Gretna Health And Rehabilitation Center

Based on staff interview, clinical record review, and facility document review, the facility staff failed to follow the provider orders for wound care and failed to obtain provider orders for a fracture for 1 of 5 closed record reviews, Resident #94. Findings included:1. The facility staff failed to complete provider ordered treatments for a hematoma on Resident #94's left calf. Resident #94 experienced a fall prior to admission to the facility. A hematoma is a localized collection of blood outside blood vessels, usually caused by injury or trauma, which can lead to swelling, pain, and discoloration. Resident #94's diagnoses included contusion of lower leg, Parkinson's disease, and muscle weakness. Section C (cognitive patterns) of Resident #94's admission Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 05/28/2024 included a Brief Interview for Mental Status (BIMS) score of 9, indicating Resident #94 was moderately impaired in cognitive skills for daily decision making. The Comprehensive Care Plan (CCP), initiated on 05/22/2024, identified impaired skin…

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 staff interview, clinical record review, and facility document review, the facility staff failed to ensure resident treatment and care in accordance with professional standards of practice for (1) one of (4) four sampled residents, Resident #1. The findings included:For Resident #1, the facility staff failed to follow a medical provider order to discontinue the medication polyethylene glycol powder (MiraLAX) after a bowel movement. Resident #1's diagnosis list indicated diagnoses, which included, but not limited to, chronic kidney disease, vascular dementia-mild with agitation, left femur fracture, and difficulty walking. The most recent admission minimum data set (MDS) with an assessment reference date (ARD) of 2/19/26, assigned the resident a brief interview for mental status (BIMS) summary score of 12 out of 15 for cognitive abilities, indicating Resident #1 was moderately impaired in cognition. A review of a medical provider progress note dated 2/16/26 read in part, .flagged for constipation greater than 3 days. Polyethylene glycol 1 (one) capful every evening has been…

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 facility document review, the facility staff failed to utilize appropriate personal protective equipment (PPE) prior to entrance into a resident room identified for contact precautions. The findings included:On 3/11/26 at 1:01 PM during an initial tour of the facility, Resident #2's room was observed to have a sign outside of the room which read in part, Contact Precautions.gown and gloves.prior to entering room. Other staff #1 (OS#1) was observed in the room with a KN95 mask visible covering their face. No gown or gloves were visible on OS#1. On 3/4/26 at 1:04 PM, unit manager #1 (UM#1) was interviewed and stated the expectation for staff entering the room is for gown and gloves to be worn. On 3/4/26 at 1:05 PM, OS#1 was interviewed and stated education on proper PPE for a contact precaution room had been received and stated a gown and gloves should be worn when entering the room. OS#1 was then observed to don a gown and gloves and then re-entered the resident room. This concern was discussed at the pre-exit meeting on 3/12/26 at 11:07 AM…

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, interviews, and facility document review, the facility staff failed to ensure 1. the resident communication system relayed calls directly to a staff person or to a centralized staff work area from all residents' rooms and 2 of 2 bathing areas, and 2. call light pull cords were in working order in 2 of 2 bathing areas. The findings were: 1. The residents' call button/bell communication system was not connected to any centralized staff work area or directly to any staff person. During a resident council meeting discussion regarding staff call bell response times, the residents reported their call buttons triggered a visual light above their door to illuminate in the hallway but there was nothing audible when they pressed the button; a handbell had been provided for an audible call bell. Following the resident council meeting which took place on 07/26/23 at 3:00 p.m., the administrator acknowledged the call button communication system was visual, not audible, and residents had been provided a hand bell for audible notifications. At approximately 4:15 p.m. on…

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 staff interview and clinical record review, facility staff failed to administer a diuretic medication per physician orders for 1 of 18 residents in the survey sample (Resident #20). Resident #20 was admitted to the facility with diagnoses including atherosclerotic heart disease, congestive heart failure, presence of implanted defibrillator, pulmonary hypertension, long-term use of insulin and anticoagulants, Parkinson's disease, type 2 diabetes mellitus, chronic respiratory failure, and essential hypertension. On the Minimum Data Set assessment with assessment reference date 6/5/2023, the resident scored 15/15 on the brief interview for mental status and was assessed as without signs of delirium, psychosis, or behaviors affecting care. Clinical record review on 7/25/23 revealed an order dated 7/13/23 for metolazone oral tablet 2.5 mg (milligrams) Give 1 tablet by mouth one time only for fluid overload 1 day to be given 30 minutes prior to torsemide. The order was entered for administration on 7/14, 7/24, and 7/31. The surveyor asked LPN #3 to check the clinical record…

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 staff interview, clinical record review and facility document review the facility staff failed to act upon pharmacist recommendations for 1 of 18 residents, Resident #40. The findings included: For Resident #40 the facility staff failed to act upon a pharmacist recommendation. Resident #40's face sheet listed diagnoses which included but not limited to anemia, depression, and psychosis. Resident #40's most recent minimum data set with an assessment reference date of 05/12/23 assigned the resident a brief interview for mental status score of 3 out of 15 in section C, cognitive patterns. This indicates that the resident is severely cognitively impaired. Resident #40's clinical record was reviewed and contained a Consultant Pharmacist Medication Regimen Review form dated 06/17/23 which read in part See report for any noted irregularities and/or recommendations. Surveyor could not locate a report in the clinical record. This surveyor requested and was provided with a copy of a Consultation Pharmacist Recommendation to Physician report dated, which read in part MRR (medication…

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, clinical record review, facility document review and during a medication pass and pour observation the facility staff failed to ensure a medication error rate of less than 5 %. There were two errors in 28 opportunities for a medication error rate of 7.14%. These errors affected Resident #60. The findings included: For Resident #60, the facility staff failed to administer the medication, amlodipine and failed to follow the physician's order for the administration of the medication, Vitamin D3. Resident #60's face sheet listed diagnoses which included but not limited to hypertension and vitamin D deficiency. Resident #60's most recent minimum data set with an assessment reference date of 06/30/23 assigned the resident a brief interview for mental status score of 15 out of 15 in section C, cognitive patterns. This indicates that the resident is cognitively intact. Resident #60's comprehensive care plan was reviewed and contained a care plan for the resident is at risk for cardiac complications secondary to chronic kidney disease, congestive heart…

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.

3. For Resident #22, facility staff failed to ensure a physician ordered supplement was available for administration. Resident #22 was admitted to the facility with diagnoses including atherosclerotic heart disease, traumatic amputation of right lower leg, methicillin resistant staphylococcus aureus, diabetes mellitus, hypertension, heart failure, gastroesophageal reflux disease, and dysphagia. On the Minimum Data Set Assessment with Assessment Reference Date 8/25/21, the resident scored 10/15 on the Brief Interview for Mental Status and was assessed as without signs of delirium or psychosis. The resident exhibited physical behaviors directed toward others 1-3 days of the week prior to the assessment. Clinical record review revealed a physician order dated 6/9/2021 for Prostat SF 30 ml one time a day for wound healing and skin integrity. The October 2021 Medication Administration Record (MAR) documented 9 (Other/ See Progress Notes) on 10/15,16, and 19 and 45 ml (instead of 30) administered on 10/18/21. Notes on 10/15, 10/16, and 10/19 documented Prostat on order, will administer…

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 staff interview and clinical record review, the facility staff failed to consistently document the results of COVID-19 tests in the (EHR) electronic health record for 23 of 26 residents. Resident's #6, #11, #16, #18, #19, #22, #24, #28, #34, #37, #42, #44, #45, #46, #51, #54, #61, #67, #71, #73, #75, #77, and #79. The findings included: The facility staff failed to consistently document the result of COVID-19 testing in the resident's EHR's. During the record reviews, the surveyors were unable to locate all of the results of recent COVID-19 tests in the resident's EHR's. 10/19/21 1:34 p.m., the (DON) Director of Nursing stated the results of the rapid COVID-19 tests were documented on the residents individual (eMARs) electronic medication administration records and the results of the (PCR) polymerase chain reaction COVID-19 laboratory tests were in a folder in a plastic tote in the conference room and were not placed in the residents EHR's. The nurse consultant stated they called the physician right away if they received a positive test result. Prior to the exit conference…

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 staff interview, employee record review, and facility document review, the facility staff failed to implement written policies and procedures that prohibit and prevent abuse, neglect, and exploitation of resident and misappropriation of resident property as evidenced by failure to pre-screen 2 of 25 new hire employees, #16 and #19. The findings included: The facility staff failed to obtain reference checks for Employee #16 and failed to obtain a criminal background check and reference checks for Employee #19. A review of the employee records for Employee #16 and #19 revealed the following documentation: Employee #16 was employed by the facility in housekeeping on 9/20/21. Employee #16's employee record did not contain documentation of a reference check review. Employee #19 was employed by the facility in human resources on 2/17/20. Employee #19's employee record did not contain documentation of a Virginia State Police criminal background check or a reference check review. On 10/20/21 at 3:36 pm, surveyor spoke with HR (human resources) staff member #1 concerning the missing…

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 staff interview and clinical record review, the facility staff failed to ensure that residents receive treatment and care by not following physician's orders for 1 of 26 residents in the survey sample, Resident #11. The findings included: For Resident #11, the facility staff failed to follow the physician's orders for the administration of Metoprolol Tartrate (a beta blocker used to treat angina and hypertension). Resident #11's diagnosis list indicated diagnoses, which included, but not limited to Unspecified Severe Protein-Calorie Malnutrition, Adult Failure to Thrive, Anorexia, Tachycardia Unspecified, and Orthostatic Hypotension. The most recent annual MDS (minimum data set) with an ARD (assessment reference date) of 7/28/21 assigned the resident a BIMS (brief interview for mental status) score of 14 out of 15 in section C, Cognitive Patterns. Resident #11's current physician's orders included an active order dated 9/01/21 for Metoprolol Tartrate tablet give 12.5 mg by mouth one time a day related to Tachycardia Unspecified hold SBP (systolic blood pressure) less than…

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, facility document review and clinical record review the facility staff failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections, specifically COVID-19, for one of one COVID unit. The findings included: For the COVID unit of the facility, the facility staff failed to don proper PPE (personal protective equipment) prior to entering a room with a resident that was COVID positive, then exited the unit and back into the facility. On 10/19/21 at 4:00 pm, surveyor observed RN (registered nurse) #1 enter the COVID unit through a zippered barrier that separated the COVID unit from the observation unit. RN #2 was wearing an N95 mask, but no other PPE. RN #2 entered Resident #231's room, without donning any other PPE. When RN #2 exited the room, surveyor introduced herself and asked RN #2 if they had donned PPE prior to entering the room, and RN #2 stated I forgot my face shield,…

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.