Greenbrier Nursing & Rehabilitation Center of Pale

Inspectors wroteBased on observation, interview, and record review the facility failed to, based on the comprehensive assessment of a resident, ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 4 residents (Resident #1) reviewed for quality of care. The facility failed to ensure Resident #1 was appropriately bathed on 4/14/26 and 4/15/26 when EKG electrodes were left adhered to her skin. The facility failed to ensure Resident #1's skin as appropriately assessed on 4/15/26 when EKG electrodes were left adhered to her skin. This failure could place all residents who receive bed baths or skin assessments at risk of skin breakdown, infection, and hospitalization.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure each resident was treated with respect and dignity and care for each resident in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 1 of 5 residents (Residents #1) reviewed for Resident Rights. The facility failed to ensure CNA A did not use profanity while completing incontinent care for Resident #1. This failure could place residents at risk of emotional distress and diminished quality of life.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 2 of 5 residents (Resident #2 and #3) reviewed for ADL care. The facility failed to ensure Residents #2 and #3 were provided appropriate incontinent care. This failure could place residents at risk of loss of dignity, skin breakdown, infection, and hospitalization.

Inspectors wroteBased on observation, interview and record review the facility 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 for 3 of 5 residents (Residents #8, #21 and #57) and of 4 of 6 staff (CNA A, CNA B, CNA C and CNA D) reviewed for infection control. 1. The facility failed to ensure CNA B and CNA D washed or sanitized their hands and failed to remove the dirty brief prior to place a new brief during incontinent care provided to Resident #8 on 1/28/2026.2. The facility failed to ensure CNA A and CNA B followed enhanced barrier precautions and wore a gown and gloves when providing direct care to Resident #57 on 01/28/2026.3. [...]

Inspectors wroteBased on observations, interviews, and records review the facility failed to ensure residents who were incontinent of bladder received appropriate treatment and services for 1 of 8 residents (Resident #1) reviewed for incontinence. 1. The facility failed to provide appropriate incontinent care to Resident #1 when he was observed sitting in a wheelchair in his room with visibly wet clothing on and a strong odor of ammonia was detected from his room on 9/8/25 from 11:28 a.m. until 1:58 p.m. 2. The facility failed to provide appropriate incontinent care to Resident #1 when he was observed lying on sheets visibly soiled with yellow and brown stains and a strong odor of ammonia was detected from his room and his pants were visibly wet around his left hip on 9/9/25 from 2:54 p.m. until 5:06 p.m. [...]

Inspectors wroteBased on observations, interviews, and records, review the facility failed to 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 disease and infection for 1 of 8 residents (Resident #1) reviewed for infection control. The facility failed to maintain an infection control program on 9/8/25 at 2:00 p.m. when CNA A assisted Resident #1 with incontinent care without changing her gloves, washing/sanitizing her hands, or cleaning from clean (urethral) to dirty (rectal) areas in the correct order. These failures could place residents at risk of diminished quality of life, urinary tract infection, or hospitalization.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents who were incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 2 of 4 residents (Resident #1 and Resident #2) reviewed for incontinence. 1. The facility failed to provide appropriate incontinent care to Resident #1 when she was observed wearing two incontinent briefs (double briefed) on 6/9/25 at 10:15 a.m. 2. The facility failed to provide appropriate incontinent care to Resident #2 when she was observed wearing two incontinent briefs on 6/9/25 at 2:30 p.m. These failures could place residents at risk of skin break down, urinary tract infection, and diminished quality of life.

Inspectors wroteBased on observation, interview and record review the facility 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 for 1 of 7 residents (Resident #1) and 1 of 4 staff (CNA A) reviewed for infection control. The facility failed to ensure CNA A washed their hands upon entering rooms, donned appropriate PPE, and washed their hands upon exiting the room of Resident #1 when she was on contact precautions on 3/9/25. This failure could place residents at risk of exposure to infectious diseases due to improper infection control practices.

Inspectors wroteBased on observation, interview and record review the facility failed to maintain all mechanical, electrical, and patient care equipment, in safe operating condition for 1 of 1 stove in the kitchen reviewed for food service. 1. The facility failed to ensure the gas stove, in the kitchen, was in proper working order. 2. The facility failed to ensure three of six gas burners, on the stove, lit automatically, when the knob was turned (front on left, middle back, and right back). 3. The facility failed to ensure the pilot lights on the burners would stay lit and the Director of Food and Nutrition Service, had to use a striker, (a lighter with a long barrel), to light the burners. These failures could place residents at risk for injury and under cooked food.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury for 1 of 4 residents (Resident #26) reviewed for abuse and neglect. The facility failed to ensure allegations of abuse were reported to the state survey agency within 2 hours after it was reported to the administrator. This failure could place residents at risk of emotional, physical and mental abuse and neglect.

Inspectors wroteBased on interview and record review the facility failed to ensure comprehensive assessments were reviewed and revised by the interdisciplinary team after each assessment, which included both the comprehensive and quarterly review assessments for 1 of 4 residents (Resident #32) reviewed for care plans. The facility failed to ensure Resident #32's care plan was revised to reflected current condition after hospitalization and readmission to the facility. This failure could place residents at risk of not receiving appropriate care to meet their current needs.

Inspectors wroteBased on observation, interview and record review the facility 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 for 1 of 4 (CNA A) staff reviewed for infection control. 1. CNA A failed to perform hand hygiene after incontinent care. 2. CNA A failed to properly handle soiled linens and the brief for Resident #39 after performing incontinent care. These failures could place residents at risk of exposure to communicable diseases and infections.