Health inspection·April 23, 2025

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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff and resident interviews, medical record review, and facility policy review, the facility failed to appropriately store resident's medication by leaving medication at bedside for one (Resident #4) of three residents sampled for unsecured medication. Resident #4 who had not been assessed for self-administration of medication was observed taking medications that had been left on his overbed table. These medications were also accessible to other residents who should not have access to them. The findings include: During an interview with Resident #4 on 04/23/2025 at 10:22 AM, the resident picked up a medicine cup from his overbed table containing multiple pills in it. When asked if the pills were his morning medications he stated, yes and then took them. A medical record review for Resident #4 indicated he was admitted to the facility on [DATE] and had a Brief Interview for Mental Status (BIMS) score of 13/15, indicating intact cognition. A review of medication to be given to Resident #4 at 9:00 AM included the following: Aspirin 81mg tab; Atorvastatin 20 mg tablet; Clopidogrel Bisulfate 75 mg tablet; Glipizide 25 mg tablet; Jardiance 25 mg tablet; Meloxicam 7.5 mg tablet; and Sodium Chloride tablet 1gm. A review of physician's orders for Resident #4 revealed no order for the resident to self-administer medications. On 04/23/2025 at 11:42 AM, a follow interview was conducted with Resident #4. The resident was asked how often medications were being left for him to take later. He stated, It happens sometimes but not very often. A review of the electronic chart for Resident #4 revealed no assessment for the resident to self-administer medications. A review of the care plan for Resident #4 revealed no care plan initiated for self-administering medications. On 04/23/2025 at 11:55 AM, the Director of Nursing (DON) was asked if medications should be left in residents' rooms. She stated that the nurse that left the medication at the bedside was immediately taken off the cart. The medication administration policy was reviewed with her and she will be Page 1 of 2 105930 105930 04/23/2025 Villa Healthcare & Rehabilitation Center 120 Chipola Ave Deland, FL 32720

F 0761 Level of Harm - Minimal harm or potential for actual harm required to pass a medication administration competency as well as being monitored while administering medications. The DON stated the entire nursing staff will be re-educated on the medication administration policy immediately and the unit manager will observe nursing during medication administration times. When asked about a policy for self-administration of medications or assessments of residents for self-administration, she stated they did not have an assessment and would look for the policy. Residents Affected - Few On 04/23/2025 at 12:32 PM, an interview was conducted with Employee D, Registered Nurse (RN). She stated she had worked at the facility for 2 years. When asked about leaving medication in Resident #4's room, she stated she was attempting to get therapy to assist her in replacing the resident's mattress. She got distracted and left the medication on his overbed table. She stated her normal procedure is to stay with the resident, assess for pain or changes and watch them take all of the medications before leaving the room. On 04/23/2025 at 12:50 PM, an interview was conducted with the Assistant Director of Nursing (ADON). When asked about residents' self-medicating, she stated they have a policy for this. When asked if they completed an assessment to ensure the resident is capable of self-medicating, she stated, No, we look at the BIMS score and we know the residents. A review of the facility's policy titled Self-Administration of Meds (revised 3/01/2021) read: Standard: It is the standard of this facility that residents who wish to self-administer their medications may do so, if it is determined that they are capable of doing so. Guidelines: 1. As part of the overall evaluation, the staff and practitioner will assess or evaluate each resident's mental and physical abilities to determine whether a resident is capable of self-administering medications. (Photographic evidence obtained) . 105930 Page 2 of 2