Health inspection·January 20, 2023

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. 2. On 1/17/23 at 10:45 a.m., during a tour of the facility, observation of one bottle of Refresh Relieva Ophthalmic Solution 0.5-0.9% eye drops sitting on Resident #21's bedside table. The medication did not have a pharmacy label with the resident's name, the name of the medication with directions for use, and/or any other pertinent information. On 1/17/23 at 10:46 a.m., Resident #21 said, she was admitted to the facility in September 2021. She said she uses the Refresh eye drop to moisturize her left eye. She is unable to put the eye drops in her eyes so when she needs the eye drops, she would call the nurse and they would put the eye drops into her eyes. She said the Refresh eye drops are kept in her room on her over the bed table even when she is not in her room. She said she did not remember the nursing staff explaining to her the directions for the use of the eye medication and how to safely keep the medication in her room. On 1/17/23 at 3:15 p.m., a bottle of Refresh Relieva Ophthalmic Solution 0.5-0.9% eye drops was observed sitting on Resident #21's bedside table. Resident #21 was not in her room during the observation. On 1/17/23 at 3:30 p.m., Registered Nurse (RN), Staff E said Resident #21 was out of the facility for an appointment. She confirmed a bottle of Refresh Relieva Ophthalmic Solution 0.5-0.9% eye drops was sitting on Resident #21's bedside table, and the medication did not have a pharmacy label with the resident's name, the name of the medication with directions for use, and/or any other pertinent information. Staff E said residents were allowed to self-administer and keep the medication in their room after a self-administration assessment was completed and the interdisciplinary team (IDT) determined it was safe for the resident to administer the medication. Then it would be safe for the resident to keep the medication in their room. Staff E said she had seen the Refresh eye drops on Resident #21's bedside table for the past couple of months but did not know how long she's had them. On 1/19/23 at 10:53 a.m., the DON confirmed Resident #21's Refresh eye drops were kept on Resident #21's bedside table, not in a secure area, and the medications did not have a pharmacy label with the resident's name, the name of the medication with directions for use, and/or any other pertinent information. 3. On 1/17/23 at 12:40 p.m., an unlabeled box of individual use Retaine eye drops was observed stored on Resident #19's bedside table. Resident #19 was in a recliner, watching television. (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: 105472 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 105472 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Village on the Isle 910 Tamiami Trail South Venice, FL 34285 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)