Resident #117 disappeared from Greenbrier Health Center sometime after 10:30 p.m. on September 14, when staff last saw him sitting in the second-floor television room wearing blue jeans, a T-shirt, blue jacket and shoes. Police didn't notify the facility he was missing until 12:50 a.m.
A local resident first spotted him at 12:08 a.m., now wearing a sweatshirt and plaid night pants. The man had been ringing doorbells at multiple homes approximately 1.5 miles from the nursing home before the resident called emergency services.
Police found him standing in the street. When officers asked what he was looking for, Resident #117 said he was searching for a local meat market. He told them his kidney hurt and was transported to a hospital for evaluation.
The incident marked another failure in the facility's supervision of a patient with a documented history of wandering. Federal inspectors found that administrators never updated Resident #117's elopement care plan despite his "multiple elopement attempts."
The Administrator confirmed during a September 24 interview that no new interventions had been added to address the resident's repeated escapes from the facility.
State inspectors also discovered that another long-term resident had been denied required care planning meetings for over a year. Resident #69, who has lived at Greenbrier since July 2023, suffered from spinal problems, muscle weakness and required assistance with daily activities like bathing and dressing.
Federal regulations require nursing homes to hold care plan meetings within two weeks of admission, then quarterly and whenever a resident's condition changes significantly. These meetings involve family members, medical staff and social workers reviewing treatment goals and adjusting care as needed.
Medical records showed no care plan meetings were documented for Resident #69 from September 2024 through September 2025. The resident remained cognitively intact but had impaired movement in one arm and both legs.
Licensed Social Worker #649 initially claimed during a September 25 interview that care conferences had been held on July 10 and July 25. She acknowledged the facility's record-keeping problems, telling inspectors: "When I got here, they were a mess."
But when pressed to provide documentation of those meetings, she couldn't produce any records. The Administrator confirmed five days later that no documentation existed to verify care plan meetings had occurred on either date.
The social worker admitted that no care conferences had been scheduled or completed before July, meaning Resident #69 went without required care planning for nearly two years after admission.
Care plan meetings serve as a critical safety net for nursing home residents, ensuring medical teams regularly assess whether treatments are working and family members stay informed about their loved one's condition. The meetings also help identify problems before they become serious medical emergencies.
For residents like #69 with complex medical needs including spinal disorders and muscle weakness, regular care planning becomes even more essential. Changes in mobility or pain levels can signal the need for different medications, physical therapy adjustments or equipment modifications.
The inspection found these violations occurred at a 180-bed facility that has struggled with oversight issues. Both deficiencies were classified as having caused minimal harm or potential for actual harm to residents.
Federal inspectors completed their review on October 8 following complaints about the facility's operations. The findings reveal systemic problems with both resident safety monitoring and required care coordination.
Resident #117's midnight wandering incident highlighted particular dangers faced by cognitively impaired nursing home patients. The man's confusion about his location, his search for a meat market in the middle of the night, and his physical complaint about kidney pain all suggested he was disoriented and potentially in medical distress.
The fact that he changed clothes between his last sighting in the TV room and when police found him raises additional questions about how long he had been missing and whether staff conducted proper searches before police were notified.
His case demonstrates how inadequate elopement prevention can put vulnerable residents at serious risk of injury, exposure or getting lost in unfamiliar neighborhoods.
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.