Gretna Health And Rehabilitation Center

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 added until [Resident #1] has a bowel movement. A review of a medical provider orders with a start date of 2/16/26 read in part, .Polyethylene Glycol 3350 Powder Give 17 gram by mouth at bedtime for Osmotic laxative (a type of medication, available over-the-counter and by prescription, that relieve constipation by drawing water from surrounding body tissues into the colon). A review of Resident #1's bowel elimination record for February 2026 disclosed the resident had a bowel movement on 2/17/26. A review of the February 2026 medication administration record (MAR) disclosed Resident #1 received polyethylene glycol at bedtime from 2/16/26 through 2/24/26. A review of the comprehensive person-centered care plan disclosed a focus and intervention which read in part, .the resident is at risk for constipation related to reduced physical mobility. An intervention related to the focus read in part, .administer medications as ordered. Requested clarification of the medical provider order to discontinue polyethylene glycol after Resident #1 had a bowel movement. On 3/12/26 at 9:48 AM, the director of nursing (DON) provided a MD (medical doctor) Communication Form dated 2/16/26, which read in part, .Diagnosis.Constipation.Orders.Polyethylene Glycol 1 (one) capful.until BM (bowel movement). The DON agreed that the MiraLAX should have been discontinued after Resident #1 had a bowel movement on 2/17/26. This concern was discussed at the pre-exit meeting on 3/12/26 at 11:07 AM with the administrator, director of nursing, and regional director of clinical services. Requested and received a facility policy titled, Non-Controlled Medication Orders with an effective date of 9/2018, which read in part, .1. Medication orders specify the following.f. Quantity or duration (length) of therapy. No further information was provided prior to exit on 3/12/26.

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 with the administrator, director of nursing, and regional director of clinical services. Requested and received a facility policy titled, Transmission Based Precautions-General Practice with an effective date of 12/1/21, which read in part, .The Center initiates transmission-based precautions (TBPs) to protect other patients, employees and visitors from the spread of confirmed or suspected infection or contagious disease.19. If protective attire is determined necessary.1. A gown must be worn when indicated by the type of isolation in order to protect clothing from coming in contact with contaminated materials.e. Put on gloves. No further information was provided prior to exit on 3/12/26.

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 software for administration times for torsemide and metolazone administered on 7/14 and 7/24. The record indicated metolazone administered on 7/14 at 9:29 AM and torsemide administered at 9:50 AM, allowing 21 minutes between administrations. On 7/24/23 the record indicated the resident received metolazone at 8:46 AM and torsemide at 8:49 AM.
During a summary meeting on 7/25/23 the surveyor notified the administrator and director of nursing of the concern with timing of medication administration.
On 7/26/23 the director of nursing informed the surveyor that the nurse practitioner reviewed the metolazone order, which was written by the cardiologist, and changed the scheduled times of the medications to 6 AM for metolazone and 8 AM for torsemide, therefore ensuring that there would be a sufficient gap between administrations to ensure effectiveness of the torsemide in the future.

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 regimen review) Date: 6/17/2023 Federal guidelines state sedative hypnotic drugs should have an attempt at a gradual dose reduction (GDR) quarterly (approximately every 3 months), when used routinely and beyond the manufacturer's recommendations for duration of use. This resident had been taking Melatonin 3 mg since 1/12/2023 without a GDR in last 3 months. Could we attempt a dose reduction at this time to verify this resident is on the lowest possible dose? If not, please indicate response below: Response: () Reduce the dose of Melatonin to: D/C (discontinue) Melatonin. This form was signed and dated by the facility family nurse practitioner on 07/26/23. The director of nursing stated that the form was just reviewed and acted upon on this day.
This surveyor requested and was provided with a facility policy entitled Medication Regimen Review which read in part 6. Resident-specific irregularities and/or clinically significant risks resulting from or associated with medication are documented in the resident's active record and reported to the Director of Nursing, Medical Director, and/or prescriber as appropriate. 7. Recommendations are acted upon and documented by the facility staff and/or prescriber. a. The prescriber accepts and acts upon recommendation or rejects provides an explanation for disagreeing.
The concern of not acting upon a pharmacist recommendation was discussed with the administrator, director of nursing and regional nurse consultant on 07/27/23 at 11:30 am.
No further information provided prior to exit.

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 failure, history of myocardial infarction, hyperlipidemia, hypertension, cardiomyopathy, CKD3 (chronic kidney disease 3) Interventions for this care plan include administer medications as ordered.
This surveyor observed licensed practical nurse ((LPN) #1 administer medications to Resident #60 on 07/26/2023 at 8:20 am. LPN #1 removed a bottle of Vitamin D3 5000 IU (international units) and placed 2 tablets in the medicine cup. LPN #1 administered the Vitamin D3, along with other medications to Resident #60. Surveyor did not observe LPN #1 administer amlodipine to the resident.
This surveyor reconciled Resident #60's medication on 07/26/2023. Resident #60's physician's order summary contained an order which read in part, Vitamin D3 capsule 125 mcg (5000 UT [units]). Give 5000 unit by mouth one time a day for vit d def (deficiency) and amlodipine besylate tablet 10 mg. Give 1 tablet by mouth one time a day related to essential (primary) hypertension.
This surveyor spoke with LPN #1 on 07/26/2023 at 9:30 am regarding Resident #60's medications. Surveyor asked LPN #1 if they had administered Resident #60's amlodipine and LPN #1 stated they had and proceeded to remove Resident #60's medications from the cart. Resident #60's amlodipine was not among the medications in the cart. LPN #1 stated, I thought I gave it, but I guess not. I'll have to pull it from the Omnicell. LPN #1 removed the amlodipine from the Omnicell and administered it to the resident. Surveyor asked LPN #1 how many Vitamin D3 tablets they had administered to Resident #60, and LPN #1 stated they had administered two, and that's what the order called for. Surveyor asked LPN #1 to review the Vitamin D3 order, and after reviewing the order, LPN #1 stated that the order read to administer one tablet.
This surveyor requested and was provided with a facility policy entitled General Guidelines for Medication Administration, which read in part Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to administer. I. Preparation 6. At a minimum, the 5 Rights-right resident, right drug, right dose, right route, and right time-should be applied to all medication administration and reviewed at three steps in the process of preparation: (1) when medication is selected, (2) when the dose is removed from the container, and (3) after the dose is prepared and the medication is put away.
The concern of not ensuring a medication error rate of less than 5% was discussed with the administrator, director of nursing, and regional nurse consultant on 07/26/23 at 4:30 pm.
No further information was provided prior to exit.

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 7/26/23, an anonymous facility staff member reported to one surveyor that it had been over a year since the call system stopped working properly and the notification boxes were removed from the nurses' stations. Call bell lights were not observed visually or audibly at any centralized location, only lighting above resident doors.
The survey team tested resident room call buttons on each unit. When the call button was pushed, the light over the resident room door illuminated but that notification was not sent to any centralized system or to any direct staff member. The nurses' stations did not contain any communication system (neither visual nor audible) which showed there was a resident room call button pushed; staff must look down each hall to see whether any lights illuminated over a resident's door. There was no sound heard when the residents' call buttons were pushed. While assessing the call button system, the survey team observed all residents' rooms (both A & B beds) for the presence of hand bells and found 39 of 87 residents did not have a hand bell. The call buttons/cords in the two shower rooms did not send a notification directly to a staff member or centralized staff work area when pushed.
On the morning of 07/27/23, the 39 residents who did not have a handbell the day before were re-assessed by the survey team. Two (2) residents did not have a handbell. One of the two, reportedly did not want one and the other resident was said to probably have it in his pocket. That resident was rarely in his room.
On 07/27/23, the administrator provided communication documents regarding the call bell system. A business' letter dated 08/05/21 indicated the repair parts for the existing system were no longer available and recommended replacement. A replacement estimate document dated 08/10/21 was provided. An email from the administrator to a corporate employee dated 03/15/23 read the call bell system needed to be addressed and described the concern.
The administrator, director of nursing and regional nurse were informed of the concern again on 07/27/23 at 11:29 a.m. No other information was provided prior to the exit conference.
2. Six (6) of six (6) call light pull cords present in the TCU Spa (bathing area) and one (1) of three (3) call light pull cords in the PCU Spa (bathing area) did not activate the facility call light system.
On 7/26/23 at 5:09 pm, surveyor and registered nurse (RN) #1 entered the TCU Spa room to test the call light system. The Spa room included six (6) call light pull cords located in a bathroom, two (2) separate shower stalls, an area containing a roll-on scale, and in a storage area. Each of the six (6) pull cords failed to activate the visual call light located in the hall outside of the TCU Spa. The TCU Spa was located behind a coded locked door.
On 7/26/23 at 5:16 pm, surveyor tested the call light system in the PCU Spa (bathing area), and the call light pull cord located in the back left shower stall did not activate the visual call light located in the hall outside of the PCU Spa. The PCU Spa was located behind a coded locked door.
On 7/26/23 at 5:18 pm, surveyor notified the regional nurse consultant of the call light observations in the TCU and PCU Spa rooms.
On 7/27/23 at 9:47 am, surveyor spoke with certified nursing assistant (CNA) #1 and asked what they would do if they were alone in the bathing area with a resident and needed assistance. CNA #1 stated they would use the call light or stick their head out of the door and ask for help.
On 7/27/23 at 11:30 am the survey team met with the administrator, director of nursing, and the regional nurse consultant and discussed the concern of the call light pull cords located in the TCU and PCU Spa rooms failing to activate the facility call light system.
No further information regarding this concern was presented to the survey team prior to the exit conference on 7/27/23.

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 documentation for Employee #16 and #19, they stated they did not have the missing documentation.
Surveyor requested and received the facility policy entitled Prevention/Screening/Training which states in part Criminal background and reference checks are performed on all employees.
On 10/21/21 at 10:45 am, surveyor met with the administrator, director of nursing, regional nurse consultant, and unit manager and discussed the concern of the missing employment screening documentation for Employee #16 and #19.
No further information regarding these issues was presented to the survey team prior to the exit conference on 10/21/21.

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 100. A review of the resident's October 2021 MAR (medication administration record) indicated Metoprolol Tartrate was administered daily at 9:00 am. The October 2021 MAR included documented blood pressures obtained three times a day on day shift, evening shift, and night shift without a specified time. However, surveyor was unable to determine if the resident's blood pressure was assessed prior to the administration of Metoprolol Tartrate.
On 10/20/21 at 9:30 am, surveyor spoke with the DON (director of nursing) concerning the order to hold Resident #11's Metoprolol Tartrate if the SBP is less than 100. The DON stated the resident's blood pressure was taken twice a day but they do not correspond with the times the medication was given and it has been corrected.
On 10/20/21 at 2:39 pm, surveyor met with the administrator, DON, regional nurse consultant, and unit manager and discussed the concern of the administration of Metoprolol Tartrate without prior assessment of Resident #11's blood pressure.
No further information regarding this issue was presented to the survey team prior to the exit conference on 10/21/21.

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 next dose. No mention of administering larger dose on 10/18.
Surveyors discussed medication availability issues with the administrator, director of nursing, and other members of the management team during meetings on 10/20 and 10/21/21. The director of nursing reported that mediation availability was an ongoing concern with the facility's current pharmacy.
5. For Resident #73, the facility staff failed to ensure the physician ordered medication Olanzapine (Zyprexa) was available for administration.
Resident #73's medical diagnosis included, but was not limited to, malignant neoplasm of colon, metabolic encephalopathy, chronic kidney disease, and osteoarthritis.
Section C (cognitive patterns) of Resident #73's quarterly (MDS) minimum data set assessment with an (ARD) assessment reference date of 10/12/2021 included a (BIMS) brief interview for mental status summary score of 2 out of a possible 15 points.
The residents (EHR) electronic health record included a physicians order for Olanzapine 5 mg tablet every 12 hours.
10/20/21 8:32 a.m., during a medication pass and pour observation with (RN) registered nurse #1 the medication was not available in the medication cart or in the backup supply (omnicell) for administration. RN #1 stated they would call the pharmacy and order the medication and stated they had recently changed pharmacies and were having issues with obtaining some medications.
10/20/2021 a review of the residents (eMARs) electronic medication administration records and progress notes revealed that this medication was not available for administration on 10/18/2021 and 10/19/2021 at 9:00 a.m. For the evening dose at 9:00 p.m., two different nurses documented that the medication had been administered.
10/20/21 2:42 p.m., the administrator, (DON) Director of Nursing, nurse consultant, and unit manager were made aware of the issue regarding the residents Olanzapine.
10/21/21 09:14 a.m., during a meeting with the administrator and DON. The DON stated the Olanzapine was signed in error and was not available for administration.
No further information regarding this issue was provide to the survey team prior to the exit conference.
Based on staff interview, clinical record review and facility document review the facility staff failed to
provide routine drugs by not ensuring medications were available for administration for 5 of 26 Residents, #44, #54, #22, #28, and #73.
A facility document entitled Unavailable Medications was reviewed and read in part, Policy: The facility must make every effort to ensure that medications are available to meet the needs of each resident.
The findings included:
1. For Resident # 44 the facility staff failed to ensure that the supplement Prostat was available for administration.
Resident #44's face sheet listed diagnoses which included but not limited to urinary tract infection, non-pressure chronic ulcer, pressure ulcer of left hip, pressure ulcer of sacral region, congestive heart failure, hypertension, type II diabetes mellitus, and peripheral vascular disease.
The most recent admission MDS (minimum data set) with an ARD (assessment reference date) of 09/22/21 assigned the resident a BIMS (brief interview for mental status) score of 14 out 15 in section C, cognitive patterns. This indicates that the resident is cognitively intact.
Resident #44's comprehensive care plan was reviewed and contained a care plan for admitted with skin impairment r/t (related to) decreased mobility, weakness, PVD (peripheral vascular disease), scattered bruising noted to bilateral up and lower extremities, hx (history) lymphedema, hx cellulitis . Interventions for this care plan included Tx (treatment) as ordered.
Resident #44's clinical record contained a physician's order summary for the month of October 2021, which read in part Prostat SF(sugar free) AWC (advanced wound care) three times a day for To Promote Wound Healing Give 30 ml via PO (by mouth) TID (three times a day).
Resident #44's eMAR (electronic medication administration record) for the month of October 2021 was reviewed and contained an entry as above. This entry was coded 9 on 10/14-10/17/21 at 0900 and 10/14-10/16/21 at 1400. Chart code 9 is the equivalent of other/see nurses notes.
Resident #44's nurses' progress notes were reviewed and contained notes which read in part, 10/14/2021 08:16 Prostat SF AWC three times a day for To Promote Wound Healing Give 30 ml via PO TID out of stock, 10/14/2021 13:50 Prostat SF AWC three times a day for To Promote Wound Healing Give 30 ml via PO TID out of stock, 10/15/2021 08:51 Prostat SF AWC three times a day for To Promote Wound Healing Give 30 ml via PO TID not in stock, 10/15/20212021 13:36 Prostat SF AWC three times a day for To Promote Wound Healing Give 30 ml via PO TID awaiting order, 10/16/202109:15 Prostat SF AWC three times a day for To Promote Wound Healing Give 30 ml via PO TID on order, 10/16/2021 14:47 Prostat SF AWC three times a day for To Promote Wound Healing Give 30 ml via PO TID on order, and 10/17/2021 08:13 Prostat SF AWC three times a day for To Promote Wound Healing Give 30 ml via PO TID on order
The concern of the medication not being available was discussed with the administrator, director of nursing, regional nurse consultant and unit manager during a meeting on 10/20/21 at 2:45 pm.
No further information was provided prior to exit.
2. For Resident #54 the facility staff failed to ensure the medication labatelol was available for administration.
Resident #54's face sheet listed diagnoses which included but not limited to generalized edema, anxiety, acute kidney failure, depression, hypertension and chronic kidney disease.
The most recent MDS (minimum data set) with an ARD (assessment reference date) 09/30/31 assigned the resident a BIMS (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 #54's clinical record contained a physician's order summary for the month of October 2021 which read in part, Labetalol HCl Tablet 100 mg Give 1 tablet by mouth tow times a day related to ESSENTIAL (PRIMARY) HYPERTENSION.
Resident #54's eMAR (electronic medication administration record) for the month of October 2021 was reviewed and contained an entry as above. This entry was coded 5 on 10/15/21 at 5 pm. Chart code 5 is the equivalent of Hold/See progress note. The entry was coded 9 on 10/16, 10/17, 10/18 for both administration times and 10/19 at 9 am. Chart coded 9 is the equivalent of Other/See progress note.
Resident #54's progress notes were reviewed and contained notes which read in part, 10/15/2021 17:50 Labetalol HCl Tablet 100 mg Give 1 tablet by mouth two times a day related ESSENTIAL (PRIMARY) HYPERTENSION on order, 10/16/2021 09:30 Labetalol HCl Tablet 100 mg Give 1 tablet by mouth two times a day related ESSENTIAL (PRIMARY) HYPERTENSION Medication unavailable in Omnicell. Awaiting from pharmacy. MD made aware, 10/17/2021 08:07 Labetalol HCl Tablet 100 mg Give 1 tablet by mouth two times a day related ESSENTIAL (PRIMARY) HYPERTENSION Medication unavailable in Omnicell. Awaiting from pharmacy. MD made aware, 10/18/2021 08:05 Labetalol HCl Tablet 100 mg Give 1 tablet by mouth two times a day related ESSENTIAL (PRIMARY) HYPERTENSION Medication unavailable in Omnicell. Awaiting from pharmacy. MD made aware, and 10/18/202119:42 Labetalol HCl Tablet 100 mg Give 1 tablet by mouth two times a day related ESSENTIAL (PRIMARY) HYPERTENSION Medication unavailable in Omnicell. Awaiting from pharmacy. MD made aware
The concern of the medication not being available was discussed with the administrator, director of nursing, regional nurse consultant and unit manager during a meeting on 10/20/21 at 2:45 pm.
No further information was provided prior to exit.
4. For Resident #28, the facility staff failed to ensure the medication Bumetanide (Bumex) (a diuretic used to treat fluid retention) was available for administration.
Resident #28's diagnosis list indicated diagnoses, which included, but not limited to Unspecified Convulsions, Hypo-osmolality and Hyponatremia, Essential (Primary) Hypertension, Edema Unspecified, and Unspecified Lack of Expected Normal Physiological Development in Childhood.
The most recent quarterly MDS (minimum data set) with an ARD (assessment reference date) of 9/03/21 assigned the resident a BIMS (brief interview for mental status) score of 3 out of 15 in section C, Cognitive Patterns.
Resident #28's current physician's orders included an active order dated 5/26/21 for Bumetanide 0.5 mg give 1 tablet by mouth one time a day related to edema. A review of the resident's September 2021 MAR (medication administration record) revealed Bumetanide was not administered on 9/18/21, 9/19/21, 9/20/21, 9/21/21, and 9/22/21.
According to Resident #28's nursing progress notes, Bumetanide was not administered for the following documented reasons:
9/18/21 11:28 am - awaiting pharmacy
9/19/21 11:13 am - awaiting pharmacy
9/20/21 9:33 am - med not in facility
9/21/21 9:24 am - medication not available in stat box pharmacy will be sending on next run will administer on next scheduled dose
9/22/21 9:35 am - waiting for delivery from pharmacy
Resident #28 was seen by the NP (nurse practitioner) on 9/22/21 and the progress note states in part The patient is being evaluated today at nursing request for reports of hyponatremia. The patient is on sodium tablets and Bumex (Bumetanide) to prevent hyponatremia. As per nursing, (he/she) has not had (his/her) Bumex for approximately five days as it has not been coming from the pharmacy. The documented plan states in part as (he/she) has not had (his/her) regular medications, we will obtain a BMP (basic metabolic panel) to evaluate for worsening hyponatremia. Resident #28's 9/23/21 BMP results revealed a sodium level of 130. Resident #28's prior sodium level on 9/15/21 was also 130 indicating no change.
On 10/20/21 at 8:40 am, surveyor spoke with the DON (director of nursing) who stated the facility changed pharmacies on 9/01/21 and there was an issue obtaining Resident #28's Bumex (bumetanide). DON stated they contacted the pharmacy through the provided app and made daily phone calls attempting to obtain the medication.
Surveyor met with the administrator, DON, regional nurse consultant, and the Unit Manager on 10/20/21 at 2:39 pm and discussed the concern of Resident #28 not receiving Bumetanide as ordered.
No further information regarding this issue was presented to the survey team prior to the exit conference on 10/21/21.

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, but I took everything else off in the room. Surveyor then informed RN #2 they had observed them entering the room, and RN #2 stated, Well, I guess you got me this time, I've been on the other side and it's about time for me to leave and I needed to ask her something. RN #2 then proceeded to unzip the barrier separating the units, and exit into the facility.
Resident #231's clinical record was reviewed and contained a face sheet which listed diagnoses including COVID-19. Resident #231's physician's order summary contained an order for enhanced droplet precautions every shift for monitoring protocol.
Surveyor observed signage on the resident's door stating Enhanced Droplet-Contact Precautions and a list of steps to be taken, including Perform Hand Hygiene, N-95 or Surgical Mask when entering room, Eye Protection (goggles or face shield) when entering room, Gown when entering room, Gloves when entering room, Keep door closed and Remove PPE and Perform Hand Hygiene before exiting room. A cart containing PPE was located outside the resident's door.
Surveyor spoke with DON (director of nursing) and RNC (regional nurse consultant) on 10/19/21 at 4:14 pm. RNC stated they will address the concern immediately. DON stated the nurse should have worn full PPE when entering the room and not went back into the facility after exiting room.
Surveyor was provided with a copy of a facility policy entitled COVID-19 which read in part, 9. Containment/Management a. Identification of a positive case in a patient: Implement Enhanced Droplet-Contact Precautions until patient meets CDC (Centers for Disease Control) criteria for discontinuation of transmission-based precautions. 13. Education d. Review with all employees and visitors the core principles of COVID-19 of infection control: Employees will wear appropriate Personal Protective Equipment (PPE) when indicated.
No further information was provided prior to exit.

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 the facility staff began documenting the results of the COVID-19 tests in the residents individual records.
No further information regarding this issue was provided to the survey team prior to the exit conference.