Inspection·May 6, 2021

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, resident and staff interview, and record review, the facility failed to have documentation of an evaluation for self-administration of medications and a physician's order to keep medications at bedside for 1 (Resident #68) of 6 residents reviewed for medication administration. Residents Affected - Few The findings included: Review of facility policy and procedure for Medication Administration Self-Administration by Resident, dated 11/17 stated, Residents who desire to self-administer medications are permitted to do so with a prescriber's order and if the nursing care center's interdisciplinary team has determined that the practice would be safe and the medications are appropriate and safe for self-administration (3) The results of the interdisciplinary team assessment are recorded on the Medication Self-Administration Assessment, which is placed in the resident's medical record. (4) If the resident demonstrates the ability to safely self-administer medications, a further assessment of bedside medication storage is conducted. (Refer to Section 4.3-Bedside Medication Storage). The Policy and Procedure for Medication Storage Bedside Medication Storage dated 10/07 states Bedside medication storage is permitted for residents who are able to self-administer medications, upon the written order of the prescriber and when it is deemed appropriate in the judgement of the nursing care center's interdisciplinary resident assessment team. (2) A written order for the bedside storage of medication is present in the resident's medical record. (3) Bedside storage of medications is indicated on the resident medication administration record (MAR) for the appropriate medications. On 5/5/21 at 9:40 a.m., during observation of medication administration for Resident #68, Licensed Practical Nurse (LPN) Staff B, stated Resident #68 administered his own inhalers, which he kept at bedside in his locked drawer. On 5/5/21 at 1:40 p.m., in an interview, Resident #68 stated he knew when to take his inhalers and he kept them at bedside. Resident #68 stated the nurses asked him if he had taken them and reminded him to rinse his mouth. On 5/6/21 at 9:00 a.m., in an interview, the Director of Nursing (DON) said he could not find the self-administration assessment in Resident #68's records. DON stated, We can't get into our old system to retract his assessment for self-administration. On 5/6/21, record review of Resident #68's electronic Medical Records (eMAR) showed the orders for Combivent and Symbicort inhalers, but it did not specify they could be kept at bedside. (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: 105363 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 105363 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/06/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Charlotte Bay Rehab and Care Center 4033 Beaver Lane Port Charlotte, FL 33952 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)