Greenbriar Healthcare Rehabilitation and Nursing C

In the surveyor’s words

From the most serious findings on record at Greenbriar Healthcare Rehabilitation and Nursing C, in the surveyor’s own words.

• Actual harm, isolatedF689Aug 20, 2024

  Based on observations, interviews, record review, and policy review, the facility failed to ensure one (#1) of four residents sampled were free from burn hazards during activities coffee social hour. Findings included: Review of the Resident Admission Record dated 08/19/24, showed Resident #1 was originally admitted to the facility on [DATE] and readmitted on [DATE]. The resident was admitted with diagnoses that included but not limited to Dementia unspecified severity, without behavioral disturbance, weakness, need for assistance with personal care, cognitive communication deficit, muscle weakness, and encephalopathy. […]

• Actual harm, isolatedF760Mar 29, 2022

  Based on observations, interviews with residents and staff, medical record reviews, and review of facility policies, the facility failed to ensure residents were free from significant medication errors to prevent harm for two (#1 and #2) of five residents sampled for medication errors. The facility failed to ensure medications were administered in accordance with professional standards of practice, which resulted in Resident #1 and Resident #2 receiving multiple high risk medications which were not prescribed to them by a physician. […]

• No harm, potential for more than minimal, patternF680Jul 17, 2025

  Based on interviews, review of facility records and policy, the facility failed to have a qualified professional over the activities program with potential to impact a full census of 77 out of 77 current residents.Findings included:Review of the facility employee roster revealed staff M, Activity Director has worked at the facility since 12/4/2024.During an interview on 07/17/2025 at 10:30 a.m. with Staff M, Activity Director, Staff M stated he was the activities director at the facility. […]

• No harm, potential for more than minimal, patternF761Jul 17, 2025

  Based on observations, staff interviews, resident interviews, medical record review, and facility policy review, it was determined that the facility failed to ensure all drugs and biologicals were stored in locked compartments and kept under proper temperature controls.Findings included: 1. During a tour of the Rapid Recovery Unit (RRU) medication room on 7/15/25 at 2:30 p.m. an observation of the small, locked medication refrigerator was made with the Director of Nursing (DON). The top open shelf portion of the refrigerator was observed to be covered in hard white frost. The white frost was observed to take up most of the room in the top shelf area.The thermometer inside the refrigerator was observed to read 28 degrees ( ) Fahrenheit (F). […]

• No harm, potential for more than minimal, patternF645Jun 8, 2023

  Based on record review, staff interviews, and review of the facility's policy, the facility failed to complete the Preadmission Screening and Resident Reviews (PASARR) for residents with a mental disorder and individuals with intellectual disability following qualifying mental health diagnosis for nine out of nine residents sampled for PASARRs (Residents #68, #19, #31, #29, #12, #30, #60, #25 and #42). Findings included: Review of the electronic medical record (EMR) revealed Resident #68 was admitted to the facility on [DATE]. […]