Inspection·September 25, 2024

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 resident reviewed for self-administration of medications, of a total sample of 39 residents, (#57). Residents Affected - Few Findings: Resident #57 was admitted to the facility on [DATE] with diagnoses including pneumonitis due to inhalants of food and vomit, adult failure to thrive, hypertensive heart disease, anemia, CVA with Left-sided hemiparesis. Review of the Minimum Data Set admission assessment with an assessment reference of 8/30/24 revealed resident #57 had a Brief Interview for Mental Status score of 2 out of 15, which indicated she was severely cognitively impaired. On 9/23/24 at 11:59 AM, resident #57 was observed lying on her back in bed watching television. Her nightstand had a square basket with personal items, including a bottle of 15 millimeter (ml) Visine eye drops and B& C Ointment wound dressing with a 60-gram tube observed at the bedside. The resident, unable to communicate verbally pointed to a paper with a phone number for her daughter. Resident #57's daughter was then interviewed by telephone. She said she brought the eye drops to the facility and placed the bottle in the basket on her mother's nightstand. The daughter also stated she put the drops into her mother's eyes each time she visited because the drops made her eyes feel better. She stated her mother used eye drops previously when she was at home. On 9/23/24 at 2:01 PM, the resident's nightstand was observed by assigned Registered Nurse (RN) A. She acknowledged the Visine eye drops 15 ml and B& C Ointment wound dressing 60 grams tube. A few minutes later she reviewed the resident's physician orders and acknowledged there were no orders for the Visine eye drops and B & C ointment found on the resident's nightstand. RN A explained before a resident could self-administer medication, they must have a self-administration evaluation completed and a physician order initiated. RN A confirmed there was no order for the Visine eye drops or the B & C ointment. She also confirmed the resident had not had a self-administration evaluation to determine if she was able to self administer the medications. On 9/25/24 at 9:36 AM, the Director of Nursing stated the self-administration assessment should be done by the Interdisciplinary Team (IDT) to ensure the resident could safely self-administer medications. She acknowledged resident #57 would not be safe to self-administer based on her severe cognitive impairment. (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: 105904 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 105904 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Atlantic Shores Nursing and Rehab Center 4251 Stack Blvd Melbourne, FL 32901 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)