Greenbriar Nursing Center

In the surveyor’s words

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

• Actual harm, isolatedF656Mar 19, 2026

  Based 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) .Findings include:A record review of the Care Plan Report revealed Resident #1 had a focus of an ADL (activities of daily living) self-care performance deficit with interventions initiated on 7/14/25 that included, BED MOBILITY: The resident requires x (times) 2 staff to turn and reposition in bed.A record review of the facility's investigation revealed that on 2/11/26 at… […]

• Actual harm, isolatedF689Mar 19, 2026

  Based 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.Findings include:A record review of the facility's investigation, undated, revealed that on 2/11/2026, at approximately 10:05 PM, CNA #1 was providing in-bed care to Resident #1, including a linen and brief change. During care, Resident #1 rolled to assist. She subsequently rolled too far and exited the bed, landing on the floor. […]

• No harm, potential for more than minimal, patternF657May 26, 2026

  Based 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. […]

• No harm, potential for more than minimal, patternF584Feb 10, 2026

  Based 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.Findings include:A review of the facility's policy, Resident Rights, revised February 2023, revealed, .The resident has the right to a dignified existence.8. Safe environment. The resident has a right to a safe, clean, comfortable, and homelike environment, including.treatment and supports for daily living safely .On 2/9/26 at 10:50 AM, during an observation and interview with the facility owner, linen closets, supply closets, and nurses' station supply rooms were observed. […]

• No harm, potential for more than minimal, patternF880Jun 12, 2025

  Based 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. Findings included: A review of the facility's Hand Hygiene Policy, dated 8/23, revealed, .The facility considers hand hygiene the primary means to prevent the spread of infections. All staff will perform proper hand hygiene procedures to prevent the spread of infection .Policy Guidelines .6. Additional considerations: a. The use of gloves does not replace hand hygiene. […]