Greenbriar Center

Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENCE OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on observation, interviews, record review, review of the facility incident investigation, and policy review, the facility failed to maintain a hazard free environment free from unsecured smoking materials and smoking inside the facility in undesignated smoking areas. Actual harm occurred on 02/12/26 when Resident #4, who was cognitively intact, wheelchair dependent, and dependent on staff assistance for transfers due to impairment to his lower extremities, lit a cigarette while in his bed and the cigarette fell to contact a flammable agent (cologne) on his bed and on his body. [...]

Inspectors wroteBased on resident interviews, staff interviews, observation and facility policy review, the facility failed to ensure sufficient staff to meet the needs of the residents. This affected four (Residents #83, #49, #42, and #95) interviewed regarding staffing concerns and had the potential to affect all 102 residents residing in the facility.

Inspectors wroteBased on record review, observation, interview and facility policy review, the facility failed to store insulin (a medication used to stabilize blood sugars) in a proper manner to ensure efficacy. This affected six (Residents #27, #61, #76, #90, #99, and #109) of 23 (Residents #3, #12, #27, #30, #31, #35, #40, #41, #49, #50, #52, #55, #61, #73, #75, #76, #78, #87, #90, #94, #95, #99, and #109) who were identified as utilizing insulin. The facility census was 102.

Inspectors wroteBased on record review, facility self-reported incident (SRI) review, interview and facility policy review, the facility failed to ensure Resident #61 was free from misappropriation. This affected one (Resident #61) of one resident reviewed for abuse, neglect and misappropriation and had the potential to affect all residents residing in the facility. The facility census was 102.

Inspectors wroteBased on record review, interview and facility policy review, the facility failed to ensure Resident #106 was safely discharged to another skilled nursing facility. This affected one (Resident #106) of the five residents reviewed for discharge. The facility census was 102.

Inspectors wroteBased on record review, interview and contract review, the facility failed to ensure medications were administered as ordered in a timely fashion after admission for Resident #111. This affected one (Resident #111) of eight residents who were reviewed for medication administration. The facility census was 102.

Inspectors wroteBased on record review and interview the facility failed to ensure Resident #101's Power of Attorney (POA) signed Resident #101's admission paperwork as the resident's representative. This affected one resident (Resident #101) out of three residents reviewed for admissions. The facility census was 95.

Inspectors wroteBased on observation, interview, record review and review of facility policy, the facility failed to ensure a call light was within reach for Resident #52. The facility also failed to ensure Resident #3 and #28 were reasonably accommodated by staff in response to call light activation for care needs. This affected three residents (Resident #3, #28 and #52) of 31 residents reviewed for call lights. The facility census was 95.

Inspectors wroteBased on record review and interview the facility failed to ensure a bed hold letter was mailed to Resident #101's Power of Attorney (POA). This affected one resident (Resident #101) of three residents reviewed for notification of bed hold. The facility census was 95.

Inspectors wroteBased on record review and interview, the facility failed to ensure Residents #9, #13, and #56 received the necessary services for showers to maintain personal hygiene. This affected three Residents (#9, #13, and #56) out of seven residents reviewed for showers. The facility census was 95.

Inspectors wroteBased on record review, interview and policy review the facility failed to complete pre and post dialysis assessments for Resident #94 on each dialysis treatment day. This affected one resident (Resident #94) of one resident reviewed for dialysis. The facility identified four residents (#9, #76, #86 and #94) as being on dialysis. The facility census was 95.

Inspectors wroteBased on record review, interview and observation the facility failed to ensure medications were administered as ordered by the physician. This affected two residents (Resident #70 and #357) of eight residents reviewed for medication administration. The facility census was 95.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure Residents #53, #55, and #89 were smoking in a safe smoking area and not an area designated as non-smoking. This affected all three Residents #53, #59, and #89 who were reviewed for smoking. The facility census was 95.

Inspectors wroteBased on medical record review, review of the facility's self-reported incident (SRI), interviews and review of the facility policy, the facility failed to ensure timely and appropriate reporting of suspected verbal abuse and rough handling of Resident #75 by staff. This affected one resident (#75) of 33 residents residing on the Regency unit of the facility. The facility census was 100.

Inspectors wroteBased on observation, medical record review, and interview, the facility failed to develop and implement comprehensive, effective and individualized pain management programs for all residents. The facility failed to ensure Resident #104 received pain medication as ordered and the facility failed to ensure Resident #60 was re-assessed timely following complaints of severe pain to determine if changes were needed to his medication regimen. This affected two residents (#60 and #104) of six residents reviewed for pain. [...]

Inspectors wroteBased on medical record review, review of controlled drug administration records and interview, the facility failed to ensure accuracy of records regarding medication administration. This affected one (Resident #60) of six residents reviewed for pain.

Inspectors wroteBased on observation, interview, record review, and review of the facility policy the facility failed to ensure Resident #48, who had an order to self-medicate, kept his medications stored appropriately. This affected one resident (#48) who the facility identified as the only resident in the facility that self-medicated. The facility census was 92.

Inspectors wroteBased on observation, interview, record review, and facility policy review the facility failed to administer medications to Resident #31 in accordance with professional standards of practice. This affected one resident (#31) of two residents observed for medication administration. The facility census was 92.

Inspectors wroteBased on interview, medical record review, and review of facility policy, the facility failed to ensure bathing was completed for Resident #55 and Resident #87 as scheduled. This affected two residents (Residents #55 and #87) of three residents reviewed for bathing. The facility census was 114.

Inspectors wroteBased on record review, observation, interview and facility policy review, the facility failed to ensure resident smoking materials were maintained by the facility staff. This affected four (Residents #15, #64, #77 and #346) of four residents reviewed for smoking. The facility census was 94.

Inspectors wroteBased on observation, interview, menu spreadsheet review and policy review the facility failed to serve palatable meals at appetizing temperatures. This affected 91 residents receiving meals from the kitchen as three residents (Residents #23, #86 and #296) were ordered nothing-by-mouth (NPO). The facility census was 94.

Inspectors wroteBased on observation, interview and policy review, the facility failed to ensure foods were labeled, dated and not retained when expired. This had the potential to affect 91 residents receiving food from the facility's kitchen as three residents (Residents #23, #86 and #296) were ordered nothing-by-mouth (NPO). The facility census was 94.

Inspectors wroteBased on record review, observation and interview, the facility failed to ensure the resident's call light was within reach. This affected one (Resident #8) of five residents reviewed for call lights. The facility census was 94.

Inspectors wroteBased on record review and interview, the facility failed to ensure showers were completed as scheduled. This finding affected two residents (Residents #54 and #350) of five residents reviewed for activities of daily living (ADLs). The facility census was 94.

Inspectors wroteBased on observation, record review and interview, the facility failed failed to ensure Resident #347's intravenous (IV) fluids were discontinued after use and Resident #26's right foot dressing was completed as ordered. This finding affected one (Resident #347) of one resident reviewed for IV therapy and one (Resident #26) of three residents reviewed for general skin conditions. The facility census was 94.

Inspectors wroteBased on observation, record review and interview, the facility failed failed to ensure Resident #347's intravenous (IV) fluids were discontinued after use. This finding affected one (Resident #347) of one resident reviewed for IV therapy.

Inspectors wroteBased on record review and staff interviews, the facility failed to ensure complete and accurate documentation for Residents #15 and #62. This affected one of three residents reviewed for restorative care (#62) and one of one record reviewed for transmission-based precautions (#15). The facility census was 94. Findings Include: 1. Review of medical records for Resident #15 revealed an admission date of 10/07/20. Resident #15 was diagnosed with MRSA (Methicillin Resistant Staphylococcus Aureus) in the urine on 06/13/23 and was subsequently placed on transmission-based precautions (contact precautions). Contact Precautions were not discontinued after completion of the appropriate antibiotic therapy. Review of Resident #15's medical records revealed the order for contact precautions was discontinued on 02/14/24. [...]

Inspectors wroteBased on observations, review of the medical record and interview with the staff, the facility failed to ensure blood sugar tests and insulin was administered as ordered for Resident #78, failed to ensure the call light was answered timely for Resident #15 and failed to ensure an intravenous antibiotic was initiated timely after admission for Resident #99. This affected two residents (Resident #78 and #99) of three reviewed for medication administration and one resident (Resident #15) of three reviewed for staffing. The facility census was 97.

Inspectors wroteBased on observation, review of the medical record and interview with the staff the facility failed to maintain a medication error rate of less than five percent. The medication error rate was calculated to be 13.3 percent and included four medication errors of 30 opportunities for error. This affected one resident ( Resident #55) out of four residents observed during medication administration. The facility census was 97.

Inspectors wroteBased on observation, review of the medical record and interviews with staff the facility failed to ensure a clean sanitary environment while providing resident care to Resident #55 and during a dressing change for resident #78. This affected two residents ( Resident #55 and #78) of three residents reviewed for infection control. The facility census was 97.

Inspectors wroteBased on observation, interview, record review, and facility policy review the facility failed to provide a clean and sanitary environment where food was being prepared. This had the potential to affect all 92 residents (#1, #2, #3, #4, #5, #6, #7, #8, #9, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27, #28, #29, #30, #31, #32, #33, #34, #35, #36, #37, #38, #39 #40, #41, #42, #43, #44, #45, #46, #47, #48, #49, #50, #52, #53, #54, #55, #56, #57, #58, #59, #60, #61, #62, #63, #64, #65, #66, #67, #68, #69, #70, #71, #72, #73, #74, #75, #76, #77, #79, #80, #81, #82, #83, #84, #85, #86, #87, #88, #89, #90, #91, #92, #93, #94, and #95) who receive their meals from the kitchen. The facility census was 96.

Inspectors wroteBased on observation, record review and interview the facility failed to develop and implement a comprehensive and individualized restorative range of motion plan for Resident #94 to prevent a decline in range of motion and to prevent the development of hand contractures. Actual Harm occurred on 10/12/21 when Resident #94, who was admitted with no impairment in functional range of motion to his bilateral upper extremities developed contractures to both hands, increased pain with hand movement and the loss of function. [...]

Inspectors wroteBased on observation, record review and interview the facility failed to ensure food was served in a sanitary manner. This affected one resident (Resident #77) and had the potential to affect all 107 residents residing in the facility. Findings Include: Review of the medical record for Resident #77 revealed an admission date of 05/05/20 with diagnoses including type 2 diabetes, dysphagia, pleurisy, chronic kidney disease (CKD) stage 3 and peripheral vascular disease. Review of the care plan, dated 01/10/22 revealed Resident #77 had a nutritional deficit related to dysphagia and feeding difficulties. Interventions included adaptive equipment such as a two-handle sipper cup, weighted utensils and a scoop plate with all meals. Food intake was to be monitored and recorded at every meal and staff was to provide feeding assistance as necessary. Review of the quarterly Minimum Data Set (MDS) 3. [...]

Inspectors wroteBased on observation, interview, facility policy and procedure review and review of the Centers for Disease Control (CDC) guidance the facility failed to maintain adequate infection control practices after providing incontinence care to Resident #45 and related to screening procedures for COVID-19 to prevent the spread of infection including COVID-19. This affected one resident (#45) and had the potential to affect all 107 residents. Findings Include: 1. On 02/08/22 at 1:30 P.M. State Tested Nursing Assistant (STNA) #820 was observed providing incontinence care to Resident #45. After the care was completed, STNA #820 was observed touching the resident's over bed table to move it, assisting Resident #45 to move up in bed using linen and handled the bed remote to raise the head of the bed with the same gloved hands as were used during incontinence care. On 02/08/22 at 1:45 P.M. [...]

Inspectors wroteBased on record review, review of infection surveillance logs, facility policy review and interview the facility failed to ensure an effective antibiotic stewardship program was maintained. This affected one resident (#34) and had the potential to affect all 107 residents residing in the facility. Findings Include: 1. Review of Resident #34's medical record revealed diagnoses including dementia, congestive heart failure, and cerebral infarction. A quarterly Minimum Data Set (MDS) 3.0 assessment, dated 12/07/21 revealed Resident #34 required extensive assistance from staff for toilet use and was always incontinent of bowel and bladder. A nursing note, dated 02/06/22 at 7:43 P.M. indicated the nurse attempted to straight cath Resident #34 per the resident's son's request because he (the son) believed the resident had a urinary tract infection. [...]

Inspectors wroteBased on record review and interview the facility failed to ensure Resident #5's wishes regarding advance directives/code status was clear and consistently noted in both the resident's electronic health record (EHR) and medical chart record (binder). This affected one resident (#5) of 32 residents reviewed for advance directives. Findings Include: Review of Resident #5's medical record revealed diagnoses including chronic obstructive pulmonary disease (COPD), epilepsy, human immunodeficiency virus (HIV), hyperlipidemia and peripheral vascular disease (PVD). An annual Minimum Data Set (MDS) 3.0 assessment, dated [DATE] revealed Resident #5 was able to make himself understood and was able to understand others. Resident #5 was assessed as cognitively intact. [...]

Inspectors wroteBased on record review and interview the facility failed to provide required transfer/discharge notifications. This affected three residents (#4, #68, and #87) of 32 residents reviewed for hospitalizations. Findings Include: 1. Review of Resident #68's medical record revealed diagnoses including type 2 diabetes mellitus, heart failure, borderline personality disorder, and mild intellectual disabilities. A nursing note, dated 02/04/22 at 4:49 P.M. indicated Resident #68 was vomiting, had garbled speech and weak hand grasps. The note indicated Resident #68 was only alert to person but was usually alert and oriented to person, place and time. Resident #68 was transported to the hospital. There was no evidence of a transfer/discharge notice being provided to Resident #68 or her representative. On 02/09/22 at 4:40 P.M. [...]

Inspectors wroteBased on record review and interview the facility failed to ensure Minimum Data Set (MDS) 3.0 assessments were accurate for all residents. This affected three residents (#3, #44 and #95) of 29 resident records reviewed for comprehensive assessments. Findings Include: 1. Review of Resident #44's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including hemiplegia, major depressive disorder and weakness. Review of Resident #44's comprehensive Minimum Data Set (MDS) 3.0 assessment, dated 12/21/21 revealed the resident received seven doses of a hypnotic medication and zero doses of an anticoagulant medication. Review of Resident #44's medication administration records from 12/15/21 to 12/21/21 revealed the resident did not receive any hypnotic medications and received seven doses of an anticoagulant medication. Interview on 02/09/22 at 9:05 A.M. [...]

Inspectors wroteBased on record review and staff interview the facility failed to refer Resident #57 for Pre-admission Screening and Resident Review (PASARR) Level Two after a new mental health diagnoses was identified. This affected one resident (#57) of three residents reviewed for PASARR. Findings Include: Record review revealed Resident #57 was admitted to the facility on [DATE] with diagnoses including diabetes insipidus, lymphedema, schizoaffective disorder (added 05/09/19), primary osteoarthritis, left knee, hypothyroidism, type 2 diabetes mellitus, and history of coronavirus disease (Covid-19). Review of Resident #57's PASARR application/form, completed on 05/17/16 revealed Section D, titled indications of serious mental illness was marked no. No other PASARR application/form was completed after 05/17/16. [...]

Inspectors wroteBased on observation, record review and interview the facility failed to ensure fall interventions were in place for Resident #7 as ordered by the physician and care plan to prevent falls. The facility also failed to implement safe smoking practices to prevent accidents/injuries associated with resident smoking. This affected three residents (#7, #44 and #49) of four residents reviewed for accidents. The facility identified 12 residents (#4, #7, #20, #44, #49, #56, #67, #70, #82, #87, #96 and #98) who smoked in the facility. Findings Include: 1. Review of Resident #7's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including unspecified dementia without behavioral disturbance, major depressive disorder and difficulty in walking. [...]

Inspectors wroteBased on observation, record review and interview the facility failed to ensure medications were stored properly. This affected two residents (#100 and #154) of six residents reviewed for medication storage. Findings Include: 1. Review of Resident #100's medical record revealed the resident was readmitted to the facility with diagnoses including diabetes, morbid obesity and weakness. Review of Resident #100's annual Minimum Data Set (MDS) 3.0 assessment, dated 01/19/22 revealed the resident exhibited intact cognition On 02/09/22 at 7:38 A.M. [...]

Inspectors wroteBased on record review and interview the facility failed to provide timely dental services for Resident #19 with identified decaying teeth. This affected one resident (#19) of 32 residents reviewed for dental condition. Findings Include: Review of Resident #19's medical record revealed diagnoses including dementia with behavioral disturbance, legal blindness, and anxiety disorder. Record review revealed the most recent dental consult was dated 02/19/21. An annual Minimum Data Set (MDS) 3.0 assessment, dated 11/17/21 indicated Resident #19 was sometimes able to make herself understood and was sometimes able to understand others. The assessment revealed Resident #19 required extensive assistance from staff for personal hygiene. The MDS indicated Resident #19 did not have obvious or likely cavities. Nurse practitioner notes, dated 11/23/21 at 4:37 P.M., 12/10/21 at 2:57 P.M., 12/21/21 at 2: [...]