Greenbriar Community Care Center

Inspectors wroteBased on record review and interviews, the facility failed to ensure the Minimum Data Set (MDS) assessments accurately reflected the resident's status for 1 (#11) of 5 (#11, #12, #13, #62, and #82) sampled residents reviewed for unnecessary medications. Review of Resident #11's Clinical Record revealed an admission date of 10/11/2021 with diagnoses, which included Abdominal Aortic Aneurysm without Rupture. Review of Resident #11's MDS with an Assessment Reference Date (ARD) of 08/21/2025 revealed in part, the following:Question N0415E1: Medications: Anticoagulant: Yes. Review of Resident #11's current Physician Orders revealed in part, the following:Start date: 10/12/2021, Aspirin Tablet Chewable 81 milligram (MG), give 1 tablet by mouth one time a day. Further review revealed no physician ordered anticoagulant. An interview was conducted on 10/01/2025 at 2:42 p.m. with S3CCC. [...]

Inspectors wroteBased on observation and interview, the facility failed to post the names, addresses, and telephone numbers of pertinent state agencies and advocacy groups, such as the State Survey Agency, the State licensure office, adult protective services where state law provides for jurisdiction in long-term care facilities, the protection and advocacy network, home and community based service programs, and the Medicaid Fraud Control Unit. This deficient practice had to the potential to affect all 159 residents residing in the facility.

Inspectors wroteBased on observations and interviews, the facility failed to ensure nurse staffing data posted on a daily basis was at the beginning of each shift and included the actual hours worked by licensed and unlicensed nursing staff directly responsible for resident care. This deficient practice had the potential to affect the 159 residents residing in the facility. On 09/29/2025 at 8:00 a.m., an observation was made of the nurse staffing hours posted at the front desk labeled scheduled and dated 09/29/2025. On 09/29/2025 at 2:26 p.m., an interview was conducted with S4AA. She stated she was responsible for posting the nurse staffing data. She stated the nurse staffing hours posted were the scheduled hours for the entire day and not the actual hours. She stated she did not post the nurse staffing hours at the start of every shift. On 09/30/2025 at 8:57 a.m. [...]

Inspectors wroteBased on interviews and record reviews the facility failed to ensure a resident's comprehensive plan of care was developed and implemented for 1 (#2) of 3 (#1, #2 and #3) residents reviewed for care plans. The facility failed to ensure Resident #2's care plan was developed for wandering behaviors. This deficient practice had the potential to affect the current 28 residents residing on E Hall.

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure an allegation of sexual abuse was reported to the administrator, state agency and the local law enforcement in the appropriate time frame for 1 (#1) of 3 ( #1, #2, and #3) residents reviewed for abuse.

Inspectors wroteBased on interviews and record review, the facility failed to ensure resident assessments accurately reflected the resident's status for 1 (#2) of 3 (#1, #2, and #3) residents reviewed for MDS.

Inspectors wroteBased on record reviews, observation, and interviews the facility failed to revise and implement a comprehensive person-centered care plan which met the needs of 1 (#2) of 3 (#1, #2 and #3) sampled residents.

Inspectors wroteBased on interviews and record review the facility failed to ensure services were provided by the facility to meet quality professional standards. The facility failed to ensure a medication was transcribed properly for 1 (#153) of 33 sampled residents.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to store and prepare food under sanitary conditions. The facility failed to ensure: 1. Food was properly stored and labeled in the walk-in freezer of the facility's kitchen; 2. Food was properly stored and labeled in the walk-in refrigerator of the facility's kitchen; and 3. Food was properly stored and labeled in the walk-in food storage room of the facility's kitchen. This deficient practice had the potential to affect 165 residents who were served meals from the facility's kitchen.

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure residents were free of significant medication errors for 1 (#87) of 2 (#82 and #87) residents reviewed during narcotic medication review. The deficient practice had the potential to effect the 165 residents residing in the facility receiving medications.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure expired medications and biologicals were not available for use and administration to residents as evidenced by: Having expired medications for 1 (Cart B) of 4 (Cart A1, Cart A2, Cart B, and Cart F) reviewed for med storage. Findings Review of the facility's policy titled Medication Administration dated 11/28/2017 revealed the following: Procedure: Do not administer medications passed their expiration date. An observation was made on 09/09/2024 at 4:36 p.m. with S6CC and S7LPN of Cart B. The following was observed: 1 bottle of eye drops with expiration date 07/2024; 1 bottle of oral liquid Morphine with open date of 07/21/2024 and no expiration date. An interview was conducted with S7LPN on 09/09/2024 at 4:37 p.m. [...]

Inspectors wroteBased on observation, interviews, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary environment to help prevent the development and transmission of infection for 1 (#87) of 5 (#11, #82, #87, #94, and #146) residents reviewed for infection control. The facility failed to ensure staff wore proper Personal Protective Equipment (PPE) while providing care to a resident who was on Enhanced Barrier Precautions (EBP).

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles for 2 (Med Room a and Med Room b) of 2 (Med Room a and Med Room b) medication storage rooms observed. The facility failed to ensure: 1. Tuberculin multi-dose vial and Influenza Vaccine multi-use vial were labeled with the date opened; and 2. Temperatures were documented for the medication refrigerator in Med Room b.

Inspectors wroteBased on record review, observations, and interviews, the facility failed to store, prepare, and serve food in accordance with professional standards for food service safety. This had the potential to effect 145 residents who were served meals from the kitchen.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure interventions for falls were implemented as identified on the care plan for 1(#127) of 3 (#99, #127, and #456) residents reviewed for falls.

Inspectors wroteBased on interviews and record review, the facility failed to electronically submit accurate payroll information for direct care staffing as required.