Greenbrier Nursing & Rehabilitation: Hygiene Failures - TX
The electrodes had been applied at the hospital on April 13. She was back at the nursing home the same day. Over the next three days, at least two staff members had direct, hands-on contact with her body and neither removed them, documented them, or reported them.
CNA A, interviewed by inspectors on April 30, said she could not recall specifically whether she had bathed Resident #1 in that window. "If it was charted, she did," the inspection report notes. She said she did not notice any electrodes. Then she said something that captures the problem plainly: she said she should have noticed them and removed them if she was giving the resident an appropriate bed bath.
She was not the only one.
LVN D told inspectors she completed a skin assessment of Resident #1 on April 15, one day before the appointment where the electrodes were finally found. She said she observed all of the resident's skin. She did not note the electrodes. When asked about it directly, LVN D said she should have seen them and removed them to perform a proper skin assessment. A third staff member, CNA C, could not be reached for an interview. The phone number the facility had on file for her was not a working number.
The Director of Nursing told inspectors she would not normally expect EKG electrodes to remain on a resident after a shower or bed bath. She said she would expect them to have been removed, or at minimum, documented if they were stuck too firmly to remove. During a skin assessment, she said, she would expect a nurse to take them off and record the finding. She acknowledged that nurses at the facility "typically only chart new findings" in skin assessments, and said no single person had been assigned responsibility for assessing residents returning from the hospital. That task had fallen to whoever the charge nurse happened to be on the floor.
After the inspection, the DON said she planned to assign the treatment nurse to assess any resident returning from a hospital stay and document all findings, including attached medical devices.
The administrator told inspectors she was ultimately responsible for supervising all staff, including nursing. She said she expected CNAs to complete baths thoroughly, document the care, and report to a charge nurse if something was wrong. She said she would not expect to find electrodes or other devices on a resident's skin after bathing. She said the risks of improper bathing and incomplete skin assessments included skin breakdown. The facility, she said, had already begun retraining staff.
Inspectors requested a skin assessment policy from the facility. The facility supplied a wound management policy instead.
The bed bath policy that inspectors did locate, undated, stated that residents "will be clean and free of dryness, irritation, or pruritic (itching)" and will "verbalize a feeling of comfort and well-being." Whether Resident #1 verbalized anything about the electrodes still attached to her body, the report does not say. What it says is that she arrived at an outside appointment, and someone there noticed what the people responsible for her daily care had not.
The inspection, prompted by a complaint, was completed April 30. CMS classified the violation as actual harm or potential for actual harm at the minimal level, affecting few residents. The facility's own administrator named the consequence: skin integrity concerns, skin breakdown. In a woman whose hospital electrodes went unnoticed for three days, that risk was not hypothetical. It was three days old before anyone looked.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Greenbrier Nursing & Rehabilitation Center of Pale from 2026-04-30 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 7, 2026 · Our methodology
Greenbrier Nursing & Rehabilitation Center of Pale in PALESTINE, TX was cited for violations during a health inspection on April 30, 2026.
The electrodes had been applied at the hospital on April 13.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.