The Graybrier Nursing and Retirement Center

In the surveyor’s words

From the most serious findings on record at The Graybrier Nursing and Retirement Center, in the surveyor’s own words.

• Actual harm, isolatedF689Jan 19, 2024

  Based on observation, record review, and interviews of resident, staff, and physician, the facility failed to provide care in a safe manner that prevented Resident #1 from rolling out of her bed during the provision of personal care. Resident #1 fell from her bed onto the floor and sustained a hematoma to her right temple and laceration to her lower right leg. Resident #1 was sent to the Emergency Department and was diagnosed with a closed hip fracture next to her hardware from a previous hip fracgture, laceration of the right lower leg that was too wide to suture, pain, and right temple hematoma head injury. This deficient practice affected one of two sampled residents (Resident#1). […]

• No harm, potential for more than minimal, patternF757Jan 6, 2022

  Based on record reviews, and staff, Nurse Practitioner and Medical Director interviews, the facility failed to hold blood pressure medications as ordered for 2 of 13 residents whose medications were reviewed (Residents #50 and #83). The findings included: 1) Resident #50 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident #50's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Hold for systolic blood pressure less than or equal to 110 or diastolic blood pressure less than or equal to 60. The annual Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #50 was alert and oriented. […]

• No harm, potential for more than minimal, isolatedF641Jan 22, 2026

  Based on record reviews and staff interviews, the facility failed to code the Minimum Data Set (MDS) assessment accurately in the areas of accidents (Resident #37) and urinary catheter (Resident #25) for 2 of 19 residents whose MDS assessments were reviewed (Resident #37 and Resident #25). The findings included: 1) Resident #37 was admitted to the facility on [DATE] with diagnoses that included muscle weakness, history of a left hip fracture and mild cognitive impairment. A review of Resident #37's medical record showed that she experienced three falls since the last quarterly MDS assessment dated [DATE]: a fall with major injury on 8/1/25, a fall with no injury on 8/9/25, and a fall with minor injury on 10/19/25. […]

• No harm, potential for more than minimal, isolatedF578Oct 17, 2024

  Based on record review and staff interviews, the facility failed to update the Do Not Resuscitate (DNR) status for 1 of 32 residents reviewed for Advanced Directives (Resident #10). The findings included: Resident #10 had been admitted on [DATE]. Resident #10's admission Minimum Data Set assessment dated [DATE] indicated she had severe cognitive impairment. A Care Plan with an initiation date of [DATE] and a review date of [DATE] indicated Resident #10 had a Full Code status. The care plan goal was to honor the Full Code status. Interventions included staff will follow the Advanced Directives as written. On [DATE] Resident #10's electronic medical record (EMR) was observed to have Full Code status indicated on the resident dashboard (information banner). […]

• No harm, potential for more than minimal, isolatedF684Oct 17, 2024

  Based on observation, record review, and interviews with the Medical Director and staff, the facility failed to obtain an order to delay the removal of sutures until the wound was healed for 1 of 2 residents reviewed for professional standards (Resident #62). The findings included: Resident #62 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease and dementia. The admission Minimum Data Set (MDS) dated [DATE] indicated Resident #62 was severely cognitively impaired without mood or behavioral concerns. Review of the nurses' notes revealed an entry dated [DATE] that Resident #62 had a witnessed fall on [DATE]. […]