LPN #692 set down Resident #61's nighttime medications and walked into the hallway without ensuring he took them, according to the September inspection report. The pills included Levetiracetam, prescribed for epilepsy, along with medications for insomnia and anxiety.
The resident's family discovered the abandoned medications firsthand.
On July 8, two aunts visiting Resident #61 found his nighttime pills still sitting on his table from the previous evening. They texted the resident's responsible party at 10:45 that morning about their discovery. When they confronted the day shift nurse, LPN #690, she admitted what had happened.
"LPN #690 confirmed the conversation included LPN #692 leaving Resident #61's night time medications at the bedside," inspectors wrote. The day nurse collected the abandoned pills and disposed of them. Resident #61 never received his prescribed medications.
Yet medical records told a different story. The Medication Administration Record showed that LPN #672 had signed off on the evening medications as "consumed" on July 7, falsely documenting administration that never occurred.
The practice wasn't isolated to one resident or one incident.
During interviews, Certified Nursing Assistant #717 told inspectors "she had seen medications left at residents' bedside when no nurses were around and revealed it occurred occasionally on different residents."
Resident #61 himself confirmed the pattern during a September interview, telling inspectors that LPN #692 "had a habit" of leaving medications in his room for him to take later.
The facility's Director of Nursing acknowledged receiving concerns about LPN #692 but couldn't recall the specific date. When the complaint surfaced in July, she called the nurse at home after her 12-hour night shift had ended. LPN #692 admitted to the DON that she had set the medications down for the resident and left the room, and that he hadn't taken them.
Federal regulations require nursing homes to ensure residents receive their prescribed medications and to accurately document administration. When medications aren't given, facilities must notify both the family and the prescribing physician.
Greenbrier failed on both counts.
The Director of Nursing confirmed that neither the family nor the resident's doctor was notified about the missed medications on July 7 or July 8, despite facility policy requiring such notification. There was no documentation in the medical record acknowledging the medication error.
The Administrator told inspectors he had notified the DON after Resident #61's sister raised concerns about medications being left at the bedside, but the facility's response proved inadequate.
Records show LPN #692 had received previous discipline for medication violations. Her personnel file contained an Employee Corrective Action Form dated July 1 for "Medication Storage, Resident Preferences education" - just one week before the family discovered the abandoned medications.
The timing suggests the corrective action failed to change the nurse's behavior.
For Resident #61, the consequences extended beyond one missed dose. His prescribed medications included Levetiracetam, an anti-seizure drug that requires consistent timing and dosing to maintain therapeutic levels in the bloodstream. Missing doses can increase seizure risk in epileptic patients.
The resident also missed his prescribed Buspirone for anxiety and sleep medication, disrupting his established treatment regimen.
The false documentation compounded the medical risk by creating an inaccurate record of care. Healthcare providers reviewing the resident's chart would see continuous medication compliance when the reality was missed doses and abandoned pills.
Inspectors classified the violation as affecting "many" residents with "minimal harm or potential for actual harm." The finding represents non-compliance investigated under complaint number 1338813.
The inspection revealed a facility where medication safety protocols had broken down at multiple levels - from bedside administration to documentation to supervisory oversight. Despite receiving a complaint and conducting corrective action, management failed to prevent continued violations by the same nurse.
Resident #61's family members became accidental monitors of their loved one's care, discovering through their own vigilance what the facility's systems had failed to catch.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Greenbrier Health Center from 2025-10-08 including all violations, facility responses, and corrective action plans.