Health inspection·March 27, 2025

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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews, and facility policy and procedure review, the facility failed to develop and implement a care plan for anticoagulant use for one (Resident #68) of five residents reviewed for medication use, from a total survey sample of 34 residents. The findings include: A record review revealed that Resident #68 was admitted to the facility on [DATE] with diagnoses including chronic ischemic heart disease, diabetes mellitus - type 2 due to underlying condition with diabetic kidney disease, and unspecified displaced fracture of the surgical neck of the right humerus. A review of Resident #68's physician's orders revealed an order for Apixaban (anticoagulant) 5 mg (milligrams) by mouth twice daily (order dated 7/12/24). The resident's physician's orders did not include orders to monitor the resident for side effects related to anticoagulant use. A review of the resident's Significant Change MDS (minimum data set) assessment, dated 1/22/25, revealed that the resident scored 15/15 on a BIMS (brief interview for mental status), indicating intact cognition. She was also documented as receiving anticoagulant medication. A review of the resident's care plan (initiated on 7/11/24), revealed no focus area addressing anticoagulant use. A review of the resident's April 2025 MAR (medication administration record) revealed that it did not include a monitoring tool for side effects of anticoagulant use. On 03/27/25 at 2:34 PM, an interview was conducted with Licensed Practical Nurse (LPN) E/Unit Manager. She was asked if a resident was receiving medications and staff were not familiar with the resident, where they would find information about the medications the resident was receiving. She stated, Under the orders. She was asked if the resident was receiving an anticoagulant, what would the physician's orders include. She stated, The type of medication it was, how much they take, monitor for signs and symptoms of bleeding, skin check frequency and those types of things. She was asked where else she would expect to find information about how to care for a resident receiving anticoagulant medications. She replied, It would depend on which anticoagulant they were taking, like for Coumadin, there would be labs ordered and dose changes. She was asked where else information would be found in the resident's record that would inform the nurse about how to care for the resident receiving anticoagulant medications. She stated, The care plan would include information about how to care for the Page 1 of 3 105735 105735 03/27/2025 Orange City Nursing and Rehab Center 2810 Enterprise Rd Debary, FL 32713

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few resident taking anticoagulants. She was asked what should be included in the care plan and she replied, Monitoring for signs and symptoms of bleeding; there would be others but I'd have to look; I can't recall off the top of my head, but definitely that should be there. On 03/27/25 at 3:01 PM, another interview was conducted with LPN E/Unit Manager. She was asked to access the anticoagulant care plan for Resident #68 in the electronic medical record (EMR). She was able to provide a care plan focus area for anticoagulant use, but confirmed that the care plan reflected anticoagulant use after the above 2:34 PM interview. She was unable to provide evidence of anticoagulant side effects monitoring on the resident's MAR. A review of the facility's policy and procedure for Anticoagulant Therapy (SHCRC30004.30 - revised 8/2023) revealed: Purpose: To effectively monitor residents receiving anticoagulant therapy and reduce the risk of bleeding by maintaining therapeutic blood levels in accordance with physicians' orders. 8. Throughout anticoagulant therapy, monitor the resident for signs and symptoms of bleeding . A review of the facility's policy and procedure for Comprehensive Person-Centered Care Plans (SHCO40001.08 - revised 8/2023) revealed: Policy: The center will develop a comprehensive person-centered care plan for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing, mental and psychological needs that are identified in the comprehensive assessment. Fundamental Information: The comprehensive plan of care will include the following: Resident's individual needs . Reflect current standards of professional practice. Include interventions to avoidable decline in function or functional level. Interventions to attempt to manage risk factors. Procedure: 3. Develop goals and approaches for each problem and/or condition that are: Realistic Specific 105735 Page 2 of 3 105735 03/27/2025 Orange City Nursing and Rehab Center 2810 Enterprise Rd Debary, FL 32713

F 0656 Measurable, and Level of Harm - Minimal harm or potential for actual harm Include interventions/approaches that relate to each stated long- or short-term goal. . Residents Affected - Few 105735 Page 3 of 3