Greenbriar Center

In the surveyor’s words

From the most serious findings on record at Greenbriar Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF760Apr 19, 2022

  Based on medical record review, review of hospital records, review of laboratory test results, review of the facility policy titled [MEDICATION(S)] Monitoring, review of the Prescriber's Digital Reference ( www.pdr.net) website and interviews with the facility staff, the facility failed to contact the physician or nurse practitioner regarding critical laboratory results and continued to administer an oral anticoagulant [MEDICATION(S)] (a blood thinning medication ) to Resident #30 who had Prothrombin Time (PT) and International Normalization Ratio ( INR) levels ( levels to monitor blood clotting time to prevent serious risk of bleeding ) at critical levels. […]

• Actual harm, isolatedF689Feb 25, 2026

  THE 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. […]

• Actual harm, isolatedF697Nov 19, 2024

  Based 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. […]

• Actual harm, isolatedF692Jul 17, 2023

  THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on observation, record review, facility policy and procedure review and interview, the facility failed to meet the total nutritional needs of Resident #71, who received all nutrition/hydration via a percutaneous enteral gastronomy (peg) tube, to prevent a severe weight loss and abnormal sodium levels. The facility also failed to timely identify the weight loss and implement effective interventions to prevent additional weight loss for the resident. […]

• Actual harm, isolatedF684Oct 11, 2022

  Based on observation, record review, facility Self-Reported Incident (SRI) review, personnel file review, facility policy and procedure review and interview the facility failed to ensure incontinence care was provided in a manner to prevent an injury to Resident #5 and to ensure the care provided met the resident's total care needs. This affected one resident (#5) of three residents reviewed for incontinence care. Actual harm occurred on 09/26/22 when State tested Nursing Assistant (STNA) #9 provided rough care and forcefully pushed Resident #5 in bed while providing incontinence care resulting in the resident's buttocks splitting into an open wound. Prior to the injury occurring, Resident #5 had asked the STNA to stop, which she did not immediately. […]