Inspection·February 20, 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 1 of 1 residents reviewed for self-administration of medications, of a total sample of 28 residents, (#42). Residents Affected - Few Findings: Resident #42 was admitted to the facility on [DATE] with diagnoses which included encounter for surgical aftercare following surgery on the digestive system, Parkinson's Disease, anemia, major depressive disorder, generalized anxiety disorder, presence of left artificial hip joint and dementia. Review of the Minimum Data Set annual assessment with assessment reference date of 12/11/24 revealed resident # 42 had a Brief Interview for Mental Status score of 15 out of 15 which indicated she was cognitively intact. On 2/17/25 at 12:58 PM, resident #42 was observed in her wheelchair watching television with her bedside tray table directly in front of her. Towards the right side of the tray table a small red pill was observed on a white tissue that had times written on it. When asked about the times written on the tissue, she explained that it was written down so that she could be reminded of when to take her eye vitamin. Resident #42 mentioned her daughter bought the vitamins for her because the eye doctor told her it was okay to take them and that they were very expensive. She stated the nurses knew she had been taking the medication on her own twice daily. A review of resident #42's medical record indicated no physician orders for eye vitamins or self administration of medication, no care plan for self-administration of medication and no assessments completed for resident #42 regarding self-administration of medications. On 2/17/25 at 2:07 PM, the assigned nurse Registered Nurse (RN) A observed and verified the red pill on a piece of tissue on resident #42's tray table in her room. With the resident's permission, RN A then retrieved the bottle of pills from an uncovered white plastic container on the resident's tray table and confirmed the pill bottle was labeled PreserVision AREDS 2. Resident #42 explained she had been taking it a long time and it was very expensive. RN A told the resident she was not allowed to have the medication at the bedside and assured her that the facility had medications in stock which could be provided. On 2/18/25 at approximately 10:00 AM, resident #42 stated she was not aware she could not take her own medication. She explained she did not know of any assessments which should be completed by nurses prior to her self-administering medication. She said that the nurse took the medication from her, (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 3 Event ID: 105720 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 105720 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/20/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mayflower Healthcare Center 1850 Mayflower Court Winter Park, FL 32792 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)