Health inspection·September 5, 2023

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on record review, interviews, and policy review, the facility failed to ensure an accurate disposition of controlled drugs to enable an accurate reconciliation for 2 of 3 residents sampled. (Resident #1 and Resident #2) The findings include: A review of Resident #1's medical record was conducted. Records revealed the controlled medication Pregabantin 25 mg was pulled out from the resident's card at 9:00 PM on 8/26/23 and 9/2/23. A physician order dated 8/16/23 ordered Pregabalin capsule 25 mg one time a day for nerve pain. The Medication Administration Record (MAR) for August and September revealed Pregabalin 25 mg was documented as given at 9:00 AM daily. The controlled medication sheet was reviewed and compared with the inventory; this review confirmed that an extra dose of medications were pulled out on 8/26/23 and 9/2/23 at 9:00 PM. Further review revealed there was no documentation of medications being wasted. A review of Resident #2's medical record was conducted. Review of physician's orders revealed Lorazepan 1 mg, a controlled medication, ordered twice a day for anxiety starting on 7/31/23, which was discontinued on 8/24/23, and a new order for Lorazepan 0.5 mg two times a day for anxiety on 8/25/23. The MAR review for August and September revealed Lorazepan 1 MG was given twice a day throughout the two months. The controlled medication sheet was reviewed and compared with the inventory and confirmed that Lorazepam 1 mg had been pulled out and there was no documentation of the 0.5 mg pills being wasted. On 9/5/23 at 11:39 AM, an interview was conducted with Staff A, a Licensed Practical Nurse (LPN). Staff A, LPN, reviewed Resident #1's pregabalin inventory sheet. She stated Staff C, another LPN, should not have pulled out the pills at 9:00 PM because there was not a physician's orders to give that medication at night. Staff A, LPN, confirmed that a day shift nurse pulled out and documented the medications at the right time on those mornings as scheduled. Staff A further stated Staff C, LPN, should have documented waste of those medications but there was no documentation. Staff A, LPN, then reviewed Resident #2's Lorazepam inventory sheet and the physician's order and stated she has been giving 1 mg instead of the 0.5 mg because she had missed the order that was placed on 8/25/23. She stated she gave the 1 mg order this morning. She acknowledged she should have given the 0.5 mg order. On 9/5/23 at 12:32 PM, an interview was conducted with Staff B, a Registered Nurse (RN) and unit manager. She stated it was concerning that a nurse pulled up a controlled medication two times for Resident #1 at a time that it was not scheduled. Staff B, RN, confirmed the medication was pulled out (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 3 Event ID: 105282 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 105282 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eden Springs Nursing and Rehab Center 4679 Crawfordville Hwy Crawfordville, FL 32326 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)