observed the medications on the overbed table and verified the nurse was not in the room or hallway. She stated it is not the practice of the facility to leave medications unattended with residents unless the Interdisciplinary Team (IDT) completed an assessment to allow residents to administer their own medications. On 2/07/23 at 9:10 AM, Licensed Practical Nurse (LPN) A stated she was resident #84's nurse. Observation of the medications left on the resident's bedside table was conducted with the LPN. She confirmed that she left the medications with the resident. She said, the resident asked me check on her vitamin because it was a different color, so I went out to check and got called to another room. It is not my practice to leave the medications in the room with the residents. On 2/08/23 at 12:16 PM, the Director of Nursing stated her expectation was for the nurse to follow the five rights of medication administration. If the resident is not eligible to administer their own medications, which requires an assessment, then the nurse must remain with the resident until all the medications are taken. Review of resident #84's physician's orders and the Medication Administration Record (MAR) revealed the following medications were left at the bedside for the resident to take: Aspirin 81 milligrams (mg.) for peripheral vascular disease, Jardiance 10 mg. for diabetes, Vitamin D supplement, (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 5 Event ID: 105291 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 105291 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Life Care Center of Melbourne 606 E Sheridan Rd Melbourne, FL 32901 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)