Inspection·June 17, 2021

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 ensure that a resident was assessed to be safe and clinically appropriate to self-administer an Albuterol inhaler for 1 of 1 resident reviewed for self-admisnitration (#192). Residents Affected - Few Findings: Resident #192 was admitted to the facility on [DATE] from the hospital with diagnoses of Chronic Obstructive Pulmonary Disease (COPD) with Acute Exacerbation, Hypertension, and Shortness of Breath. Chronic Obstructive Pulmonary Disease with acute exacerbation is a long-term lung condition that makes it hard for you to breathe with flare ups of more trouble breathing. (retrieved on 6/17/21 from www.webmd.com). Review of the Admission/readmission Data Collection-CHC form, dated 6/10/21, revealed resident #192 was alert, oriented to person, place and time, made herself understood and had the ability to understand others. Review of physician orders showed a medication order, dated 6/10/21, for Albuterol Sulfate HFA Aerosol Solution 1 puff by oral inhalation every 4 hours as needed for shortness of breath. Albuterol Sulfate inhaler is a medication that prevents spasms or narrowing of the airways in the lungs for people with certain types of COPD and asthma. (retrieved on 6/17/21 from www.drugs.com). On 6/14/21 at 11:33 AM, an Albuterol Sulfate inhaler was observed on resident #192's bedside table. She stated she self-administered the inhaler and used 2 puffs every 4 hours when needed. This conflicted with the physician's ordered dosage of 1 puff every 4 hours. On 6/17/21 at 10:17 AM, resident #192 stated she used an Albuterol inhaler at home or when out shopping. She said, It is always in my hand or close by when it is needed. Observations on 6/15/21 at 11:15 AM and 2:00 PM, and 6/16/21 at 11:10 AM revealed the Albuterol inhaler remained on resident #192 bedside table, available for self-administration as needed. Resident #192's medical record did not reveal an Evaluation for Self-Administration of Medication or a physician's order for self-administration of Albuterol inhaler medication. On 6/16/21 at 11:11 AM, Licensed Practical Nurse (LPN) A, stated residents needed a physician's order to self-administer medications, an assessment to ensure they were capable of accurate self-administration of the medication, and an updated care plan. Upon review of resident #192's medical record with LPN A, she stated that the resident did not have an order to self-administer medication and a completed evaluation. She stated the evaluation was usually completed upon admission and nurses were responsible. Review of the baseline care plan did not reveal any interventions for (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 9 Event ID: 105325 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 105325 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/17/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Space Coast Healthcare and Rehabilitation Center 125 Alma Blvd Merritt Island, FL 32953 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)