Inspection·July 13, 2023

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. 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 according to professional standards of practice for 2 residents, Resident #31 and Resident #3. Residents Affected - Few Findings include: During an observation on 7/10/2023 at 9:43 AM, Resident #31 was lying in her bed. There were 3 halves of medication tablets in a medication cup on the bedside table in front of Resident #31. During an observation on 7/10/2023 at 9:44 AM, Staff A, Licensed Practical Nurse (LPN), was standing outside of Resident #31's room, facing the room. Resident #31's room door was ajar. Staff A was intermittently glancing in the direction of Resident #31's room and at her computer screen. Resident #31's room door was not fully open and Staff A did not constantly maintain visual supervision of Resident #31. During an interview on 7/10/2023 at 9:44 AM, Staff A stated, I park right here and keep an eye on her. Review of Resident #31's medical records did not show the resident had been assessed as able to safely self-administer medications. During an observation on 7/10/2023 at 12:20 PM, Resident #3 was seated at a dining table in the main dining room. Staff A approached Resident #3 and put a medication cup that contained one large tablet in front of Resident #3. Staff A then turned her back to Resident #3 and walked away from Resident #3 towards the kitchen area. Review of Resident #3's medical records did not show the resident had been assessed as able to safely self-administer medications. During an interview on 7/12/2023 at 9:41 AM, the Director of Nursing stated she would expect the nurse to watch the resident take medications and not leave the medications at bedside. She added she would expect the nurse to keep their eyes on the resident at all times when administering medications to the resident. During an interview on 7/12/2023 at 12:27 PM, the Director of Nursing confirmed Resident #3 and Resident #31 had not been assessed for self-administration of medications. Review of the facility policy and procedures titled Medication Administration, last reviewed on (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 6 Event ID: 105963 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 105963 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lafayette Nursing and Rehabilitation Center 512 W Main St Mayo, FL 32066 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)