Health inspection·May 15, 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 a medication self-administration assessment to ensure safety for 1 of 1 resident reviewed for self-administration of medications, of a total sample of 38 residents, (#38). Residents Affected - Few Findings: Resident #38 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included chronic respiratory failure, unspecified dementia, functional quadriplegia (partial paralysis), anxiety disorder, constipation, and depression. Review of the Minimum Data Set annual assessment with assessment reference date of 3/06/25 revealed resident #38 had a Brief Interview for Mental Status Score of 15 out of 15 which indicated she was cognitively intact. On 5/12/25 at 11:31 AM, resident #38 was in bed, awake, alert, and oriented. On her bedside table there was a medicine cup with a liquid inside and the resident explained it was medication for constipation. Resident# 38 said the nurse had left it along with a liquid supplement in another cup because she wanted to take it later. The East Wing Unit Manager (UM) arrived to the room at approximately 11:37 AM, and shook her head. She explained to resident #38 that medications were not allowed to be left at the bedside for self-administration by residents. The resident said that she was not aware the nurse was not supposed to leave medications to be taken later. On 5/12/25 at 11:44 AM, assigned Registered Nurse (RN) C acknowledged she had left the supplement and the liquid medication at resident #38's bedside and had forgotten to check back to see if the resident took them. RN C explained the resident wanted the medication to be left at the bedside, and confirmed she left them for her to take later. RN C said she should not have left the medication at the bedside, and was unable to say if resident #38 had an order for self-administration of medication. Review of resident #38's medical record indicated physician orders for Lactulose Solution 10 grams (GM)/15 milliliter (ml). The order detailed 30 ml by mouth was to be given once a day for constipation and the medication was to be held for loose stools. A review of the medication audit report for May 2025 showed Lactulose was scheduled for 9:00 AM, and documented as administered at 9:57 AM by RN C. However, at 11:31 AM, the medication was still at resident #38's bedside. Review of the medical record revealed no care plan for self-administration of medication. Further review revealed there were no assessments for self-administration of medications documented for Page 1 of 2 106024 106024 05/15/2025 Solaris Healthcare College Park 730 Courtland Street Orlando, FL 32804

F 0554 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few resident #38, nor a physician's order for self-administration of medications. A care plan initiated on 5/22/24 revealed resident #38 was at risk for coughing or choking during meals or while swallowing a medication. On 5/13/25 at 9:57 AM, the Director of Nursing (DON) acknowledged the medications left at resident #38's bedside and stated the facility recently had completed education on self administration of medication. She said assigned RN C had signed the education in-service but conveyed nurses needed re-education on the topic. On 5/14/25 at 12:53 PM, the DON stated the expectation was that medications should not have been left at the resident's bedside. Review of the facility policy on Medication Administration Guidelines revised January 2018, section B 14, revealed, Residents can self-administer medications when specifically authorized by the attending physician and in accordance with procedures for self-administration of medications. 106024 Page 2 of 2