Health inspection·June 19, 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 medications were administered by a licensed nurse and not stored on an over bed table for self-administration for one (#4) out of three sampled residents. Residents Affected - Few Findings Included: On 06/19/2023 at 10:00 a.m., the west unit was toured and revealed a souffle cup sitting on top of an over bed table. The cup was observed with multiple pills that ranged in different sizes and colors. Resident #4 was not in the bedroom at the time (photographic evidence obtained). At 10:11 a.m., Staff A, Assistant Director of Nursing (ADON) was in the hallway, and was asked who administered medications on the west unit. She stated, she's right there. The ADON went to the nursing station and returned shortly with Staff B, Registered Nurse. At 10:12 a.m., Staff B, along with the ADON observed the cup of medications on Resident #4's, over bed table. At that time, the ADON pushed the souffle cup next to the tissue box. Staff B stated, he can take his own medications. He went to take a shower first then to physical therapy. The ADON and RN were asked if the resident had a self-administration assessment. They left the bedroom and returned to the nursing station. The medications remained unsupervised on the over bed table. Staff B provided a copy of Resident #4 Self Administration of Medication Evaluation form with Effective Date: 01/10/2023. Review of the form Instructions: Complete this assessment prior to resident initiating self administration of medication and with any medication order changes, changes in function/condition that might affect the resident ability to safely self administer medications. A. List all medications that are being considered for resident self administration. List medication, route, dose and frequency. Number of medications considered for self administration Medication #1 order: albuterol inhaler, Medication #2 order: anoro elipata. At 10:28 a.m., the Director of Nursing (DON) was asked about their process on leaving medications at the bedside. He did not immediately respond. The DON observed the medications that remained on Resident #4's over bed table and removed the cup. The DON confirmed medications should not be left unattended. He was informed the ADON and Staff B had observed the cup of medications on the table and left the bedroom and the medications indicating it was common practice. The DON confirmed it was not a facility practice to leave medications unsupervised. (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: 105697 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 105697 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE East Bay Rehabilitation Center 4470 E Bay Dr Clearwater, FL 33764 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)