Health inspection·February 16, 2023

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Based on record review, staff interview, and policy review the facility failed to develop a comprehensive care plan regarding anticoagulant use for 1 of 2 sampled residents reviewed who received anticoagulant medications. (Resident #28) The findings include: Review of resident #28's medical record revealed the resident had been receiving Pradaxa (an anticoagulant medication) 75 Milligrams (mg) by mouth twice daily since 1/3/23. The 5 day minimum data set with an assessment reference date of 1/10/23 indicated the resident received an anticoagulant medication 7 out of 7 days. The record revealed no care plan regarding the use of the anticoagulant medication. An interview was conducted with employee A, Minimum Data Set Registered Nurse, on 2/15/23 at approximately 11:30 AM. She stated the resident should have a care plan for risk of bleeding due to anticoagulant use and confirmed she did not have a care plan regarding the use of the anticoagulant and risk for bleeding. Review of the facility policy Care Plans (effective 2020) revealed a comprehensive care plan will be developed for each resident using the results of the comprehensive assessment. A comprehensive interdisplinary plan of care, based on the comprehensive assessment of the needs of the individual resident, will be developed and implemented within 7 days after the completion of the comprehensive assessment. Each resident's care plan shall include measurable objectives and timetables to meet all residents' needs identified in the comprehensive assessment. Page 1 of 3 105282 105282 02/16/2023 Eden Springs Nursing and Rehab Center 4679 Crawfordville Hwy Crawfordville, FL 32326

F 0842 Level of Harm - Minimal harm or potential for actual harm Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Based on record review, family interview, staff interview, and policy review, the facility failed to maintain accurate medical records for 1 of 1 resident's sampled for advanced directives. (Resident #90) Residents Affected - Few The findings include: Review of resident #90's medical record revealed a printed physician order dated 2/1/23 through 2/28/23 and signed by the physician on 2/1/23 indicating the resident was full code status (would require cardiopulmonary resuscitation in the event of cardiac arrest). Review of the legal tab in the resident record revealed a state of Florida Do Not Resuscitate (DNR) Order signed by a physician on 6/20/22. A telephone interview was conducted with the resident's son on 2/14/23 at 2:01 PM. He stated it was his intent that resident #90 was not to be resuscitated in the event of cardiac arrest. An interview was conducted with the Director of Nursing (DON) on 2/14/23 at 2:36 PM. She confirmed the resident had a signed DNR and the printed orders stated full code status. She stated the current MD order should have matched the DNR. Further interview was conducted with the DON on 2/14/23 at 3:34 PM. The DON stated the full code order should have been caught by nursing when they review the orders each month. She stated when the resident was admitted the DNR was not signed so the pharmacy orders defaulted to full code. Review of the facility policy Medical Records (effective 2015) revealed the facility shall maintain accurate medical records to document all physician orders, diagnostic reports, consultants' reports and care/services provided to the resident. 105282 Page 2 of 3 105282 02/16/2023 Eden Springs Nursing and Rehab Center 4679 Crawfordville Hwy Crawfordville, FL 32326

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, staff interview, and policy review the facility failed to ensure staff effectively disinfect shared blood glucose meters and storage containers during 2 of 2 random observations of blood glucose sampling for resident #55 and #67. Residents Affected - Few The findings include: An observation of blood glucose sampling for resident #55 was conducted with employee B, Licensed Practical Nurse (LPN), on 2/14/23 at 4:23 PM. Employee B obtained the blood glucose meter, a pink basket, alcohol pad, and sampling strips from the medication cart and placed all supplies in the pink basket. She then placed the basket with the supplies on the over bed table in the resident's room with no barrier on the table. Employee B then obtained blood from the resident and placed the sample on the blood glucose meter. She read the result and disposed of the sampling strip, then placed the blood glucose meter on top of the over bed table with no barrier on the table. Employee B then placed the blood glucose meter in the pink basket and then took the basket to the medication cart. She placed the pink basket with the blood glucose meter on top of the medication cart with no barrier. Employee B then cleansed the blood glucose meter with a bleach wipe, allowed it to air dry, and then placed it back in the pink basket. She did not clean the pink basket. She then placed the blood glucose meter in the basket back in the medication cart. An observation of blood glucose sampling for resident #67 was conducted with employee B (licensed practical nurse) 2/14/23 at 4:40 PM. Employee B obtained the same pink basket from the medication cart and placed the blood glucose machine in the basket. She took the basket to the resident's room and placed it on the over bed table with no barrier on the table. Employee B then obtained blood from the resident, placed the sample on the blood glucose meter, and then read the result. She then placed the basket with the blood sampling meter on top of the medication cart with no barrier. Employee B then cleansed the blood glucose meter with a bleach wipe, allowed it to air dry, and then placed it back in the pink basket. She did not clean the pink basket. She then placed the blood glucose meter in the basket back in the medication cart. An interview was conducted with employee B, LPN, on 2/16/23 at approximately 4:47 PM. She stated she had received training regarding cleansing the blood glucose meter with bleach wipes when she was hired. She stated she only cleans the blood glucose machine and confirmed she should have cleaned the basket as well. Review of the undated facility policy Steps for Blood Glucose Monitoring revealed collect supplies and place glucose meter on barrier, collect other supplies to include test strip, lancet, alcohol pads, and place in a plastic cup. Do not take test strip bottle into room. Place barrier on top of med cart for dirty glucose meter when it comes out of room, take glucose meter and supplies into resident room, set cup with supplies down and set glucose meter on a barrier. Perform blood glucose check. Appropriately discard all supplies (including any unused supplies), place lancet and test strip back into plastic cup to discard into sharps container upon exiting room. Use barrier to take glucose meter out of room and place it on clean barrier on cart. Discard lancet and test strip by dumping them from plastic cup directly into sharps container. Discard cup into trash can. Put on gloves to disinfect glucose meter. Ensure glucose meter is saturated on all sides with disinfectant. Place glucose meter on clean barrier and allow to dry per manufacturer's instructions. 105282 Page 3 of 3