Greenbrier Nursing Center: Infection Control Failures - TX
The inspection, completed January 29, found that staff were not following the facility's own Enhanced Barrier Precautions protocol, a targeted infection control measure designed specifically to slow the spread of multidrug-resistant organisms. Under that protocol, staff are required to wear gowns and gloves during hands-on care for residents who have indwelling medical devices or open wounds. Inspectors found the protocol was not being followed consistently.
The administrator told inspectors that residents requiring Enhanced Barrier Precautions included anyone with a multidrug-resistant organism, a wound, a feeding tube, a urinary catheter, or an open area on their skin. That is a wide population in any nursing home. She acknowledged the risk plainly: if staff did not follow infection control measures, residents and staff both faced the possibility of infection.
She also said hand hygiene should be performed every time a staff member touched something.
A certified nursing assistant identified in the report as CNA C had been checked off on both female perineal care and handwashing during a proficiency audit conducted September 15, 2025, roughly four months before the inspection. The audit indicated she had demonstrated competency in both skills. What inspectors found during their January visit suggested that documented competency and actual practice in the facility were not the same thing.
The facility's own infection control policy, dated April 2024, defines Enhanced Barrier Precautions as an intervention that uses gown and glove use during high-contact resident care activities to reduce transmission of multidrug-resistant organisms. The policy specifically lists urinary catheters, feeding tubes, central lines, and tracheostomies as the kinds of indwelling devices that trigger the requirement. A separate, undated policy on infection control fundamentals states that hand hygiene is the primary means of preventing the transmission of infection and lists specific moments when it must be performed, including after removing gloves.
The policies existed. The training had been completed, at least on paper. The practice had not followed.
The director of nursing told inspectors that retraining had begun the day before, on January 28, the day before the inspection concluded. The retraining focused on hand hygiene and Enhanced Barrier Precautions. The administrator said the director of nursing was responsible for infection control training and that going forward, the facility planned to conduct in-service training with return demonstrations, meaning staff would have to show, not just hear, that they understood what was required.
Inspectors classified the violation as causing minimal harm or potential for actual harm, and noted that some residents were affected.
In a nursing home, the distance between "potential for harm" and actual harm is often measured in days. Multidrug-resistant organisms, by definition, do not respond to standard antibiotics. A resident with a urinary catheter who acquires a resistant infection faces a narrower range of treatment options than a healthier person would. A resident with an open wound or a feeding tube is already compromised. The gown and gloves that staff skipped are not bureaucratic formality. They are, as the administrator herself put it, protection for the residents and for the staff.
The facility's plan, as of January 29, was to retrain. Whether the staff who had been moving through resident rooms without the required protective equipment, touching catheters and wounds and feeding tubes, had transmitted anything in the time before inspectors arrived is not something an inspection report can answer. The residents living with those catheters and wounds will not know either.
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 2026-01-29 including all violations, facility responses, and corrective action plans.
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: August 9, 2026 · Our methodology
GREENBRIER NURSING & REHABILITATION CENTER OF PALE in PALESTINE, TX was cited for violations during a health inspection on January 29, 2026.
Under that protocol, staff are required to wear gowns and gloves during hands-on care for residents who have indwelling medical devices or open wounds.
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.