Greenbrier Village Health and Rehabilitation

In the surveyor’s words

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

• Immediate jeopardy, patternF678Feb 10, 2023

  On [DATE], an Immediate Jeopardy (IJ) situation was determined to exist related to the facilities failure to ensure Resident #100 received CPR; the facility failed to ensure a systemic approach was used to determine what a resident's code status was for four (#60, 75, 89 and #95) of four sampled residents. Resident #100 had a physician's order for CPR/full code on [DATE], no DNR was in place. On [DATE] at 9:48 p.m. Resident #100 presented with a cough. 22 minutes later at 10:10 p.m. per a late entry nurses note at 11:45p.m. Resident #100 was found with pupils fixed and dilated. The physician was notified at 10:15 p.m. and there was no documentation that CPR had been initiated. […]

• No harm, potential for more than minimal, widespreadF812Jun 25, 2026

  Based on observation, record review, and interview, the facility failed to ensure their ice machine was maintained in a sanitary condition. The DON identified 99 residents received food and drinks from the kitchen.Findings: On 06/21/26 at 10:53 a.m., the ice machine located in the dining room was observed to have a black substance inside the ice storage bin when wiped with a paper towel. The facility had no documentation to show the ice machine was cleaned and sanitized. An Ice Machines and Ice Storage Chests policy, dated 01/01/12, read in part, To help prevent contamination of ice machines, staff shall clean and sanitize the tray and ice scoop daily. On 06/21/26 at 10:54 a.m., dietary #1 stated the ice machine was cleaned by environmental staff. […]

• No harm, potential for more than minimal, widespreadF851Jun 25, 2026

  Based on record review and interview, the facility failed to ensure the required PBJ staffing data was submitted to CMS within the mandated timeframe.The DON identified 99 residents resided in the facility.Findings:A PBJ Staffing Data Report, dated 01/01/26 through 03/31/26 (Fiscal Year quarter 2 2026), showed the facility had not provided the staffing data to CMS for the PBJ staffing data report for quarter two of federal fiscal year 2026.On 06/24/26 at 2:59 p.m., the administrator stated they could not locate documentation the PBJ staffing data was submitted to CMS for quarter two.

• No harm, potential for more than minimal, widespreadF880Jun 25, 2026

  Based on record review and interview, the facility failed to implement their legionella water management program to prevent waterborne contaminants. The DON identified 99 residents resided in the facility.Findings: A Legionella Water Management Program policy, dated 09/01/22, read in part, The water management program includes the following elements:a. A detailed description and diagram of the water system in the facility.b. The identification of areas in the water system that could encourage the growth and spread of Legionella or other waterborne bacteria.c. The identification of situations that can lead to Legionella growth.d. Specific measures used to control the introduction and/or spread of Legionella.e. A diagram of where control measures are applied.f. […]

• No harm, potential for more than minimal, widespreadF727Jul 3, 2025

  Based on record review and interview, the facility failed to ensure RN coverage for eight consecutive hours seven days per week.The administrator identified 81 residents resided in the facility.Findings:A PBJ [Payroll Based Journal] Staffing Data Report, dated 01/01/25 through 03/31/25, showed no RN hours on 03/30/25. A Timecard Report, dated 03/30/25, did not show RN coverage for eight consecutive hours.A Timecard Report, dated 06/01/25 through 06/30/25, did not show RN coverage for eight consecutive hours on 06/07/25.On 07/03/25 at 9:49 a.m., the administrator stated they had an RN scheduled for the dates above, but they called in. The administrator stated they replaced the RN with a license practical nurse.