Greenbriar Nursing Center

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to revise care plans to accurately reflect residents' infection control status for two (2) of three (3) residents reviewed for infection control. Resident #1 and Resident #3Findings include:A review of the facility's policy, Care Plan Revisions Upon Status Change, dated November 2024, revealed, .to provide a consistent process for reviewing and revising the care plan. Policy Guidelines.1. care plan will be reviewed, and revised as necessary. 2. Procedure for.revising the care plan.d.care plan will be updated with the new or modified interventions. f. Care plans will be modified as needed. h.to ensure care plans have been updated to reflect current resident needs. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement the comprehensive person-centered care plan requiring two (2) staff to assist with bed mobility, when staff provided care without the required assistance, resulting in the resident falling from the bed and sustaining a proximal humeral fracture (a break in the upper arm bone near the shoulder) for one (1) of three (3) sampled residents (Resident #1) .

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident was free from accident hazards during bed mobility when a Certified Nursing Aide (CNA) performed a linen and brief change without the required two (2) person assistance, in which Resident #1 fell from the bed and sustained a proximal humeral fracture (a break in the upper arm bone near the shoulder) for one (1) of three (3) residents reviewed for accidents.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure the residents' right to a clean, comfortable, and homelike environment as evidenced by adequate clean linens and washcloths were unavailable for resident care for one (1) of two (2) survey days.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure perineal care was provided in a manner to prevent the possible spread of infection when a Certified Nurse Aide (CNA) failed to perform hand hygiene during care for one (1) of four (4) residents observed for care, Resident #22.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to maintain privacy during the provision of perineal care for one (1) of four (4) residents observed for care, Resident #22.

Inspectors wroteBased on observation, interview, and record review, and facility policy review the facility failed to ensure the protection of privacy and confidentiality of resident care information when clinical instructions were posted in public view without safeguards for one (1) of eighteen (18) sampled residents, Resident #78.

Inspectors wroteBased on record review, staff interview, and facility policy review, the facility's Quality Assurance and Performance Improvement (QAPI) Committee failed to sustain corrective actions to prevent recurrence of a previously cited deficiency, specifically, the facility was cited for failing to provide Percutaneous Endoscopic Gastrostomy (PEG) care in a manner to prevent the possible spread of infection during an annual recertification survey on 2/8/24 and was cited again for the same deficiency during the current survey, demonstrating that QAPI failed to sustain ongoing monitoring and oversight to prevent recurrence for one (1) of four deficiencies cited. F880.

Inspectors wroteBased on staff interview, record review, and facility policy review, the facility failed to report an allegation of sexual abuse within two (2) hours, as required, when Resident #1 verbalized she was sexually abused for one (1) of three (3) sampled residents.

Inspectors wroteBased on observation, staff interview, record review, and facility policy review, the facility failed to provide peg tube care (Resident #29) and catheter care (Resident #61) in a manner to prevent the possible spread of infection for two (2) of five (5) resident care observations. Findings Include: Review of the facility's Gastrostomy Site Care Policy, dated 10/23, revealed, Policy: It is the policy of this facility to perform gastrostomy site care as ordered. Policy Guidelines .14. Using soap and water/wound cleanser gently clean the area around the tube and continue in an outward circular fashion, ensuring that under the bolster is cleaned . Review of the facility's Hand Hygiene Policy, dated 8/23, revealed, Policy: This facility considers hand hygiene the primary means to prevent the spread of infections. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain a comfortable room temperature levels of 71 degrees to 81 degrees Fahrenheit (F) for two (2) of 18 sampled residents.

Inspectors wroteBased on observation, interviews, record review, and the facility policy review, the facility failed to accurately code the Minimum Data Set (MDS) related to restraints for two (2) of 18 sampled residents. Resident #30 and Resident #36 Findings Include: A review of the facility's MDS 3.0 Completion Policy, dated October 2023, revealed, Policy Statement: Residents are assessed, using a comprehensive assessment process, in order to identify care needs and to develop an interdisciplinary care plan .Policy Guidelines .4. Care Plan Team Responsibility for Completion go MDS Sections .a. ii. Persons completing .the assessment must attest to the accuracy of the section they completed . Resident #30 During an observation on 2/5/24 at 1:35 PM, Resident #30 was observed to have one full length bedrail on one side of the bed and 1/4 (quarter) length side rail on the other. [...]

Inspectors wroteBased on staff interviews and record review, the facility failed to ensure two (2) of two (2) sampled residents received written notice of transfer to the hospital. Resident # 23 and Resident # 67.

Inspectors wroteBased on observation, staff interviews, record review and facility policy review the facility failed to follow the care plan related to catheter/incontinent care and failed to develop an approach for securing a catheter tube for two (2) of 19 care plans reviewed, Resident #35 and Resident #117. Findings Include: Record review of the facility's policy, Comprehensive Care Plans, dated September 2018, it is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident's rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified assessment in the resident's comprehensive assessment. Resident #35 On 11/3/21 at 9:55 AM. [...]

Inspectors wroteBased on observation, staff interviews, record review and facility policy review the facility failed to provide catheter/incontinent care in a manner to prevent infection and trauma to the meatus during catheter/incontinent care for two (2) of three (3) catheter care observations Resident #35 and Resident #117.

Inspectors wroteBased on observation, staff and resident interviews, the facility failed to ensure food was served at a palatable and satisfactory temperature for five (5) of twelve (12) residents interviewed in Resident Council. (Residents #16, #26, #38, #42, and #53) Finding Include: On 11/02/21 at 2:00 PM, during Resident Council meeting, residents complained of receiving cold food if they decide to eat in their rooms and not in the dining area. The residents explained that all three meals have been served cold in their rooms. Residents explained they have talked about food being cold in previous resident council meetings and have made the Social Worker aware of the cold food. At 3:00 PM on 11/02/21, during an interview with Social Worker, she explained she does attend the resident council meetings monthly at the request of the residents and takes the meeting minutes. [...]

Inspectors wroteBased on observations, interviews, record reviews, and facility policy review, the facility failed to prevent the possible spread of infection while providing incontinent care for two (2) of three (3) observations. Resident #35 and Resident #45. Findings Include: Record review of the facility's policy, Hand Hygiene Policy, dated March 2020, revealed, Policy: The purpose of this policy is to provide guidelines for proper hand hygiene to prevent spread of infection to other personnel, residents, and visitors. Policy Guidelines: All facility personnel must perform hand hygiene for at least 20 seconds under the following conditions: .8. Before handling clean or soiled dressings/linens/etc. 9. Before performing resident care procedures .11. After handling soiled dressings/linen, contaminated equipment, etc. 12. [...]