Inspection·September 25, 2025

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 conduct medication self-administration assessment to ensure safety for 3 of 3 residents reviewed for self-administration of medications, of a total sample of 41 residents, (#8, #86 & #113).1.Resident #8 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included cerebral palsy, acute kidney failure, unspecified glaucoma, type 2 diabetes mellitus, blindness to the left eye and dysphagia. Residents Affected - Few A review of the Minimum Data Set (MDS) admission Five-day assessment with assessment reference date (ARD) of 6/19/25 revealed resident # 8 had a Brief Interview for Mental Status (BIMS) Score of 14 out of 15 which indicated she was cognitively intact. The MDS assessment revealed the resident had no behaviors, nor rejection of care and her vision was highly impaired. A review of resident #8's electronic medical record revealed no physician's order to self-administer medications, no care plan for self-administration of medications, nor an assessment completed to indicate it was safe for resident #8 to self-administer her medications. A review of the Medication Administration Audit report for 9/22/25 revealed documentation that Licensed Practical Nurse (LPN) A administered the Omega 3 Oral Capsule 1000 milligrams (mg) at 10:57 AM, along with all of resident #8's other morning medications between 10:56 AM and 10:59 AM. On 9/22/25 at 12:05 PM resident #8 was in her room with a friend standing at her bedside. There was a large, clear yellowish capsule in a medication cup with some applesauce in another medication cup on the resident's bedside table. The resident stated the medication was fish oil and that because this was such a large pill, she took a long time to swallow it. Resident #8 said she had asked the nurse to leave the pills because she understood the nurses were quite busy and did not want her to be held up. She explained her friend would assist her with the medications. The resident's friend said it was okay; she would help administer the pills. The friend continued to explain that resident #8 took the small pills with no problem, but the fish oil took a while to swallow, which was why it was still there on the bedside table. On 9/22/25 at 3:48 PM, LPN A explained for resident #8 that today was the only time she did that [left the medication at the bedside] because she was called away by the Unit Manager (UM). The nurse confirmed that even though she was called away, she should not have allowed resident #8's friend to help administer the medication. The UM for the 300 and 400 halls joined the interview and LPN A explained that because the UM called her away, she left the medication with the resident's friend. The UM confirmed the resident did not have a self-administration assessment completed nor was she care planned to allow her friend to assist with self-administration of medications. The UM continued to explain that the assigned nurse, LPN A, should have not allowed the resident's friend to administer (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 4 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 09/25/2025 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)