Eden Springs Nursing And Rehab Center

Based on observation and interview, the facility failed to provide adequate supplies of clean laundry in all resident care areas throughout the entire facility. The findings include: On 2/28/24 at approximately 1:20 PM, Resident #3 was observed in the hallway in a reclined geriatric chair. He had a pillow under his legs. The pillow did not have a pillow case on it. On 2/28/24 at approximately 1:20 PM, an interview was conducted with Resident #6. Her bed was stripped with no sheets on it and the call light was on. Resident #6 explained that she has been waiting for staff to change her bed so she can lay down. She complained that there has been a shortage of sheets and other linens. The resident said she has to lay on the bed without sheets sometimes. She stated that staff often run out of sheets and it is not until evening time when she gets her bed made. She said she likes a sheet under her blanket and often staff are unable to put a flat sheet under the blanket due to the shortage of linen supplies. She also explained that sometimes staff runs out of under pads to place on the bed.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews with staff and residents, the facility failed to provide a safe clean homelike environment in 17 of 40 sampled resident rooms or shower rooms in the facility. (Resident rooms 142, 141,140, 139, 138, 137, 136, 135, 134, 128, 127,116, 111, 108, as well as shower rooms [ROOM NUMBER]) The findings include: On 1/18/24 at approximately 10:15 AM, a facility tour was initiated. The following issues were noted: A live roach was observed crawling on the floor in room [ROOM NUMBER]A. The room had an area where a cabinet was removed. The floor was unfinished in this area. Two wheelchair foot rests were on the bare floor. The floor under the cabinet had a buildup of soil, a coin, a piece of candy, and a piece of food laying on the bare floor next to the wheelchair foot rests. (Photographic evidence obtained) In room [ROOM NUMBER], there was a geriatric chair with a thick build of rust and soil on it. The tires had a hair like substance wrapped around them. The room had an area where a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews with staff and residents, the facility failed to maintain an effective pest control program. The findings include: Observations: On 1/18/24 at approximately 10:15 AM, a live roach was observed crawling on the floor in room [ROOM NUMBER]A. (Photographic evidence obtained) On 1/18/24 at approximately 11:20 AM in room [ROOM NUMBER], there was a roach on the floor under an unfinished cabinet. (Photographic evidence obtained) Interviews: Based upon the observations made by surveyors, staff and residents were asked about the effectiveness of the pest control program at the facility. On 1/18/24 at approximately 10:15 AM, Certified Nursing Assistant (CNA) E said she sees roaches crawling around the facility frequently. On 1/18/24 at approximately 10:20 AM, CNA H was asked if she sees pests around the facility. She explained that she mostly sees roaches. She explained that it has been a consistent problem at the facility. On 1/18/24 at approximately 10:30 AM an interview was conducted…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, record review, and policy review, the facility failed to provide assistance with nail care for 4 of 10 resident sampled for Activities of Daily Living (ADL) care. (Resident #10, #12, #14, and #16) The findings include: On 1/18/24 at 10:30 AM, during an interview with Resident #10, it was observed that the residents nails were long. The surveyor asked resident if she would like her nails trimmed. She indicated that she recently had pneumonia, which has made herbeen weak and would like assistance with getting her nails done. On 1/19/24, a review of the care plan for Resident #10 was conducted. The care plan noted that the resident has an ADL self-care performance deficit r/t Activity Intolerance, Fatigue, Impaired balance, Limited Mobility, Pain, and Shortness of Breath. The resident had been diagnosed with pneumonia on 1/16/24. The care plan directs staff to provide assistance as needed with ADLs. On 1/19/24 at approximately 11:00 AM, it was noted that Resident #12 had long soiled nails. Certified Nursing Assistant (CNA) E was in the room at the time…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, record review, interviews and facility policy review, the facility failed to ensure that CPAP (Continuous Positive Airway Pressure- a device that delivers continuous pressured air through a tubing into a mask that is wore while asleep) masks were properly stored to prevent cross-contamination for 2 of 3 residents sampled (Resident #1 and resident #4). The findings include: On 9/5/23 at 11:30 AM, Resident #1's CPAP mask was observed hanging from the window's blind. On 9/5/23 at 1:31 PM, Resident #4's CPAP mask is on the floor. A review of Resident #1's clinical records revealed a diagnosis of obstructive sleep apnea and a physician's order to use a CPAP device at night. A review of Resident #4's clinical records revealed a diagnosis of dependence on supplemental oxygen. A review of the physician's orders stated, CPAP at night at bedtime for sleep apnea and clean CPAP mask and tubing with warm soapy water and let air dry during day to prepare for use during night on Sundays. On 9/5/23 at 2:42 PM, an interview was conducted with the Director of Nursing (DON). The…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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) 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…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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. 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…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.