Greenbrier Nursing And Rehabilitation Center

Based on observations, interviews, and facility policy review, it was determined that the facility failed to ensure medication on 2 of 2 medications carts and 1 of 1 treatment cart had medications safely secured and 1 of 1 medication room had medications safely secured for 3 carts and 1 medication room reviewed for medication storage. Findings include: Review of a facility policy titled, Medication Storage in the Facility, revised in January 2018, indicated medications should be stored safely and securely with access limited to licensed personnel and pharmacy staff. During an observation on 09/10/2024 at 4:57 AM, the 500-Hall medication room, located directly behind the nurse's desk, had the door propped open by a trash can in the doorway. A sign on the door stated, Medication Room, as well as a sign on the door indicating Door to be closed at all times. LPN (Licensed Practical Nurse) #5 was sitting at the nurse's desk, along with Certified Nursing Assistant (CNA) #13 standing at the kiosk, located to the left of the nurse's desk. At 5:20 AM, LPN #5 had prepared medication for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and interview the facility failed to ensure food products were discarded on or before the expiration date, food preparation surfaces are sanitized between use, and staff properly washed hands with soap and water to prevent cross-contamination effecting 74 of 74 residents who reside within the facility and receive foods or services from the kitchen. The findings include: During an observation and interview on 09/09/2024 at 1:00 PM, the Dietary Manager walked outside of the facility to where the dumpsters were located, and she opened the gate for the dumpsters. Upon re-entering the kitchen and without washing her hands, the Dietary Manager opened the ice machine lid and touched parts of the inside of the ice machine. This ice machine was used by kitchen staff to provide beverages for all residents. The Dietary Manager stated her hands should have been washed between going outside and coming inside and touching clean supplies. During a concurrent observation and interview on 09/09/2024 at 2:00 PM, Dietary Aide #1 wiped down the kitchen countertop with a washcloth.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews, record review, facility document review, facility policy review, it was determined that the facility failed to ensure aseptic technique was maintained during Peripherally Inserted Central Catheter (PICC) line Intravenous (IV) medication administration 1 (Resident #14) of 6 residents observed during medication administration. The facility also failed to initiate and or follow Enhanced Barrier Precautions (EBP) for 3 residents (Resident #14, #24, and #53) of 9 residents reviewed for infection control. Findings include: 1. Review of a facility policy titled, Handwashing/Hand Hygiene, dated 11/22/2017, indicated hand hygiene was the primary means to prevent the spread of infections and should not be replaced with the use of gloves. Integration of hand hygiene with glove use is recognized as best practice for preventing healthcare-associated infections. 2. Review of an undated facility policy titled, Infusion Therapy/Medication Administration indicated, hand hygiene should be performed after identifying the resident and explaining the procedure. An…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, record review, and interviews, it was determined the facility failed to provide an environment that promoted maintenance or enhancement of the resident's quality of life by not dressing the resident in clean clothes after showering/bathing and not dressing the resident in clean clothes daily for 1 (Resident #45) of 1 resident reviewed for resident rights. The findings are: The annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/20/2024, revealed Resident #45 had a Brief Interview for Mental Status (BIMS) score of 3 which indicated the resident had severe cognitive impairment. Further review indicated the resident had a diagnosis of Alzheimer's disease and required setup assistance for upper body dressing. A review of Resident #45's care plan, revised on 07/19/2021, revealed the resident had an activity of daily living (ADL) self-care deficit related to Alzheimer's, confusion, and dementia. Interventions included providing assistance of one staff for bathing and dressing. On 09/09/2024 at 11:44 AM, during a concurrent observation and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews, record review, and facility policy review, it was determined the facility failed to ensure a Minimum Data Set (MDS) assessment was accurately completed for 1 (Resident #50) of 18 sampled residents who were reviewed for MDS assessment accuracy. Specifically, the facility failed to ensure information regarding a resident's tobacco use was accurately completed. Findings include: A review of the admission Record, indicated the facility admitted Resident #50 with diagnoses that included nicotine dependence, cigarettes, with other nicotine-induced disorders and heart disease. The admission MDS, with an Assessment Reference Date (ARD) of 04/11/2024, revealed Resident #50 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident was cognitively intact. Section J1300 indicated Resident #50 was not a tobacco user. A review of Resident #50's care plan, with a revised date of 07/15/2024, revealed no focus, goal or interventions for tobacco use. A review of the Nsg [Nursing] Smoking Assessment and Care Plan, dated 04/05/2024,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews, record review, and facility policy review, it was determined the facility failed to ensure a care plan was accurately completed for 1 (Resident #50) of 18 sampled residents who were reviewed for a comprehensive care plan. Specifically, the facility failed to ensure information regarding a resident's tobacco use was accurately documented. Findings include: Review of the admission Record, indicated the facility admitted Resident #50 with diagnoses that included nicotine dependence, cigarettes, with other nicotine-induced disorders and heart disease. The admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/11/2024, revealed Resident #50 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident was cognitively intact. Section J1300 indicated Resident #50 was not a tobacco user. Review of Resident #50's care plan, with a revised date of 07/15/2024, revealed no focus, goal or interventions for tobacco use. Review of the Nsg [Nursing] Smoking Assessment and Care Plan, dated 04/05/2024, revealed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review the facility failed to ensure milk and refrigerated foods were not stored and served to residents beyond the expiration or use by date and food and beverages were served in a sanitary manner to prevent cross contamination for 1 (Resident #51) of 5 (Residents #40, #51, #57, #60 and #61) sampled residents who eat in the 400 Hall Dining Room. The failed practices had the potential to affect 67 residents who received meals from the kitchen (total census: 67) as documented on a list provided by the Administrator on 08/24/23 at 4:15 PM and 10 residents who eat in the 400 Hall Dining Room as documented on a list provided by the Administrator on 08/24/23 at 10:35 AM. The findings are: 1. On 08/21/2023 at 10:31 AM, the Surveyor observed 6 half-pint cartons of 1% milk with an expiration date of 08/16/23 in the cooler. The Surveyor asked Dietary Employee (DE) #1 what the process was for putting milk on the breakfast trays, and who was responsible for serving milk to the residents. DE #1 said, The dishwasher puts milk on the trays. DE #2…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure Physician Orders for oxygen were followed for 1 (Resident #49) and all oxygen tubing, humidifier bottles and oxygen bags were dated for 2 (Residents #49 and #568) of 3 (Residents #12, #49 and #568) sampled residents who had Physician Orders for oxygen therapy on the 100 Hall and the 300 Hall. The findings are: 1. Resident #49's Physician Orders dated 04/30/23 noted the resident was to receive Oxygen (O2) at 2 liters per minute via nasal cannula every shift and the O2 tubing was to be changed and dated every Saturday on day shift. a. A Care Plan with an initiated date of 05/18/21 noted Resident #49 received O2 therapy at 2 liters per minute via nasal cannula and the O2 tubing was to be changed and dated every Saturday. b. On 08/21/23 at 11:40 AM, Resident #49 was lying in bed receiving O2 via nasal cannula at 1 liter per minute. c. On 08/22/23 at 10:50 AM, Resident #49 was lying in bed receiving O2 via nasal cannula at 1 liter per minute. The humidifier bottle on the concentrator was not dated. d. On…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure floors and bedside tables were clean for 1 (Resident #7) of 19 (Residents #3, #7, #10, #12, #14, #18, #20, #29 #33, #37, #40, #41, #49, #53, #54, #57, #60, #61 and #568) sampled residents. The findings are: a. On 08/21/23 at 1:01 PM, Resident #7 was lying in bed. A clear liquid measuring half the length of the bed was on the floor under Resident #7's bed. b. On 08/21/23 at 4:14 PM, Resident #7 was lying in bed with the bedside table across the bed. Smeared across half of the surface of the bedside table was a sticky, clear substance. The large amount of clear liquid remained on the floor under the bed. c. On 08/22/23 at 10:48 AM, Resident #7 was lying in bed. The bedside table was across the bed and the same sticky, clear substance remained on over half of the surface of the tabletop with Resident #7's personal belongings sitting on top of the smeared surface. The clear liquid remained under the bed. The liquid now measured less than half the length of the bed. d. On 08/22/23 at 3:43 PM, the Surveyor…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review and interview, the facility failed to ensure nail care was regularly provided for 1 (Resident #7) of 5 (Residents #3, #7, #10, #49 and #54) sampled residents on the 100 Hall. The findings are: a. A Care Plan with a revision date of 07/05/23 noted Resident #7 had an ADL (Activities of Daily Living) self-care performance deficit related to impaired mobility and required extensive assistance for personal hygiene needs. b. On 08/21/23 at 1:01 PM, Resident #7 was lying in bed. Her fingernails extended approximately ¼ to ½ inch past the fingertips with a brown substance underneath them. Resident #7 stated, My nails are in horrible shape. I used to have beautiful nails. When you can't see to do them yourself, you can't help it. The Surveyor asked if she liked her nails the way they were. Resident #7 answered, No, they need cutting. They are sharp. c. On 08/22/23 at 10:48 AM and 3:15 PM, Resident #7's fingernails remained approximately ¼ to ½ inch past the tips of her fingers with a brown substance under them. d. On 08/22/23 at 3:42 PM, the Surveyor…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure dental/oral care products were stored in a sanitary manner to prevent the potential for infection for 1 (Resident #37) of 1 sampled resident on the 300 Hall. a. On 08/21/23 at 11:37 AM, sitting on the back of Resident #37's bathroom sink were 2 unlabeled denture cups. A denture toothbrush and a tube toothpaste were lying on the back of sink behind the handles of the sink. The toothbrush was uncovered, and the bristles of the toothbrush were touching the sink. The toothpaste did not have a lid on it. b. On 08/22/23 at 9:53 AM, sitting on the back of Resident #37's bathroom sink was 2 unlabeled denture cups. A denture toothbrush and a tube toothpaste were lying on the back of sink behind the handles. The toothbrush was uncovered, and the bristles were touching the sink. The toothpaste did not have a lid on it. c. On 08/23/23 at 1:45 PM, sitting on the back of Resident #37's bathroom sink were 2 unlabeled denture cups. A denture toothbrush and a tube of toothpaste were lying on the back of the sink behind…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.