Greenbrier Health Center

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Oct 8, 2025

  Based on observation, medical record review, review of a police report, facility policy review, and interview, the facility failed to provide adequate supervision to prevent Resident #117, a cognitively impaired resident with a history of elopement from eloping. This resulted in Immediate Jeopardy and the potential for Actual Harm on 09/14/25 at approximately 10:30 P.M. when Resident #117 exited the facility without staff knowledge and was found by local police (on 09/15/25 at approximately 12:10 A.M.) in the middle of a residential street of a neighborhood approximately 1.7 miles from the facility. When found, Resident #117 was confused and speaking in his native language (Russian), asking to go to a local ethnic meat market. […]

• Actual harm, isolatedF684Oct 26, 2023

  Based on closed medical record review, facility policy review and interview, the facility failed to collaborate care between nursing and physician services to identify and assess risk factors affecting quality of care and wellbeing of Resident #129 and placing Resident #129 at risk for the development of a blood clot and rehospitalization within 30 days of admission. Actual harm occurred on 09/01/23 when Resident #129, who had a history of embolism (blood clot), was at high risk for developing blood clots and was non-ambulatory, insisted on being sent to the hospital because the facility was not doing anything to address his complaints of severe pain in his left leg which was being treated at the facility as neuropathic pain. […]

• No harm, potential for more than minimal, widespreadF606Oct 8, 2025

  Based on personnel file review, interview, facility policy review and review of the Ohio Revised Code (ORC), the facility failed to hire staff free of disqualifying offenses. This affected three out of 12 personnel files reviewed for Licensed Practical Nurse (LPN) #639, Certified Nursing Assistant (CNA) #660 and Supply Coordinator (SC)/CNA #604 and had the potential to affect all 123 residents residing in the facility. Findings include:Review of CNA #660's personnel file revealed a date of hire of 01/25/22. Review of CNA #660's background check dated 12/27/22 revealed a conviction of theft 2913.02 from March 2004. No personal character standards were located in the personnel file or background check envelope. Review of SC/CNA #604's personnel file revealed a date of hire of 06/08/22. […]

• No harm, potential for more than minimal, widespreadF761Oct 8, 2025

  Based on observation, interview, record review and review of the facility policy revealed the facility failed to ensure stored medications for residents use were not expired and were kept at an appropriate temperature for use and failed to ensure Resident #61 medications were not left at bedside unsecured without confirmation of administration. This affected one resident (Resident #61) and had the potential to affect all residents residing at the facility. The facility census was 123. Findings include:1. Observation and interview on 09/23/25 at 12:05 P.M. of the medication storage room with Unit Manager (UM) #629 revealed expired stock medications located in the storage room. […]

• No harm, potential for more than minimal, widespreadF804Oct 8, 2025

  Based on observation and interviews, the facility failed to serve hot and palatable foods. This affected seven residents (Resident #3, #27, #52, #54, #69, #99 and #128) and had the potential to affect 120 of 123 residents receiving meals from the facility. The facility indicated three residents (Resident # 17, #23, and #67) who received nothing by mouth. The facility census was 123.1. Review of the medical record for Resident #3 revealed and admission date of 08/12/25. Diagnoses included but were not limited to acute embolism and thrombosis of right femoral vein, type II diabetes mellitus with neuropathy, and mild-protein calorie malnutrition. Resident #3 was noted to be cognitively intact, received a therapeutic diet and required set up for meals. Interview on 09/22/25 at 12:05 P.M. […]