Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around January 2027
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Greenbrier Health Center during CMS and state inspections, most recent first.
A cognitively impaired resident with a history of wandering and elopement exited the facility without staff knowledge and was found by police in a confused state over a mile away, after not receiving required 1:1 supervision due to a staff call-off that was not reported to administration. Additionally, the facility failed to secure smoking materials for several residents, with cigarettes and lighters found unsecured in resident rooms and combustible items present in the smoking area, contrary to facility policy.
Surveyors found expired medications in storage, improper refrigeration of temperature-sensitive drugs, and instances where an LPN left medications unsecured at a resident's bedside without confirming administration or documenting missed doses. These failures were confirmed by staff and affected at least one resident with multiple medical conditions.
Surveyors identified multiple deficiencies in facility cleanliness and maintenance, including chipped and rough hallway handrails, dusty and insect-filled light fixtures, missing light bulbs, water-stained ceiling tiles, stained privacy curtains, scuffed walls, dirty air conditioner filters, damaged bathroom doors, detached heat pipe covers, holes in wall coverings, extremely dirty wheelchairs, wall cracks, and exposed live telephone wires. These issues were observed in several resident rooms and common areas, impacting the safety and sanitation of the environment for all residents, staff, and visitors.
Multiple dependent residents did not receive scheduled showers as required by their care plans and facility policy, with documentation showing missed showers, incomplete records, and improper use of 'not applicable' in the MDS. Residents and staff confirmed that showers were not consistently provided, and observations noted poor hygiene in some cases. The deficiency was widespread and involved failures in both care delivery and documentation.
Multiple residents did not receive wound and device care as ordered, including missed or delayed dressing changes for wounds, central lines, and nephrostomy tubes, as well as inadequate incontinence care. Staff documented treatments that were not performed, and some residents were left in soiled briefs for extended periods, resulting in skin breakdown and wounds. The facility lacked clear policies and consistent practices for wound and device management.
The facility did not maintain sufficient nursing staff on the second floor, resulting in missed showers, delayed incontinence care, and prolonged wait times for assistance. Multiple residents reported unmet care needs, and staff confirmed that daily CNA coverage was consistently below the facility's own minimum requirements. Observations included a resident with a worsening wound due to infrequent care and another with a tracheostomy who was not suctioned as needed.
The facility did not update care plans to reflect the current needs of two residents. One resident with dementia and a rare brain disorder experienced multiple elopement incidents, but the care plan was not revised after these events. Another resident with physical impairments had no documented care plan meetings for over a year, despite claims that meetings occurred. These deficiencies resulted in care plans that did not accurately address the residents' needs.
A resident with multiple stage three pressure wounds did not receive wound care dressings as ordered. Although documentation indicated that daily wound care was completed, an LPN confirmed that the dressings were not actually provided as scheduled, and the records were inaccurate. This failure resulted in non-compliance with the facility's wound care policy.
A resident with a history of hemiplegia, COPD, and diabetes, who required substantial assistance with toileting, was found with a saturated incontinence brief, deep red skin on the buttocks, and dried urine stains on the bedsheets. The resident reported not being changed since the previous evening, and staff interviews revealed inconsistent incontinence care, contrary to facility policy.
Surveyors observed two residents receiving insulin injections where LPNs failed to properly prime insulin pens according to manufacturer instructions, resulting in a medication error rate above 5%. Both residents were cognitively intact and required daily insulin, but staff did not follow correct priming procedures before administration.
Two residents experienced significant medication errors due to missed and improperly administered medications. One resident did not consistently receive a prescribed medication for short bowel syndrome because it was locked in a provider office and not accessible to nursing staff, while another resident missed several doses of a prescribed antibiotic due to pharmacy delivery delays and issues with medication removal from the dispensary. These errors were confirmed through record reviews, staff interviews, and pharmacy documentation.
A resident with chronic pain conditions did not receive pain medication as ordered due to an unfamiliar ADON working the floor. The resident, who was supposed to receive hydromorphone every four hours, waited over an hour for relief, causing distress. The Unit Manager intervened after concerns were raised, highlighting a failure to adhere to the facility's pain management policy.
The facility failed to ensure effective discharge planning for two residents, leading to deficiencies in their care transitions. One resident was discharged to an assisted living facility without proper documentation or updates to the care plan, while another resident's desire to move to South Carolina was not reflected in the discharge plan. The facility did not adequately document or update the discharge plans, violating its own policy.
A resident with multiple health conditions was injured during a transfer when a mechanical lift malfunctioned due to improper use by a single STNA, contrary to facility policy requiring two staff members. The resident dropped into her wheelchair, sustaining a forehead cut.
The facility failed to provide timely incontinence care for several residents, leading to situations where residents were found with urine and stool soaked through their incontinence briefs and bed sheets. Staff members were often unaware of when residents were last checked or changed, indicating a lack of communication and accountability in resident care assignments.
A resident in a LTC facility, dependent on staff for transfers, was left in her wheelchair for hours despite requesting assistance to return to bed. The resident contacted her son, who called the police, leading to her eventual assistance. Interviews revealed complaints about staff rudeness and unresponsiveness, highlighting a failure to honor resident rights and dignity.
The facility failed to maintain a clean and sanitary environment, affecting two residents. Soiled incontinence briefs were found on a resident's wheelchair, and a large pile of dirty linens with a foul odor was observed in another resident's room. Staff confirmed these observations and acknowledged the issues.
Elopement and Smoking Safety Deficiencies
Penalty
Summary
A cognitively impaired resident with a history of elopement exited the facility without staff knowledge and was found by local police in the middle of a residential street approximately 1.7 miles from the facility. The resident was confused, speaking in his native language, and seeking a local ethnic meat market. The resident was subsequently transported to a local hospital for evaluation. Prior to this incident, the resident had previously eloped from the facility's smoking area by kicking open a gate and was returned by emergency services. Despite being identified as an elopement risk with documented wandering and exit-seeking behaviors, the resident's care plan and interventions were not consistently updated to reflect the need for increased supervision, such as 1:1 monitoring, and behavior monitoring was not completed on the shift when the elopement occurred. Staff interviews revealed that the resident was known to be restless, had poor safety awareness, and required significant redirection. On the evening of the incident, the staff member assigned to provide 1:1 supervision for the resident called off, and administration was not notified, resulting in the resident not receiving the required supervision. The facility was unable to determine exactly how the resident exited the building, but it was believed the resident left through the front door, which was keypad-secured. The facility's elopement prevention policy included regular rounds, environmental modifications, and protected lists of at-risk residents, but these measures were not sufficient to prevent the incident. Additionally, the facility failed to maintain a safe environment related to resident smoking. Observations showed that smoking materials, including cigarettes and lighters, were not kept in locked areas as required by facility policy. Multiple residents were found with smoking paraphernalia unsecured in their rooms, and some did not have required smoking contracts or access to secure storage. The outdoor smoking area was observed to have cigarette butts and combustible items mixed in ash trays, further contributing to accident hazards.
Removal Plan
- Local police notified facility that Resident #117 was found outside and transported to the hospital.
- A headcount was completed by facility staff to ensure each resident was accounted for.
- Resident #117 returned to the facility and was immediately assessed by the nurse.
- Resident #117 was placed on one on one (1:1) supervision with a plan for 1:1 supervision to remain in place until the resident was no longer identified as high risk for elopement which would be assessed quarterly using the wandering observation tool.
- Maintenance Director completed an audit to validate all windows and doors were secure and functioning properly.
- The DON/designee reported to the facility Quality Assessment and Performance Improvement (QAPI) committee the concerns related to Resident #117's elopement.
- The QAPI committee met to complete a root cause analysis.
- Maintenance Director changed all secure door codes.
- LPN completed a wandering assessment, pain assessment and head to toe assessment on Resident #117.
- The Administrator conducted staff education for all facility staff in person, via Onshift software (e-learning platform) and via phone calls related to Elopement prevention and management overview and Unit Supervision with emphasis on safety and supervision.
- Resident #117's physician and emergency contact was notified.
- The clinical interdisciplinary team which consists of the Director of Nursing, assistant Director of Nursing and Unit Managers completed wandering/elopement assessments on all residents.
- Elopement/wandering care plans were reviewed for all residents at risk by the DON/designee.
- The facility elopement binder was reviewed by the DON/designee.
- Resident #117's care plan was updated by Minimum Data Set Nurse to include 1:1 supervision for an elopement intervention.
- Two residents (Resident #37 and Resident #100) care plans were updated with elopement interventions by Minimum Data Set Nurse.
- The facility implemented a plan to monitor for ongoing compliance, elopement drills would be completed twice weekly for two weeks, then weekly for two weeks. The drills would be conducted by the DON/designee on night shift, day shift, evening shift and day shift.
- The Administrator/DON/Designee began calling the facility at the start of each shift to ensure coverage of one-on-one (1:1) care providers for Resident #117 and others as needed. This would continue every shift indefinitely until the facility Quality Assessment and Performance Improvement (QAPI) committee deemed appropriate changes.
- The facility implemented a plan for the DON/designee to complete observation audits to ensure resident(s) who had one on one supervision were provided five days a week every three months.
- The DON/designee would complete observation audits to ensure interventions were in place for elopement risk residents, five days a week for three months.
Medication Storage and Administration Deficiencies Identified
Penalty
Summary
Surveyors identified multiple deficiencies related to medication management within the facility. During an observation of the medication storage room, expired stock medications intended for resident use were found, including Tylenol, enteric coated Aspirin, Geri Max antacid, and Docusate Sodium. The Unit Manager and Supply Coordinator confirmed the presence of these expired medications and acknowledged that expired drugs should have been removed and disposed of according to facility policy. Additionally, the medication storage refrigerator was found to be operating at 50°F, above the recommended range for medication storage, with water pooling inside. Several temperature-sensitive medications, such as insulin and Micafungin injection, were stored in this refrigerator, contrary to manufacturer recommendations. Further investigation revealed that a resident with a history of hemiplegia, epilepsy, insomnia, anxiety, and diabetes had medications left unsecured at the bedside by an LPN, without confirmation of administration. The resident reported that this was a recurring practice by the nurse, and interviews with staff and the resident's responsible party corroborated that medications were left at the bedside overnight and not administered as intended. The Medication Administration Record indicated the medications were signed as given, but there was no documentation of the missed doses or notification to the physician or family regarding the incident. The facility's failure to ensure medications were not expired, were stored at appropriate temperatures, and were not left unsecured at the bedside without proper administration or documentation affected at least one resident and had the potential to impact all residents. These findings were confirmed through observation, interviews with staff and residents, and review of facility policies and records.
Failure to Maintain Clean and Sanitary Environment
Penalty
Summary
The facility failed to maintain a clean and sanitary environment, as observed during an environmental tour and confirmed by the Housekeeping Director. Hallway handrails were chipped, scuffed, and rough, while light fixtures throughout the hallways contained dust, dirt, and dead insects. In several resident rooms, issues included missing light bulbs, water-stained ceiling tiles, stained privacy curtains, severely scuffed walls, and damaged or scraped bathroom doors. Wall-unit air conditioners in some rooms displayed a clean filter indicator light, with filters coated in dust. Additional deficiencies included detached protective covers on heat pipes, holes or gouges in wood wall coverings, extremely dirty wheelchairs with accumulations of food and debris, a visible wall crack, and a missing cover on a wall telephone line exposing live wires. These conditions were observed in multiple resident rooms and common areas, affecting the overall cleanliness and safety of the environment for all residents, staff, and the public.
Failure to Provide Scheduled Showers for Dependent Residents
Penalty
Summary
The facility failed to ensure that residents who were dependent on staff for activities of daily living (ADL), specifically bathing and showering, received showers as required by their care plans and facility policy. Multiple residents with varying degrees of cognitive and physical impairment, including those with diagnoses such as renal dialysis dependence, hemiplegia, dementia, and chronic obstructive pulmonary disease, were scheduled for regular showers but did not consistently receive them. Documentation revealed missed showers, incomplete records, and instances where showers were marked as 'not applicable' without evidence of refusal or alternative care, such as bed baths. Interviews with residents and staff confirmed that showers were not provided as scheduled, with some residents reporting not having been bathed for weeks and staff acknowledging the lack of proper documentation and completion of scheduled showers. In several cases, the Minimum Data Set (MDS) assessments marked bathing as 'not applicable' because the residents had not been bathed during the look-back period, further confirming the lack of care. Observations also noted poor hygiene, such as oily hair and dirty nails, in residents who had missed scheduled showers. The deficiency was widespread, affecting a significant number of residents reviewed for showers, and was corroborated by both record review and staff interviews. Facility policy required at least two showers per week for dependent residents, but this standard was not met for many individuals. The lack of documentation for missed showers, refusals, or alternative bathing methods indicated a systemic failure to provide and record essential ADL care as required.
Failure to Provide Comprehensive Wound and Device Care
Penalty
Summary
The facility failed to ensure a comprehensive wound management system was in place for multiple residents, resulting in deficiencies in wound care and treatment according to physician orders. One resident with a recent surgical amputation and moderate cognitive impairment was observed with a dressing on the left lower leg that was not changed as ordered, with documentation indicating the dressing was not current. Another resident with a central venous catheter and intact cognition was discharged with a central line dressing that was not intact and had not been changed as ordered, despite documentation in the facility records indicating otherwise. The home care nurse reported the dressing had not been changed for several weeks, and photographic evidence supported this finding. A third resident with a nephrostomy tube and intact cognition had physician orders for regular dressing changes, but interviews and observations revealed the dressing was not changed as ordered. Staff interviews confirmed that documentation of dressing changes was inaccurate, with nurses signing off on treatments that were not performed. The facility also lacked a policy for nephrostomy tube care, contributing to the inconsistency in treatment. Additionally, a resident with chronic conditions and limited mobility was not provided with timely incontinence care or wound assessments. Observations showed the resident remained in a soiled brief for extended periods, resulting in redness and open areas on the buttocks. Staff interviews confirmed that the resident was not checked or changed as required, and wound care was not performed according to orders. The wound care nurse had not assessed the resident for several weeks, and inappropriate application of wound care products was observed.
Failure to Provide Adequate Nursing Staff to Meet Resident Needs
Penalty
Summary
The facility failed to provide adequate nursing staff each day to meet the needs of all residents, as required by their own facility assessment and federal regulations. Staffing schedules for the second floor consistently fell below the minimum number of Certified Nursing Assistants (CNAs) needed, with multiple days showing only four to seven CNAs present when at least eight were required. The Human Resource Manager confirmed that the facility did not use agency staff and relied on an outsourced scheduling company, resulting in persistent understaffing. The Administrator acknowledged that staffing levels did not meet the facility's own assessment standards for the entire review period. Direct observations and interviews revealed that residents experienced significant delays in receiving care, including long waits for assistance, missed showers, and inadequate incontinence care. Several residents reported not receiving showers for weeks, waiting up to 1.5 to 2 hours for call lights to be answered, and not having their needs addressed in a timely manner. Staff interviews corroborated these concerns, with CNAs and LPNs stating that there were not enough staff to meet resident needs, leading to missed care and incomplete documentation. Specific resident cases highlighted the impact of insufficient staffing. One resident with chronic conditions and limited mobility developed a sacrococcygeal wound, with observations showing prolonged periods without incontinence care or repositioning, resulting in saturated briefs, foul odor, and open wounds. Another resident with a tracheostomy was observed with thick mucus accumulation and a dusty suction machine, with staff unable to confirm when suctioning last occurred. Multiple records confirmed that scheduled showers were not completed for several residents, and staff consistently reported that the number of CNAs on duty was inadequate to provide necessary care.
Failure to Revise and Document Resident Care Plans
Penalty
Summary
The facility failed to revise and update care plans to reflect the current needs of two residents. For one resident with diagnoses including Parkinsonism, a rare brain disease, and dementia, the care plan identified the resident as an elopement risk but was not updated after multiple incidents of elopement. The resident was involved in two separate elopement events: in the first, the resident exited through a gate in the smoking area and was found in the parking lot, and in the second, the resident was found by police approximately 1.7 miles away from the facility after being reported missing. Despite these incidents, the only direct intervention implemented was one-on-one supervision, and the care plan was not revised to include new interventions addressing the repeated elopement attempts. For another resident with cognitive intactness and physical impairments, there was no documentation of any care plan meeting being completed from admission through over a year later. Although the social worker reported that care conferences were scheduled and completed on two occasions, there was no documentation available to confirm these meetings. The lack of documented care plan meetings indicates that the resident's care plan was not reviewed or revised as required, failing to ensure that the care plan reflected the resident's current needs.
Failure to Complete Pressure Ulcer Wound Care as Ordered
Penalty
Summary
A resident with a history of quadriplegia, diabetes, and schizophrenia was admitted and later readmitted to the facility. The resident had multiple stage three pressure wounds, including on the mid-spine, right back, sacrum, and left buttock, all of which were documented as improving. Physician orders required daily wound care, including cleansing with wound cleanser, application of a collagen sheet, and securing with a bordered foam dressing to several wound sites. Survey findings revealed that the wound care dressings for the resident were not completed as ordered. Specifically, the dressings were signed off as completed on the medication and treatment administration records by an LPN, but the actual dressing dates did not match the documentation, confirming that the care was not provided as scheduled. The facility's wound care policy required treatment based on wound characteristics, but the records and staff interview confirmed a failure to follow the prescribed wound care regimen and maintain accurate documentation.
Failure to Provide Timely Incontinence Care
Penalty
Summary
Resident #119, who was admitted with diagnoses including hemiplegia and hemiparesis following a cerebral infarction, chronic obstructive pulmonary disease, and diabetes, was identified as being frequently incontinent of bowel and bladder and requiring substantial to maximal assistance with toileting hygiene. The resident's care plan reflected these needs. On observation, the resident was found with a saturated incontinence brief and deep red discoloration on both buttocks, with a large dried yellow stain on the bedsheets beneath her. The resident reported that she had not been changed since the previous evening and that staff did not respond to her call light requests. Interviews with staff revealed inconsistencies in the timing and frequency of incontinence care provided to the resident. One CNA stated the resident was last changed at 6:00 A.M. on the day of observation, while the resident herself reported the last change occurred the previous evening. The facility's perineal care policy requires regular care to maintain cleanliness, comfort, and skin integrity, but this was not followed, resulting in prolonged exposure to urine and compromised skin condition for the resident.
Failure to Properly Prime Insulin Pens Results in Medication Errors
Penalty
Summary
A medication error rate of 6.7% was identified during observation of medication administration, record review, and staff interviews. Two residents with diabetes, both cognitively intact and receiving daily insulin injections, were affected. For one resident, an LPN prepared and administered insulin using a pen-injector but failed to prime the pen before administration, contrary to manufacturer instructions. The LPN confirmed she did not prime the pen and stated she believed it was unnecessary. For another resident, a different LPN primed the insulin pen-injector before attaching the needle, then administered the insulin without priming after the needle was attached. The LPN confirmed this sequence and acknowledged not priming the pen after the needle was in place. Manufacturer instructions reviewed by surveyors specified that priming should occur after the needle is attached and before each injection to ensure the correct dose is delivered. These failures to follow proper insulin pen priming procedures resulted in medication administration errors.
Failure to Prevent Significant Medication Errors for Two Residents
Penalty
Summary
The facility failed to ensure that two residents were free from significant medication errors, as evidenced by missed and improperly administered medications. One resident with a history of Crohn's disease, chronic pain, and other related conditions was prescribed Gattex for short bowel syndrome. Despite physician orders and care plan interventions to provide medications as ordered, the resident received the medication inconsistently over several months. Documentation on the Medication Administration Record (MAR) indicated that the medication was often marked as unavailable or not given, with progress notes confirming that Gattex was either on order or not accessible to nursing staff. Interviews revealed that the medication was present in the facility but locked in a provider office, leading to miscommunication and failure to administer the drug as prescribed. Another resident, admitted with diagnoses including altered mental status and infection due to a central venous catheter, was prescribed amoxicillin-potassium clavulanate for a bacterial infection. The resident did not receive all ordered doses of the antibiotic, with the MAR and pharmacy records confirming that several doses were missed due to delays in pharmacy delivery and issues with medication removal from the facility's medication dispensary. Staff and pharmacy interviews corroborated that only a portion of the prescribed antibiotics were administered, and the resident ultimately received fewer doses than ordered. The facility's medication administration policy required medications to be administered within a specific time frame and properly documented. However, in both cases, the facility failed to follow these procedures, resulting in significant medication errors for two residents. These findings were confirmed through record reviews, staff interviews, and pharmacy documentation.
Failure to Administer Pain Medication Timely
Penalty
Summary
The facility failed to administer pain-relieving medications as ordered for a resident with chronic pain conditions, including Crohn's disease and intervertebral disc degeneration. The resident, who had intact cognition, was supposed to receive hydromorphone every four hours as needed for pain. On the day in question, the Assistant Director of Nursing (ADON) was working the floor due to a staff call-off and was unfamiliar with the medication administration on that unit. The ADON did not administer the pain medication in a timely manner, causing the resident to wait at least an hour for relief, despite the resident's request and visible distress. The incident was investigated after concerns were raised by staff, residents, and family members about the delay in medication administration. The Unit Manager took over the medication administration from the ADON and provided the resident with the overdue hydromorphone. The facility's policy on pain management and assessment requires staff to ensure residents receive treatment and care in accordance with professional standards, which was not adhered to in this case. This deficiency was investigated under a specific complaint number, indicating non-compliance with the facility's pain management protocols.
Deficient Discharge Planning for Two Residents
Penalty
Summary
The facility failed to ensure effective discharge planning for two residents, leading to deficiencies in their care transitions. Resident #125, who had intact cognition and required supervision for activities of daily living, was discharged to an assisted living facility without documented changes to the discharge plan or updates to the care plan. The social worker confirmed that no updates were made to the medical record regarding the discharge planning process, indicating a lack of proper documentation and planning. Resident #126, who also had intact cognition but required moderate to maximum assistance for activities of daily living, expressed a desire to move to South Carolina to be closer to family. Despite this, the discharge care plan was not updated to reflect this change, and there was no documentation of the discharge planning process in the medical record. The resident was discharged with arrangements made for a flight and transportation, but the discharge summary lacked details about the hospital or potential facilities for placement in South Carolina. Interviews with facility staff and external parties involved in the discharge process revealed that the facility did not adequately document or update the discharge plans for these residents. The facility's policy required regular re-evaluation and updates to the discharge plan, which were not followed in these cases. This deficiency was investigated under a specific complaint number, highlighting the facility's non-compliance with discharge planning requirements.
Failure to Follow Mechanical Lift Protocol
Penalty
Summary
The facility failed to ensure that all staff followed the mechanical lift protocol, which resulted in an incident involving Resident #135. The resident, who had diagnoses including diabetes, chronic kidney disease, morbid obesity, spinal stenosis, and osteoarthritis, was dependent on mechanical lift transfers. During a transfer, the Hoyer lift scale detached, causing the resident to drop into her wheelchair, and the scale hit her forehead. Although the resident did not fall, she sustained a cut on her forehead. The incident was reported by the Unit Manager LPN #309, who noted that the transfer was conducted by STNA #312 without the required assistance of a second staff member. Interviews and observations revealed that the mechanical lift malfunction occurred when the weight scale got caught, causing the Hoyer bar to drop suddenly. Maintenance Assistant #311 confirmed that the mechanical lifts were checked monthly, and the issue was reported on the day of the incident. The facility's policy required two employees to assist with mechanical lift transfers, but this protocol was not followed by STNA #312, who received a final written warning for her actions. The incident was self-reported, and a full investigation was conducted.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide timely incontinence care for several residents, as observed during a survey. Resident #102, who has Alzheimer's disease and dementia, was found in a wheelchair with wet pants and a puddle of urine on the seat. The assigned STNA was unaware of the resident's need for incontinence care and could not confirm when the resident was last checked or changed. This indicates a lack of communication and accountability among staff regarding resident care assignments. Resident #115, with intellectual disabilities and muscle weakness, was reported by a roommate to have not been changed all night. Upon observation, the resident was found saturated with urine and stool, which had soaked through the incontinence brief and bed sheets onto the mattress. The STNAs responsible for the resident's care were unsure when the resident was last attended to, highlighting a failure in maintaining regular incontinence care schedules. Resident #117, who has cognitive deficits and a tracheostomy, was also found with a large amount of urine that had soaked through the bed sheets to the mattress. The STNA on duty had not provided care since the start of her shift and was unable to state when the resident was last checked. Similarly, Resident #120, with morbid obesity, was found with urine and stool soaked through her incontinence brief and sheets. The STNA responsible did not know when the resident was last changed, indicating a systemic issue in providing timely incontinence care across the facility.
Failure to Honor Resident Rights and Dignity
Penalty
Summary
The facility failed to honor the rights of residents to be treated with respect and dignity, as well as their right to self-determination and communication. This deficiency was highlighted by an incident involving a resident who required assistance with activities of daily living and was dependent on staff for transfers. The resident, who had intact cognition, requested assistance to be transferred back to bed in the evening but was not helped. After several hours without assistance, the resident contacted her son, who then called the police. Upon the police's arrival, the resident was finally assisted back into bed. Interviews with staff and other residents revealed a pattern of complaints about staff being rude and unresponsive to resident needs. The incident was further corroborated by a police report, which indicated that the resident had been left in her wheelchair for an extended period and had soiled herself twice. The facility's policy on resident rights, which includes the right to be treated with respect and to decide when to go to bed, was not adhered to in this case. The facility's administration acknowledged the incident and obtained a copy of the police report, confirming the resident's account of events. This deficiency was investigated under a specific complaint number, indicating a formal recognition of the issue by regulatory authorities.
Failure to Maintain Clean and Sanitary Environment
Penalty
Summary
The facility failed to maintain a clean and sanitary environment, affecting two residents. During an observation, two soiled incontinence briefs were found on a resident's wheelchair, with gnats flying around them. An STNA revealed that she had picked up the briefs from the floor and placed them on the wheelchair. In another instance, a large pile of dirty linens was observed on the floor of a resident's room, emitting a foul odor. The resident confirmed that the linens had been there since the previous night after his bed was changed. This was corroborated by an STNA who acknowledged the situation and indicated she would dispose of the linens.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Parma Heights
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| East Park Care Center | 1.4 mi | — | 7 | 0 |
| Royal Oak Nursing & Rehab Ctr | 1.4 mi | — | 0 | 0 |
| North Park Care Center | 1.7 mi | — | 0 | 0 |
| Pleasant Lake Villa | 2.2 mi | — | 0 | 0 |
| Pleasantview Care Center | 2.2 mi | — | 0 | 0 |
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