GREENBRIAR COMMUNITY CARE CENTER
Non profit - Corporation
174 Beds
COMMCARE CORPORATION
Data: November 2025
Trust Grade
65/100
#72 of 264 in LA
Photo by Greenbriar Community Care Center
Photo by Greenbriar Community Care Center
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Last Inspection: September 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Greenbriar Community Care Center has a Trust Grade of C+, indicating a decent rating that is slightly above average among nursing homes. In Louisiana, it ranks #72 out of 264, placing it in the top half, and #5 out of 8 in St. Tammany County, meaning there are only a few local facilities rated higher. The facility is on an improving trend, having reduced its issues from 5 in 2024 to 4 in 2025. Staffing is a strength, with a rating of 4 out of 5 stars and a turnover rate of 40%, which is below the state average. Additionally, the facility has not incurred any fines, suggesting compliance with regulations. However, there are some concerns, such as failure to label opened medication vials and issues with food safety practices, which could impact residents. On a positive note, the facility has more RN coverage than 77% of Louisiana facilities, which helps ensure better oversight of patient care.
- Trust Score
- C+
- In Louisiana
- #72/264
- Safety Record
- Low Risk
- Inspections
- Getting Better
- Staff Stability ○ Average
- 40% turnover. Near Louisiana's 48% average. Typical for the industry.
- Penalties ✓ Good
- No fines on record. Clean compliance history, better than most Louisiana facilities.
- Skilled Nurses ⚠ Watch
- Each resident gets only 21 minutes of Registered Nurse (RN) attention daily — below average for Louisiana. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 19 deficiencies on record. Higher than average. Multiple issues found across inspections.
65/100
Top 27%
No red flags
5 → 4 violations
★★★☆☆
3.0
Overall Rating
★★★★☆
4.0
Staff Levels
★★★☆☆
3.0
Care Quality
★★★☆☆
3.0
Inspection Score
↔
Stable
2024: 5 issues
2025: 4 issues
The Good
-
4-Star Staffing Rating · Above-average nurse staffing levels
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
-
Staff turnover below average (40%)
8 points below Louisiana average of 48%
Facility shows strength in staffing levels, fire safety.
The Bad
3-Star Overall Rating
Above Louisiana average (2.4)
Meets federal standards, typical of most facilities
Staff Turnover: 40%
Near Louisiana avg (46%)
Typical for the industry
Chain: COMMCARE CORPORATION
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 19 deficiencies on record
Mar 2025
4 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to ensure an allegation of sexual abuse was reported to the administ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to ensure an allegation of sexual abuse was reported to the administrator, state agency and the local law enforcement in the appropriate time frame for 1 (#1) of 3 ( #1, #2, and #3) residents reviewed for abuse.
Findings:
Review of the facility's policy titled, Abuse Components Plan Elder Justice Act and Affordable Care Act with a revision date of 10/24/2022, revealed, in part, the following:
Identification:
Immediately upon discovery of any alleged and or suspected incident of abuse ., staff is communicating a verbal report to the Charge Nurse and/or Department Head.
Reporting:
1. All alleged violations involving abuse .will be reported by the Administrator or designee, to the following persons or agencies as required to provide notification:
a. State agency online tracking incident system.
d. Law enforcement officials .
2. An alleged violation involving abuse .will be reported immediately, but no later than:
a. Two hours if the alleged violation involves abuse .
Review of the clinical record for Resident #1 revealed she was admitted to the facility on [DATE].
Review of Resident #1's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/29/2024, revealed a Brief Interview for Mental Status (BIMS) of 15 which indicated Resident #1 was cognitively intact.
Review of the Nurse's Notes for Resident #1 dated 02/11/2025 at 1:44 a.m., revealed S3LPN documented Resident #1 called her into her room stating, Some man is in here, feeling me down.
Review of the Incident/Accident Log dated December 2025 through present revealed no entry for Resident #1 for 02/11/2025.
On 03/12/2025 at 8:40 a.m., an interview was conducted with S3LPN. She confirmed she worked 02/11/2025 from 11:00 p.m. to 7:00 p.m. S3LPN stated Resident #1 reported a man was in her room, lifted her shirt up and was feeling her breast. S3LPN stated Resident #1 reported the man was in her room for 15 minutes. S3LPN stated she did not feel like this was an emergency and did not report this allegation immediately to her supervisor. She stated she reported this allegation of sexual abuse to S4LPN on 02/11/2025 at 6:00 a.m. by telephone.
On 03/12/2025 at 9:30 a.m., an interview was conducted with S4LPN. S4LPN stated she was never notified of a sexual abuse allegation made by Resident #1 on 02/11/2025. She stated she would expect staff to report all sexual abuse allegations immediately to their supervisor.
On 03/13/2025 at 1:45 p.m., an interview was conducted with S2DON. He stated he expected staff to report all allegations of sexual abuse immediately. He stated when Resident #1 alleged she was sexually abused to a staff member, the staff member should have reported the alleged abuse immediately to a supervisor. He confirmed he was not aware of an allegation of sexual abuse made by Resident #1 on 02/11/2025.
On 03/13/2025 at 1:50 p.m., an interview was conducted with S1ADM. She stated she expected staff to report all allegations of sexual abuse immediately. She stated when Resident #1 alleged she was sexually abused to a staff member, the staff member should have reported the alleged abuse immediately to a supervisor. She confirmed she was not aware an allegation of sexual abuse was made by Resident #1 on 02/11/2025 and she did not notify the law enforcement or the state agency.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure resident assessments accurately reflected the resident's st...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure resident assessments accurately reflected the resident's status for 1 (#2) of 3 (#1, #2, and #3) residents reviewed for MDS.
Findings:
Review of Resident #2's Clinical Record revealed she was admitted to the facility on [DATE] and had diagnoses which included, in part, mild intellectual disabilities.
Review of Resident #2's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/27/2024 revealed the following, in part: Behavioral Symptoms - Presence & Frequency: Physical behavioral symptoms directed toward others was coded as 0, which indicated the behavior was not exhibited.
Review of Resident #2's Nursing Notes dated 11/25/2024 revealed the following, in part:
Resident #2 was in the dining room and pulled off the head band of another resident's head and stated that it was hers. Signed by S5LPN.
On 03/13/2025 at 1:32 p.m., an interview was conducted with S6SSD. S6SSD stated she was responsible for completing resident's MDS Behavior assessments. S6SSD reviewed Resident #2's nursing progress note dated 11/25/2024 indicating she pulled the head band off of another resident and stated that it was hers. S6SSD confirmed she would consider this a physical behavior. S6SSD reviewed Resident #2's Quarterly MDS with an ARD of 11/27/2024 and confirmed Resident #2 was not coded for physical behaviors and should have been.
On 03/13/2025 at 1:45 P.M., an interview was conducted with S2DON. S2DON reviewed the above mentioned findings and confirmed Resident #2's MDS was not coded for physical behaviors and should have been.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, observation, and interviews the facility failed to revise and implement a comprehensive person-centered...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, observation, and interviews the facility failed to revise and implement a comprehensive person-centered care plan which met the needs of 1 (#2) of 3 (#1, #2 and #3) sampled residents.
Findings:
Review of Resident #2's Clinical Record revealed she was admitted to the facility on [DATE] and had diagnoses which included, in part, mild intellectual disabilities.
Review of Resident #2's most recent Care Plan dated 03/10/2024 revealed the following:
Problem: I have a behavior problem. I am sexually inappropriate at times and I act out when I don't get my way.
Review of Resident #2's nursing progress notes, dated 11/10/2024, revealed Pt pulled up shirt showing breasts in dining area. Signed per S9LPN.
An interview was conducted with S7CNA on 03/11/2025 at 12.54 P.M. S7CNA stated she had been employed at this facility for approximately six months and cares for Resident #2. S7CNA did not recall the incident noted 11/10/2024 but knew Resident #2's care plan included inappropriate sexual behaviors. S7CNA stated that redirection to a different activity, like coloring, was her intervention when Resident #2 displayed disruptive or sexually inappropriate behaviors.
An interview was conducted with S5LPN on 03/13/2025 at 11:30 a.m. S5LPN confirmed she was responsible for E Hall residents' care plans. S5LPN stated she was aware of the incident on 11/10/2024 and would consider it sexual. S5LPN confirmed the care plan should have been revised after the incident and was not.
An interview was conducted with S1ADM on 03/13/2025 at 12:50 P.M. S1ADM stated she reviewed video footage on 11/10/2024 and it revealed Resident #2 lifting her shirt in the common area in front of other residents. S1ADM stated this was considered a behavior.
An interview was conducted with S9LPN on 03/13/2025 at 1:04 P.M. S9LPN stated she was caring for and remembered the incident on 11/10/2024. S9LPN stated Resident #2 lifted her shirt up in the common area in front of other residents. S9LPN stated Resident #2 was removed from the area and reported this to S5LPN.
An interview was conducted with S2DON on 03/13/2025 at 1:45 P.M. S2DON reviewed the aforementioned incident and confirmed Resident #2's care plan should have been revised after the incident on 11/10/2024 and was not.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to ensure a resident's comprehensive plan of care was developed and i...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to ensure a resident's comprehensive plan of care was developed and implemented for 1 (#2) of 3 (#1, #2 and #3) residents reviewed for care plans.
The facility failed to ensure Resident #2's care plan was developed for wandering behaviors.
This deficient practice had the potential to affect the current 28 residents residing on E Hall.
Findings:
Review of Resident #2's Clinical Record revealed she was admitted to the facility on [DATE] and had diagnoses which included, in part, mild intellectual disabilities.
Review of Resident #2's most recent Care Plan did not address or provide interventions for Resident #2's wandering behaviors.
An interview was conducted with S7CNA on 03/11/2025 at 12:54 p.m. S7CNA stated Resident #2 is known to wander into other resident rooms. S7CNA stated that redirection techniques, including art and coloring, are used as interventions when Resident #2 exhibits disruptive behaviors such as wandering or shouting. S7CNA stated the resident's care plan does not specify a need for increased supervision.
An interview was conducted with Resident #3 on 03/11/2025 at 1:25 p.m. Resident #3 stated Resident #2 wandered into his room uninvited. Resident #3 did not recall any prior incidents like this. Resident #3 recalled that when staff saw Resident #2 in his room, staff immediately removed her.
An interview was conducted with S5LPN on 03/13/2025 at 12:35 p.m. S5LPN stated that she is responsible for E Hall care plans. S5LPN stated she is aware Resident #2 is known to wander into other resident rooms' uninvited. S5LPN stated staff will redirect Resident #2's attention when that behavior occurred. S5LPN confirmed Resident #2 should be care planed for these behaviors and was not.
An interview was conducted with S2DON on 03/13/2025 at 1:45 p.m. He reviewed Resident #2's care plan and confirmed Resident #2 was not care planned for wandering behaviors and should have been.
Sept 2024
5 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0760
(Tag F0760)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to ensure residents were free of significant medication...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to ensure residents were free of significant medication errors for 1 (#87) of 2 (#82 and #87) residents reviewed during narcotic medication review. The deficient practice had the potential to effect the 165 residents residing in the facility receiving medications.
Findings:
Review of the facility's policy titled Medication Administration, dated 11/28/2017, revealed the following, in part:
3.0 Procedure
Prior to giving medication, regardless of the type of medication, always follow the six rights:
1. Right Individual
2. Right medication
3. Right dose
4. Right time
5. Right route
6. Right documentation
Review of Resident #87's clinical record revealed she was admitted to the facility on [DATE] with diagnoses which included Pain and Muscle Wasting and Atrophy.
Review of Resident #87's Physician Orders dated September 2024 revealed the following, in part:
Oxycodone HCL oral tablet 10 mg. Give 10 mg by mouth every 4 hours as needed for breakthrough pain. Order date: 09/03/2024.
MS Contin oral tablet 15 mg. Give 15 mg by mouth two times a day for pain. Order date: 09/03/2024.
Review of Resident #87's MAR dated 09/01/2024-09/30/2024 revealed the following, in part:
Oxycodone HCL oral tablet 10 mg. Give 10 mg by mouth every 4 hours as needed for breakthrough pain. Order date: 09/03/2024.
Given on 09/09/2024 at 3:57 p.m.
Review of Resident #87's MAR dated 09/01/2024-09/30/2024 revealed the following, in part:
MS Contin oral tablet 15 mg. Give 15 mg by mouth two times a day for pain. Order date: 09/03/2024.
On 09/09/2024 at 4:03 p.m., an observation was conducted of medication Cart A1 with S8LPN. An observation was made of the narcotic medication sign out documentation for Resident #87. The MS Contin oral tablet 15 mg pill pack was counted and was noted to be missing 1 tablet. S8LPN stated Resident #87 was scheduled to receive MS Contin oral tablet 15 mg daily at 8:00 a.m. and 8:00 p.m. and a second narcotic, Oxycodone, could be given as needed every four hours. S8LPN stated she gave Resident #87 the wrong narcotic medication at 3:57 p.m. S8LPN stated she thought she administered Oxycodone, but had administered MS Contin instead.
On 09/10/2024 at 4:00 p.m., an interview was conducted with S3DON. He stated S8LPN removed and administered Resident #87's scheduled MS Contin, instead of the PRN Oxycodone, on 09/09/2024 at 3:57 p.m. He stated this resulted in Resident #87 receiving MS Contin four hours earlier than the medication was scheduled to be administered. He confirmed S8LPN had not followed the 6 rights of medication administration and made a medication error.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
Based on observation, interviews, and record review, the facility failed to ensure expired medications and biologicals were not available for use and administration to residents as evidenced by:
Havin...
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Based on observation, interviews, and record review, the facility failed to ensure expired medications and biologicals were not available for use and administration to residents as evidenced by:
Having expired medications for 1 (Cart B) of 4 (Cart A1, Cart A2, Cart B, and Cart F) reviewed for med storage.
Findings
Review of the facility's policy titled Medication Administration dated 11/28/2017 revealed the following:
Procedure:
Do not administer medications passed their expiration date.
An observation was made on 09/09/2024 at 4:36 p.m. with S6CC and S7LPN of Cart B. The following was observed:
1 bottle of eye drops with expiration date 07/2024;
1 bottle of oral liquid Morphine with open date of 07/21/2024 and no expiration date.
An interview was conducted with S7LPN on 09/09/2024 at 4:37 p.m. She stated she did not know why the expired medication bottles were in Cart B, but should have been removed. S7LPN verified liquid Morphine was administered on 09/09/2024 at 12:06 a.m. and was beyond expiration date.
An interview was conducted with S6CC on 09/09/2024 at 4:40 p.m. She confirmed eye drops were expired and should have been removed from Cart B. She stated nurses were responsible for monitoring and checking the medication carts for expired medications.
An interview was conducted with S4ADON on 09/09/2024 at 4:40 p.m. She confirmed the eye drops were beyond expiration date and should have been discarded. She stated it was the night nurses' responsibility to check carts for expired medications. She added all nurses were responsible for checking expiration dates prior to administrating medications. S4ADON confirmed nursing staff had not removed expired medications and should have.
An interview was conducted with S3DON on 09/10/2024 at 4:00 p.m. He stated each nurse who administers medications was responsible for checking expiration dates. He further stated the floor nurse was responsible for checking medication carts for expired medications. S3DON confirmed eye drops were expired, should have been discarded, and had not been.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, the facility failed to maintain an infection prevention and control program...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary environment to help prevent the development and transmission of infection for 1 (#87) of 5 (#11, #82, #87, #94, and #146) residents reviewed for infection control. The facility failed to ensure staff wore proper Personal Protective Equipment (PPE) while providing care to a resident who was on Enhanced Barrier Precautions (EBP).
Findings:
Review of the facility's policy titled Enhanced Barrier Precautions revised on 04/2024, revealed the following, in part:
Policy Interpretation and Implementation
2. EBP's employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply.
3. Examples of high-contact resident care activities requiring the use of gown and gloves for EBP's include:
g. device care or use
Observation of the Enhanced Barrier Precautions sign posted on Resident #87's door revealed the following, in part:
Providers and staff must also:
Wear gloves and a gown for the following high-contact resident care activities.
Device care or use: central line
Review of Resident #87's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses of Surgical Site Infection and Long Term Current Use of Antibiotics.
Review of Resident #87's current Physician Orders revealed the following, in part:
Enhanced Barrier Precautions. Every shift for central line, chronic wound. Wear gown and gloves when providing high contact resident care.
An observation was made on 09/10/2024 at 10:55 a.m. of S9LPN administering an IV antibiotic to Resident #87 through her PICC line. S9LPN was not wearing a gown during the use of the central line.
An interview was conducted on 09/10/2024 at 12:02 p.m. with S9LPN. S9LPN verified Resident #87 was on EBPs. She confirmed she did not wear a gown when administering the IV antibiotic through Resident #87's PICC line and should have.
An interview was conducted on 09/10/2024 at 1:14 p.m. with S3DON. S3DON confirmed per EBP guidelines, nurses should wear a gown when administering IV antibiotics through a resident's PICC line.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review the facility failed to ensure services were provided by the facility to meet quality profe...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review the facility failed to ensure services were provided by the facility to meet quality professional standards. The facility failed to ensure a medication was transcribed properly for 1 (#153) of 33 sampled residents.
Findings:
Review of Resident #153's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses which included Depression and Insomnia.
Review of Resident #153's Psychoactive Gradual Dose Reduction Report dated 06/11/2024 revealed the following:
1. Trazadone HCl 100mg give one tablet my mouth at bedtime.
Further review revealed on 06/13/2024, S11NP selected a dose reduction was appropriate for Resident #153 and wrote a new order for Trazadone 50 mg HS.
Review of Resident #153's active Physician Orders revealed the following:
Start Date: 02/16/2024-Trazadone HCl 100 mg give one tablet by mouth at bedtime.
Further review revealed no order for Trazadone 50 mg HS.
Review of Resident #153's MAR dated June 2024 and September 2024 revealed the resident received Trazadone HCl 100mg po HS.
On 09/16/2024 at 9:52 a.m., an interview was conducted with S10MR. She stated she was responsible for making sure Psychoactive Gradual Dose Reduction changes were inputted into the computer for implementation. She stated after the DON reviewed Psychoactive Gradual Dose Reduction reports, she received them and entered the changes into the computer. S10MR reviewed Resident #153's Psychoactive Gradual Dose Reduction report dated 06/11/2024 and Resident #153's active Physician's orders and confirmed she did not see the new order for Trazadone 50 mg HS and did not input it into the computer and stated she should have.
On 09/16/2024 at 10:09 a.m., an interview was conducted with S3DON. S3DON stated medical records department was responsible for inputting Psychoactive Gradual Dose Reduction changes into the computer for implementation. S3DON reviewed Resident #153's Psychoactive Gradual Dose Reduction report dated 06/11/2024 and Resident #153's active Physician's orders and confirmed the new order for Trazadone 50 mg HS was not entered into the computer system and should have been.
On 09/16/2024 at 11:11 a.m., a telephone interview was conducted with S11NP. She stated she expected staff to properly transcribe orders from the Psychoactive Gradual Dose Reduction reports. S11NP confirmed Resident #153 should have had a current order for Trazadone 50mg HS, not Trazadone HCl 100mg HS.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
Based on observation, interviews, and record review, the facility failed to store and prepare food under sanitary conditions. The facility failed to ensure:
1. Food was properly stored and labeled in...
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Based on observation, interviews, and record review, the facility failed to store and prepare food under sanitary conditions. The facility failed to ensure:
1. Food was properly stored and labeled in the walk-in freezer of the facility's kitchen;
2. Food was properly stored and labeled in the walk-in refrigerator of the facility's kitchen; and
3. Food was properly stored and labeled in the walk-in food storage room of the facility's kitchen.
This deficient practice had the potential to affect 165 residents who were served meals from the facility's kitchen.
Findings:
Review of the facility's policy titled Food Receiving and Storage dated October 2017 revealed the following:
8. All foods stored in the refrigerator or freezer will be covered, labeled and dated (received and/or open date).
During the initial tour of the facility's kitchen with S5DM on 09/09/2024 at 9:00 a.m., the following observations were made:
Walk-In Freezer:
1 large black, plastic bag unlabeled and undated containing 2 slabs of uncooked ribs.
Walk-In Refrigerator:
1 large plastic container of salad dressing opened and undated.
Dry Storage Room:
22 quart plastic container of potatoes, dated opened 08/28/2024. No discard by or expiration date labeled.
16 ounce container of Ground Cinnamon opened and undated.
An interview was conducted on 09/10/2024 at 12:45 p.m., S5DM verified the above observations and confirmed the facility failed to store foods under sanitary conditions. She confirmed all opened food products should be labeled with date it was opened and an expiration/discard date. She further stated she was responsible for ensuring staff complied with policy. She confirmed all previously cooked items, stored in refrigerator should be discarded in 3-4 days.
An interview was conducted on 09/10/2024 at 1:05 p.m. with S1ADM. S1ADM confirmed all food storage items should be labeled, checked for both opened and expiration dates, and should not contain staff personal food items.
Oct 2023
4 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to ensure interventions for falls were implemented as ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to ensure interventions for falls were implemented as identified on the care plan for 1(#127) of 3 (#99, #127, and #456) residents reviewed for falls.
Findings:
A review of the facility's Falls and Fall Risk policy revealed, in part:
Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent residents from falling and to try to minimize complications from falling.
Review of the clinical record for Resident #127 revealed the resident was admitted to the facility on [DATE]. The resident had diagnoses that included Unspecified Dementia and Falls.
Review of the most recent MDS with an ARD of 8/13/2023, revealed Resident #127 had a BIMS of 4, which indicated severe cognitive impairment. Maybe add if resident required assistance and to what extent. Did the MDS have anything about falls mentioned?
Review of the most current Care Plan revealed the following:
Problem:
11/25/2022- Fall- Intervention-11/25/2022- non-slip strips in front of recliner.
On 10/24/2023 at 9:50 a.m., an observation was made of Resident #127's room and there were no non- slip strips in front of her recliner.
On 10/24/2023 at 12:00 p.m., an interview was conducted with S14CNA. S14CNA stated when Resident #127 sat in her recliner staff had to really watch her because she would scoot out of the chair and fall.
On 10/24/2023 at 12:15 p.m., an observation and interview was conducted with S12LPN. S12LPN reviewed Resident #127's care plan and verified the intervention for falls was non- slip strips in front of Resident #127's recliner. During an observation of Resident #127's room, S12LPN verified there were no non-slip strips in front of Resident #127's recliner.
On 10/24/2023 at 12:30 p.m., an observation and interview was conducted with S7CC. She verified Resident #127's care plan interventions listed non-slip strips to be placed in front of her recliner. S7CC then verified through observation there were no non slip strips in front of Resident #127's recliner and should have been.
On 10/25/2023 at 10:40 a.m., an interview was conducted with S4DON. He confirmed Resident #127's care plan had an intervention for non-slip strips to be place in front of her chair and should have been implemented.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected most or all residents
Based on observations, interviews, and record review, the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principle...
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Based on observations, interviews, and record review, the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles for 2 (Med Room a and Med Room b) of 2 (Med Room a and Med Room b) medication storage rooms observed. The facility failed to ensure:
1. Tuberculin multi-dose vial and Influenza Vaccine multi-use vial were labeled with the date opened; and
2. Temperatures were documented for the medication refrigerator in Med Room b.
Findings:
An observation was made of the medication refrigerator in Med Room b on 10/23/2023 at 10:17 a.m. with S11LPN. There was 1 opened Tuberculin multi-dose vial without an open date on the vial and 1 opened Influenza Vaccine multi-use vial without an open date on the vial.
An interview was conducted on 10/23/2023 at 10:17 a.m. with S11LPN. She confirmed all opened multi-dose vials should have an open date. She confirmed both vials were available for resident use and were not labeled with an open date.
Review of the Medication Refrigerator Temperature Log for the refrigerator located in Med Room b revealed no documentation of temperatures for 10/20/2023 - 10/23/2023.
An interview was conducted on 10/23/2023 at 10:10 a.m. with S10LPN. She confirmed there was no documentation of temperatures recorded for 10/20/2023 - 10/23/2023. She stated night shift was responsible for documenting the medication refrigerator temperatures each night.
An interview was conducted on 10/23/2023 at 10:12 a.m. with S5CC. She confirmed there was no documentation of temperatures recorded for 10/20/2023 - 10/23/2023. She stated night shift was responsible for documenting medication refrigerator temperatures each night.
An interview was conducted on 10/24/2023 at 10:35 a.m. with S4DON. He confirmed all opened multi-dose vials should have an open date. He confirmed night shift was responsible for ensuring the medication refrigerator temperature log was filled out during their shift. He confirmed these logs should not have any missing data.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based on record review, observations, and interviews, the facility failed to store, prepare, and serve food in accordance with professional standards for food service safety. This had the potential to...
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Based on record review, observations, and interviews, the facility failed to store, prepare, and serve food in accordance with professional standards for food service safety. This had the potential to effect 145 residents who were served meals from the kitchen.
Findings:
Review of the facility's policy titled Food Preparation and Service revealed the following:
Policy Statement:
Food and nutrition services employees prepare and serve food in a manner that complies with safe food handling practices.
Food Preparation, Cooking and Holding Time/Temperatures:
1. The danger zone for food temperatures is between 41 degrees Fahrenheit and 135 degrees Fahrenheit.
An observation was made on 10/23/2023 at 8:45 a.m. of the facility's walk-in pantry with S9FSM. The following was observed:
-Four boxes of gumbo mix with an expiration date of 07/27/2023.
-Two opened gallons of soy sauce with a label, which read, refrigerate after opening.
An observation was made on 10/23/2023 at 8:48 a.m. of the facility's walk-in refrigerator with S9FSM. The following was observed:
-One opened bottle of enchilada sauce with black and green fuzzy spots, 1 inch x 1 inch in length, on the bottle's lid.
-One opened bottle of sweet and sour sauce with black and green fuzzy spots, 1 inch x 1 inch in length, on the bottle's lid.
-One opened half gallon of buttermilk with an expiration date of 10/06/2023
-One opened gallon bottle of raspberry vinaigrette salad dressing with no opened date.
An observation was made on 10/23/2023 at 8:50 a.m. of the facility's walk-in freezer with S9FSM. The following was observed:
-One opened box of biscuits in an unsealed plastic bag.
An interview was conducted on 10/23/2023 at 8:51 a.m. with S9FSM. She confirmed the above observations. She confirmed all of the above food items were available for resident use. She confirmed all expired food items should have been discarded and not available for resident use. She confirmed all food items requiring refrigeration after opening should have been placed in the refrigerator. She stated the black and green fuzzy spots on the lid of the enchilada and sweet and sour sauce bottles were mold. She confirmed all opened food items should have a label including an opened date. She confirmed all food items should be properly sealed at all times.
An observation was made on 10/23/2023 at 11:43 a.m. of the food serving station as S13FS performed a temperature check on the potato salad. The temperature check for the potato salad resulted in 42.6 degrees Fahrenheit and S13FS served the potato salad to the residents.
An interview was conducted on 10/23/2023 at 11:44 a.m. with S13FS. He stated the temperature of the potato salad should be less than 41 degrees Fahrenheit. S13FS confirmed he served the potato salad, which was 42.6 degrees Fahrenheit, to the residents.
An interview was conducted on 10/23/2023 at 11:46 a.m. with S9FSM. She confirmed the potato salad should have been less than 41 degrees Fahrenheit. She confirmed the potato salad, which was 42.6 degrees Fahrenheit, should not have been served to residents.
An interview was conducted on 10/25/2023 at 9:05 a.m. with S3ADM. She confirmed all expired food items should have been discarded and not available for resident use. She confirmed all food items requiring refrigeration after opening, should have been stored in the refrigerator. She stated for no reason should mold be growing on a container of food available for resident use. She confirmed all opened food items should have a label including an opened date. She confirmed all food items should be properly sealed at all times. She confirmed the potato salad temperature should have been less than 41 degrees Fahrenheit and should not have been served to the residents at 42.6 degrees Fahrenheit.
MINOR
(C)
Minor Issue - procedural, no safety impact
Staffing Data
(Tag F0851)
Minor procedural issue · This affected most or all residents
Based on interviews and record review, the facility failed to electronically submit accurate payroll information for direct care staffing as required.
Findings:
Review of the PBJ Staffing Data Report...
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Based on interviews and record review, the facility failed to electronically submit accurate payroll information for direct care staffing as required.
Findings:
Review of the PBJ Staffing Data Report for Fiscal Year Quarter 3 2023 (April 1-June 30) revealed
One Star Staffing Rating was triggered.
Review of the facility's CMS Submission Report PBJ Final File Validation Reports for Fiscal Quarter 1, 2, and 3 revealed, in part, Total Employee Link Records were not submitted.
An interview was conducted on 10/25/2023 at 9:54 a.m. with S1CHRD. She stated the facility changed payroll systems in December of 2022. She confirmed if the PBJ system did not accept the employee file changes, the information should have been manually entered into the system and it was not. She stated she was responsible for entering employee information for Fiscal Quarter 2 and 3. She stated S2CAO was responsible for entering the employee information during Fiscal Quarter 1.
An interview was conducted on 10/25/2023 at 10:50 a.m. with S2CAO. She confirmed the facility changed payroll systems during December of 2022. She stated she was responsible for entering the employee information during Fiscal Quarter 1. She stated the PBJ system did not accept the employee file changes. She confirmed if the PBJ system did not accept the employee file changes, the information should have been manually entered into the system and it was not. She confirmed the facility's staffing data was not entered into the PBJ system for Fiscal Year 2023, Fiscal Quarters 1, 2, and 3.
Apr 2023
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0552
(Tag F0552)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure the resident had the right to be informed in advance, by th...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure the resident had the right to be informed in advance, by the physician or other practitioner or professional, of treatment and to choose the alternative or option he or she preferred for 1(#1) of 5(#1, #2, #3, #4, #5) sampled residents. The facility failed to ensure Resident #1 was informed she was tested for Sexually Transmitted Diseases.
Findings:
Review of the clinical record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses that included Multiple Sclerosis, Neurogenic Bladder, Anxiety and Depression.
Review of the annual MDS with an assessment reference date of 03/11/2023 revealed Resident #1 had a BIMS of 15, which indicated she was cognitively intact.
Review of the current Physician Orders dated 01/2023 revealed orders for care, treatments, and services consistent with the resident's condition and diagnosis. Orders included:
01/13/2023: UA for chlamydia, gonorrhea, Trichomoniasis, and UA with c/s one time only for burning with urination.
Review of the policy titled, Resident Rights revealed the following:
Policy: Employees shall treat all residents with kindness, respect and dignity.
Policy Interpretation and Implementation
1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to:
a. a dignified existence;
b. be treated with respect kindness and dignity
p. be informed of, , his or her care planning and treatment;
s. choose an attending physician and participate in decision-making regarding his or her
care;
On 04/17/2023 at 11:30 a.m., an interview was conducted with Resident #1. She stated she had been a resident at the facility for about two years, and she had a urinary catheter since admission. She stated in January 2023, she had burning with urination and foul smelling urine, which she reported to the nurse. She stated the nurse informed her she was to collect a Urinalysis for a Urinary Tract Infection. She stated she checked her patient portal for her lab results and saw that she had been tested for Sexually Transmitted Diseases. She stated she was not informed other tests were ran. She stated she was offended lab work was ran for Sexually Transmitted Diseases. She stated it made her feel degraded and judged like either she and or her spouse were having an affair. She stated she questioned S2NP, and S2NP stated since she complained of burning with urination, the doctor and herself found it appropriate to test for Sexually Transmitted Diseases.
On 04/17/2023 at 1:45 p.m., an interview was conducted with S1LPN. She stated she was very familiar with Resident #1. She stated Resident #1 came to her in January 2023 asking her why she was tested for Sexually Transmitted Diseases when she only complained about burning with urination. She stated she felt like Resident #1 was embarrassed. She stated Sexually Transmitted Diseases were not normally ordered with a Urinalysis in the Nursing Home setting. She stated Resident #1 should have been informed of the testing prior to the urine being collected.
On 04/17/2023 at 2:45 p.m., an interview was conducted with S2NP. She confirmed she ordered the Urinalysis for Resident #1 in January 2023 related to burning with urination. She stated she did not inform the resident of the Gonorrhea/Chlamydia test being added to the urinalysis and should have. She stated she did not know the lab results would show up in the patient portal and that her husband would see the results. She stated Resident #1 came to her upset that she had been tested for Sexually Transmitted Diseases.
Jan 2023
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0888
(Tag F0888)
Could have caused harm · This affected 1 resident
Based on interviews and record review, the facility failed to implement processes for ensuring staff that provided care, treatment or services for the facility residents met the COVID-19 staff vaccina...
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Based on interviews and record review, the facility failed to implement processes for ensuring staff that provided care, treatment or services for the facility residents met the COVID-19 staff vaccination requirement. The facility failed to ensure 2 (S4DA, S7AD) staff members were fully vaccinated for COVID-19 within the CMS requirement.
This deficit practice had the potential to affect 146 residents that resided in the facility.
Findings:
Review of the facility's policy, New Federally Mandated Policy Requiring Vaccinations revealed the following, in part:
Application of the Fully Vaccination Requirement:
The CMS IFC requires that each individual who is to be present in the facility or at the physical site of patient care (based upon frequency) must be fully vaccinated.completion of the primary series for vaccination, employees are required to receive the first dose of a 2 dose-series, or the single dose COVID-19 vaccination prior to employment start date and complete the primary series according to manufacture recommendations.
An interview was conducted on 01/17/2023 at 11:00 a.m. with S2ICP. She confirmed S4DA and S7AD have continued to work in the facility since their date of hire with no disruptions. She also confirmed the following:
S4DA with a date of hire of 12/08/2022 was listed as an active employee with dose 1 of Pfizer dated 12/05/2022. S4DA was listed as partially vaccinated on vaccination matrix with no exemption or delay for further vaccination. Further review revealed S4DA missed his appointment to get his second dose.
S7AD with a date of hire of 10/14/2022 was listed as an active employee with dose 1 of Pfizer dated 10/19/2022. S7AD was listed as partially vaccinated on vaccination matrix with no exemption or delay for further vaccination. Further review revealed S7AD had forgot about getting her second dose, and had not received it.
An interview was conducted on 01/17/2023 at 11:15 a.m. with S1ADM and S2ICP. Both verified S4DA and S7AD who were listed as partially vaccinated had no exemption, temporary delay, requested or pending exemption. Both, S1ADM and S2ICP confirmed the facility failed to implement processes for ensuring staff that provided care, treatment or services for the facility residents met the COVID-19 staff vaccination requirement.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0887
(Tag F0887)
Could have caused harm · This affected multiple residents
Based on policy review, record review and interviews, the facility failed to implement their policies and procedures as evidenced by failing to ensure COVID-19 vaccination status of staff was tracked ...
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Based on policy review, record review and interviews, the facility failed to implement their policies and procedures as evidenced by failing to ensure COVID-19 vaccination status of staff was tracked and documentation maintained for 5 (S3LPN, S4DA, S5CNA, S6DA, S7AD) of 234 staff listed on the facility's COVID-19 Staff Vaccination Status for Providers. This deficient practice had the potential to affect the 146 residents who resided in the facility.
Findings:
Review of the facility's policy, New Federally Mandated Policy Requiring Vaccinations, revealed the following, in part:
Documentation of Staff Vaccinations:
The CMS IFC also requires that we track and securely document the vaccination status of each staff member, including those for whom there is a temporary delay in vaccination,
In order to comply with the CMS mandate, all staff COVID-19 vaccines must be appropriately documented. This documentation will be an ongoing process as new staff are on boarded.
Review of the facility's COVID-19 Staff Vaccination Status for Providers form, provided by S2ICP, revealed a list of 234 total staff. Further review revealed 5 (S3LPN, S4DA, S5CNA, S6DA, and S7AD) of the 234 staff were listed as Partially Vaccinated.
S3LPN with a date of hire of 10/03/2022, was listed as an active employee with dose 1 of Moderna dated 01/07/2021.
S4DA with a date of hire of 12/08/2022, was listed as an active employee with dose 1 of Pfizer dated 12/05/2022.
S5CNA with a date of hire of 10/06/2022, was listed as an active employee with dose 1 of Pfizer dated 11/24/2021.
S6DA with a date of hire of 08/04/2022, was listed as an active employee with dose 1 of Moderna dated 07/28/2022.
S7AD with a date of hire of 10/14/2022, was listed as an active employee with dose 1 of Pfizer dated 10/19/2022.
An interview was conducted on 01/17/2023 at 11:00 a.m. with S2ICP. She confirmed S3LPN, S4DA, S5CNA, S6DA, and S7AD have continued to work in the facility since their date of hire with no disruptions. She also confirmed the following:
S3LPN was listed as partially vaccinated on vaccination matrix with no exemption or delay for further vaccination. Further review revealed S3LPN received her second dose of Moderna dated 02/04/2021. S2ICP verified the dose was not documented until 01/17/2023 when brought to her attention.
S4DA was listed as partially vaccinated on vaccination matrix with no exemption or delay for further vaccination. Further review revealed S4DA did not obtain his second dose of the vaccination.
S5CNA was listed as partially vaccinated on vaccination matrix with no exemption or delay for further vaccination. Further review revealed S5CNA received her second dose of Pfizer dated 04/08/2022, and a booster on 12/28/2022. S2ICP verified the doses were not documented until 01/17/2023 when brought to her attention.
S6DA was listed as partially vaccinated on vaccination matrix with no exemption or delay for further vaccination. Further review revealed S6DA received her second dose of Moderna dated 01/15/2023. S2ICP verified the dose was not documented until 01/17/2023 when brought to her attention.
S7AD was listed as partially vaccinated on vaccination matrix with no exemption or delay for further vaccination. Further review revealed S7AD had not obtained her second dose of the vaccination.
S3LPN was present, working and interviewed on 01/18/2023. She stated she was fully vaccinated with 2 doses of Moderna. She provided her vaccination card and it documented she received her Moderna vaccination doses dated 01/07/2021 and 02/04/2021. S2ICP verified the dose was not documented until 01/17/2023 when brought to her attention.
An interview was conducted on 01/17/2023 at 11:15 a.m. with S1ADM and S2ICP. Both verified S3LPN, S4DA, S5CNA, S6DA, and S7AD who were listed as partially vaccinated had no exemption, temporary delay, requested or pending exemption. Both, S1ADM and S2ICP confirmed the facility failed to implement their policies and procedures as evidenced by failing to ensure COVID-19 vaccination status of staff was tracked and documentation was maintained.
Sept 2022
3 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Grievances
(Tag F0585)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to make prompt efforts to resolve grievances for 1 (#49) of 28 reside...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to make prompt efforts to resolve grievances for 1 (#49) of 28 residents reviewed for grievances. The facility failed to ensure a grievance was promptly investigated when Resident #49 reported missing hearing aids to staff.
Findings:
Review of facility's Resident Care Grievance Policy states, in part:
1.
Upon receipt of a grievance from a resident or any concerned party, an impartial investigation will be initiated by the facility Administrator or their designee. The investigator shall complete the PCC GRIEVANCE/COMPLAINT REPORT form or enter the information in the Risk Management section of the resident's electronic health record. Documentation of the investigation process should include:
Date/time of alleged incident
Location and circumstances of the alleged incident
Name(s) of witnesses and their account of alleged incident
Complainant's account of incident (if applicable)
Employees/Supervisor/Department Head account of incident (if applicable)
Recommendations for corrective action or grievance resolution (if applicable)
4.
The grievance investigation report along with recommendations for action should be completed within 5 working days. In all grievance cases the complainant must be informed of the investigation outcome.
Resident #49 was admitted to the facility on [DATE]. Diagnosis included: Congestive Heart Failure, Acute and Chronic Respiratory Failure, Hyperlipidemia, and Chronic Kidney Disease.
Review of Resident #49's Quarterly MDS with an ARD of 06/23/2022 revealed Resident #49 had a BIMS Summary score of 15 which indicated Resident #49 was cognitively intact. Appropriate assessments included, in part: Resident #49 used hearing aids.
Review of Grievance Log dated August 2022 revealed no grievance report for Resident #49's lost hearing aids.
On 09/06/22 at 9:31 a.m., an interview was conducted with Resident #49. She asked for surveyor to speak loudly because she lost her hearing aids two weeks ago. She stated she notified her nurse. She stated her nurse helped her look for them but could not find them. She stated her nurse was going to report them missing but she has not heard anything about them since.
On 09/08/2022 at 8:21 a.m., an interview was conducted with S4LPN. S4LPN reported Resident #49's hearing aids had been missing for approximately two weeks. She stated she helped Resident #49 look for them but could not find them. She stated she reported the missing hearing aids to the social worker. She stated whenever a resident loses personal property it is reported to the social worker and the social worker handles it.
On 09/08/2022 at 10:15 a.m., an interview was conducted with S6SW. She stated she found out today that Resident #49 lost her hearing aids. She verified there was no grievance filed for the lost hearing aids. She stated when a resident loses personal property the nurse is to file a grievance report and notify the Social Worker so it can be investigated. When S6SW was informed that S4LPN stated she notified her two weeks ago of the lost hearing aids, S6SW replied, I don't know.
On 09/09/2022 at 9:07 a.m., an interview was conducted with S1ADM. She confirmed a grievance should have been filed two weeks ago when Resident #49 complained of her hearing aids missing.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to develop and implement a comprehensive person-centered plan of care t...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to develop and implement a comprehensive person-centered plan of care to include measurable objectives and timeframes to meet a residents medical needs for 2 (#49, #67) of 28 residents reviewed for care plans. The facility failed to ensure Resident #49's impaired hearing and Resident #67's order for Hospice was reflected in the current plan of care.
Findings:
Review of facility's Care Plans, Comprehensive Person-Centered Policy stated, in part:
Policy Statement
A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.
Policy Interpretation and Implementation
2.
The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required MDS assessment (Admission, Annual or Significant Change in Status), and no more than 21 days after admission.
Resident #49
Review of the Clinical Record revealed Resident #49 was admitted to the facility on [DATE] with diagnoses which included, in part: Congestive Heart Failure, Acute and Chronic Respiratory Failure, Hyperlipidemia, and Chronic Kidney Disease.
Review of Resident #49's Quarterly MDS with an ARD of 06/23/2022 revealed a BIMS of 15, which indicated the resident was cognitively intact. Appropriate assessments included, in part: Resident #49 used hearing aids.
Review of Resident #49's Care Plan dated 05/05/2022 revealed the resident was not Care Planned for impaired hearing.
On 09/08/2022 at 1:19 p.m., an interview was conducted with S3LPN. She stated Resident #49 should have been Care Planned for Hearing Aids.
On 09/09/2022 at 8:34 a.m., an interview was conducted with S2DON. He verified that Resident #49's Care Plan should have addressed loss of hearing.
Resident #67
Review of the Clinical Record revealed Resident # 67 was admitted to the facility on [DATE] with diagnoses which included, in part: Chronic Congestive Heart Failure, Nonrheumatic Mitral Valve Insufficiency, Major Depressive Disorder, Generalized Anxiety Disorder, and Unspecified Dementia without Behavioral Disturbances.
Review of Resident #67's Quarterly MDS with an ARD of 04/20/2022 revealed a BIMS of 09, which indicated Resident #67 was moderately cognitively impaired. Review of the current Physician Orders included, in part: Resident admitted to Heart of Hospice on 06/29/2022.
Review of Care Plan dated 07/26/2022 revealed Resident #67 was not Care Planned for Hospice.
On 09/08/2022 at 1:15 p.m., an interview was conducted with S3LPN. She verified that Resident #67 was not and should have been Care Planned for Hospice.
On 09/09/2022 at 8:32 a.m., an interview was conducted with S2DON. He confirmed Resident #67 was not and should have been Care Planned for Hospice.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record review, the facility failed to ensure drugs used in the facility were stored properl...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record review, the facility failed to ensure drugs used in the facility were stored properly by failing to ensure insulin that had exceeded the recommended discard date was removed from resident use, as evidenced by:
1. an Aspart insulin FlexPen on med cart A available for resident #39's use had an opened date of [DATE] and continued to be used on Resident #39 past the recommended discard date of [DATE].
This deficient practice had the potential to affect any of the facility's 19 residents listed on the Resident Census List that received Aspart (Novolog) Insulin FlexPen.
Review of Policy and Procedure titled: Insulin/ Insulin FlexPens and Insulin Documentation, dated [DATE] revealed:
Policy, in part:
Opened/ In-Use devices:
Novolog FlexPens are kept at room temperature (below 86 degrees) for up to 28 days.
FlexPen Insulin Administration:
1. Note the FlexPen pharmacy label and write date device is opened/ expires, Never share insulin pens among residents.
3. Compare Clinician order with the FlexPen device and label- check/ confirm correct resident name, insulin type, frequency, dosage and expiration.
Review of Policy for Storage of Medications included:
4. Drug containers that have missing, incomplete, improper, or incorrect labels are returned to the pharmacy for proper labeling before storing. Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed.
Review of manufacturer's recommendation for storage of FlexPen(Novolog/Aspart) per reference.medscape.com/drug/fiasp-novolog-insulin-aspart-999001#11 revealed:
Storage: Used vials, pens and cartridge
Store at room temperature below 30 degrees C (86 degrees F) for up to 28 days.
Findings:
On [DATE] at 11:21 a.m. during a focused medication administration observation on med Cart A, S5RN prepared to administer 2 units of Aspart 100 units/ml FlexPen for Resident #39. The Aspart 100units/ml FlexPen labeled for Resident #39 had an observed opened date labeled [DATE]. S5RN proceeded to prepare resident #39's 2 units of Aspart insulin, and this surveyor verified the 2 unit dose as dialed with S5RN. This surveyor then interrupted S5RN prior to administration of the prepared dose from this Aspart FlexPen.
On [DATE] at 11:25 a.m. an interview was conducted with S5RN in which she was asked when an Aspart FlexPen is considered expired. She said the facility's policy stated an Aspart FlexPen expired after 28 days from the opened date on the label. She verified that the currently opened & labeled Aspart FlexPen for Resident #39, dated [DATE], had expired and should not have been used. S5RN verified the resident had continued to receive this expired Aspart FlexPen insulin per Sliding scale daily since it was opened on [DATE], and it should have been discarded on [DATE] but it was not.
On [DATE] at 10:10 a.m. an interview was conducted with S2DON. He stated an Aspart FlexPen should be discarded 28 days after the pen is opened. When asked what he would expect a nurse to do with an opened, labeled and expired Aspart FlexPen, he stated the nurse should discard it. He verified med cart A's Aspart FlexPen labeled for Resident #39's use had expired on [DATE] and the nurse should have discarded it and removed it from use on that date.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • No major safety red flags. No abuse findings, life-threatening violations, or SFF status.
- • No fines on record. Clean compliance history, better than most Louisiana facilities.
- • 40% turnover. Below Louisiana's 48% average. Good staff retention means consistent care.
Concerns
- • 19 deficiencies on record. Higher than average. Multiple issues found across inspections.
Bottom line: Mixed indicators with Trust Score of 65/100. Visit in person and ask pointed questions.
✓ Report will be sent to your email
About This Facility
What is Greenbriar Community's CMS Rating?
CMS assigns GREENBRIAR COMMUNITY CARE CENTER an overall rating of 3 out of 5 stars, which is considered average nationally. Within Louisiana, this rating places the facility higher than 99% of the state's 100 nursing homes. This mid-range rating indicates the facility meets federal standards but may have areas for improvement.
How is Greenbriar Community Staffed?
CMS rates GREENBRIAR COMMUNITY CARE CENTER's staffing level at 4 out of 5 stars, which is above average compared to other nursing homes. Staff turnover is 40%, compared to the Louisiana average of 46%. This relatively stable workforce can support continuity of care.
What Have Inspectors Found at Greenbriar Community?
State health inspectors documented 19 deficiencies at GREENBRIAR COMMUNITY CARE CENTER during 2022 to 2025. These included: 18 with potential for harm and 1 minor or isolated issues.
Who Owns and Operates Greenbriar Community?
GREENBRIAR COMMUNITY CARE CENTER is owned by a non-profit organization. Non-profit facilities reinvest revenue into operations rather than distributing to shareholders. The facility is operated by COMMCARE CORPORATION, a chain that manages multiple nursing homes. With 174 certified beds and approximately 156 residents (about 90% occupancy), it is a mid-sized facility located in SLIDELL, Louisiana.
How Does Greenbriar Community Compare to Other Louisiana Nursing Homes?
Compared to the 100 nursing homes in Louisiana, GREENBRIAR COMMUNITY CARE CENTER's overall rating (3 stars) is above the state average of 2.4, staff turnover (40%) is near the state average of 46%, and health inspection rating (3 stars) is at the national benchmark.
What Should Families Ask When Visiting Greenbriar Community?
Based on this facility's data, families visiting should ask: "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?"
Is Greenbriar Community Safe?
Based on CMS inspection data, GREENBRIAR COMMUNITY CARE CENTER has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 3-star overall rating and ranks #1 of 100 nursing homes in Louisiana. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.
Do Nurses at Greenbriar Community Stick Around?
GREENBRIAR COMMUNITY CARE CENTER has a staff turnover rate of 40%, which is about average for Louisiana nursing homes (state average: 46%). Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.
Was Greenbriar Community Ever Fined?
GREENBRIAR COMMUNITY CARE CENTER has no federal fines on record. CMS issues fines when nursing homes fail to meet care standards or don't correct problems found during inspections. The absence of fines suggests the facility has either maintained compliance or corrected any issues before penalties were assessed. This is a positive indicator, though families should still review recent inspection reports for the full picture.
Is Greenbriar Community on Any Federal Watch List?
GREENBRIAR COMMUNITY CARE CENTER is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.