Greenbrier Health Center

F 0657

one-on-one supervision.

Level of Harm - Minimal harm or potential for actual harm

Review of a late-entry nursing progress note dated 09/15/25 at 8:00 A.M. revealed the facility was notified by the municipal police department at 12:50 A.M. on 09/15/25 that Resident #117 had been determined to be missing from the facility and was found approximately 1.7 miles away. The last known sighting of Resident #117 was at 10:30 P.M., when he was observed sitting in the television room on the second floor wearing blue jeans, a T-shirt, a blue jacket, and shoes.

Residents Affected - Few

Review of a police report dated 09/15/25 revealed that at 12:08 A.M. Resident #117 was identified by a local resident at a home approximately 1.5 miles away from the facility. He was wearing a sweatshirt and plaid night pants. The local resident called emergency services after observing Resident #117 ring the doorbells of multiple homes in the area. Resident #117 was located in the street by police. When asked what he was looking for, Resident #117 stated he was searching for a local meat market. He further stated that his kidney hurt and was subsequently transported to a local hospital for evaluation.

An interview with the Administrator on 09/24/25 at 10:10 A.M. confirmed that Resident #117's elopement/wandering care plan was not updated to include new interventions to address his multiple elopement attempts.

1. 2. Record review for Resident #69 revealed an admission date of 07/21/23. Diagnosis included spondylosis,

radiculopathy lumbar region, abnormal posture, and muscle weakness.

Review of the Annual MDS dated [DATE REDACTED] revealed Resident #69 was cognitively intact. Resident #69 had impairment on one side of the upper extremities and both sides of the lower. Resident #69 required assistants with activities of daily living (ADL's).

Review of the medical record for Resident #69 from 09/01/24 through 09/22/25 revealed no documentation of any care plan meeting being completed.

Interview on 09/25/2025 at 11:27 A.M. with Licensed Social Worker (LSW) #649 revealed she had Resident #69 down as having a care conference on 07/10/25 and 07/25/25. LSW #649 revealed there were no care conferences scheduled or completed prior to that stating, When I got here, they were a mess. LSW confirmed care plan meetings were to be held on admission, quarterly (every three months), and when there was a significant change in condition. LSW #649 revealed she will find and provide the documentation of the care plan meetings completed on 07/10/25 and 07/25/25.

Interview on 09/30/25 at 2:00 P.M. with Administrator confirmed there was no documentation available to confirm any care plan meeting was completed for Resident #69 on 07/10/25 or 07/25/25.

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/08/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Greenbrier Health Center

6455 Pearl Rd Parma Heights, OH 44130

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 Level of Harm - Minimal harm or potential for actual harm

Review of Resident #123's Quarterly MDS 3.0 assessment dated [DATE REDACTED] revealed the resident exhibited intact cognition and the shower/bathing section was documented as not applicable.

Review of Resident #123's ADL Care Plan revealed an intervention dated 09/18/25 revealed the resident was totally dependent assistance of one staff member for personal hygiene.

Residents Affected - Some

Record review of the electronical tasks record for shower/bath for Resident #123 revealed Resident #123 was to receive a shower/bath every Monday and Thursday. Record review revealed that of the eight showers/baths scheduled to be completed for August 2025, Resident #123 had no documentation of four of

the eight being offered (08/07/25, 08/11/25, 08/14/25, or 08/21/25). Of the three shower/baths scheduled for September 2025, Resident #123 had no documentation of two of the three being completed (09/04/25 or 09/08/25).

Interview and record review of the shower/bath record for Resident #123 on 09/29/2025 at 11:22 A.M. with DON confirmed Resident #123 had no documentation of the showers not completed being refused or offered. DON stated, If nothing was documented , the shower was not done.

1. 14. Closed review of Resident #134's medical record revealed the resident was admitted on [DATE REDACTED] and

discharged on 05/31/25 with diagnoses including encounter for surgical aftercare, chronic obstructive pulmonary disease, muscle weakness, and need for assistants with personal care.

Review of Resident #134's admission MDS 3.0 assessment dated [DATE REDACTED] revealed the resident exhibited intact cognition.

Review of Resident #134's ADL Care Plan revealed an intervention dated 05/29/25 for setup/cleanup assist for shower/bathing.

Record review of the electronical tasks record for shower/bath for Resident #134 revealed Resident #134 was to receive a shower/bath every Wednesday and Saturday. Record review revealed that of the four showers/baths scheduled to be completed for May 2025, Resident #134 had no documentation of two of

the four being offered (05/24/25 or 05/28/25).

Interview and record review of the shower/bath record for Resident #134 on 09/29/2025 at 11:25 A.M. with DON confirmed Resident #134 had no documentation of the showers not completed being refused or offered. DON stated, If nothing was documented , the shower was not done.

This deficiency represents noncompliance investigated under Complaint Numbers 1338811, 1338812, and

2. 1338813. FORM CMS-2567 (02/99)

Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/08/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Greenbrier Health Center

6455 Pearl Rd Parma Heights, OH 44130

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684

This deficiency represents non-compliance investigated under Complaint Number 2596048, 2561886, and

1. 1338808. Level of Harm - Minimal harm

or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/08/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Greenbrier Health Center

6455 Pearl Rd Parma Heights, OH 44130

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Level of Harm - Minimal harm or potential for actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

record review and interview, the facility failed to ensure Resident #38's pressure ulcer wound care dressings were completed as ordered. This finding affected one (Resident #38) of seven residents reviewed for pressure wounds. Findings include:Findings include:Review of Resident 38's medical record revealed

the resident was initially admitted on [DATE REDACTED] and readmitted on [DATE REDACTED] with diagnoses including quadriplegia, diabetes and schizophrenia.Review of Resident #38's Quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE REDACTED] revealed the resident exhibited intact cognition.Review of Resident #38's physician orders revealed an order dated 09/17/25 to cleanse the mid-spine, right back, sacrum, right ischium, left buttock, right lateral leg and left lower extremity with wound cleanser, apply collagen sheet to

the base of the wound and secure with a bordered foam dressing daily and as needed.Review of Resident #38's wound progress note dated 09/24/25 at 3:39 P.M. revealed the resident had a mid-spine pressure wound at a stage three which was improving and measured 2.1 centimeters (cm) length by 1 cm width by 0.3 cm depth; a right back stage 3 pressure wound which was improving and measured 3.3 cm length by 4 cm width by 0.3 cm depth; a sacrum stage three pressure wound which was improving and measured 4.6 cm length by 3 cm width by 0.2 cm depth; and a left buttocks stage three pressure wound which was improving and measured 7 cm length by 5.1 cm width by 0.2 cm depth. Interview on 09/24/25 at 12:16 P.M. with Licensed Practical Nurse (LPN) Wound Nurse #690 confirmed Resident #38's dressings to his mid spine, right back, sacrum, and the left buttocks dressings were signed off by LPN #707 on 09/23/25 as completed on the resident's medication administration records (MARS) and treatment administration records (TARS) but the dressings reflected a date of 09/22/25 which confirmed the dressings were not completed as ordered and the MARS and TARS were inaccurate. Review of the undated Wound Care policy revealed residents/patients admitted with or develop skin integrity issues would receive treatment as indicated based on location, stage and drainage.This deficiency represents non-compliance investigated under Complaint Numbers 2561886, 1338811 and 1338808.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/08/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Greenbrier Health Center

6455 Pearl Rd Parma Heights, OH 44130

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Resident #86's quarterly MDS 3.0 assessment dated [DATE REDACTED] revealed the resident exhibited intact cognition. Review of Resident #86's medical record revealed the resident did not have a smoking contract

in place. Observation on 09/29/25 at 8:17 A.M. revealed Resident #86 had a package of cigarettes and a lighter located on the top of his nightstand next to the bed. Interview on 09/29/25 at 8:18 A.M. with LPN #614 confirmed Resident #86 had cigarettes and a lighter on his nightstand. Interview on 09/29/25 at 10:50 A.M. with admission Director #69 confirmed residents were supposed to have smoking contracts and she was working on obtaining them. admission Director #69 revealed all residents were supposed to have a locked cabinet for their smoking paraphernalia.b. Review of Resident #103's medical record revealed the resident was admitted on [DATE REDACTED] with diagnoses including encounter for other orthopedic aftercare, moderate persistent asthma and muscle weakness. Review of Resident #103's Smoking Care Plan revealed an intervention dated 04/23/25 to educate the resident/resident representative to designated smoking areas, and long-term side effects of extended nicotine use. Review of Resident #103's Smoking assessment dated [DATE REDACTED] revealed the resident can light a cigarette and dispose of a cigarette appropriately. Review of Resident #103's quarterly MDS 3.0 assessment dated [DATE REDACTED] revealed the resident exhibited intact cognition. Observation on 09/25/25 at 12:58 P.M. revealed Resident #103 had one pack of cigars with a black lighter sitting on top of the cigars, one single cigarette sitting on top of a food item and a tray table near the door that contained one orange and one yellow lighter. Interview on 09/25/25 at 1:00 P.M. with MD #712 confirmed the above findings. Interview on 09/29/25 at 10:50 A.M. with admission Director #69 revealed all residents were supposed to have a locked cabinet for their smoking paraphernalia. c. Review of Resident #113's medical record revealed the resident was initially admitted on [DATE REDACTED] and re-admitted on [DATE REDACTED] with diagnoses including heart failure, vascular dementia and major depressive disorder. Review of Resident #113's smoking care plan revealed an intervention dated 06/10/22 to educate the resident on the facility smoking policy and obtain the resident's signature. Review of Resident #113's annual MDS 3.0 assessment dated [DATE REDACTED] revealed the resident exhibited moderate cognitive impairment. Review of Resident #113's Smoking assessment dated [DATE REDACTED] revealed the resident can light and dispose of cigarettes appropriately. Review of Resident #113's medical record revealed the resident did not have a smoking contract. Observation on 09/29/25 at 8:35 A.M. revealed Resident #113 had a cigarette pack in his top drawer of his nightstand. The resident stated the facility wanted $45.00 for a lost key for the cigarette lockbox. Interview on 09/29/25 at 8:40 A.M. with CNA #612 confirmed the cigarettes were located in Resident #113's top drawer. Interview on 09/29/25 at 10:50 A.M. with admission Director #69 confirmed residents were supposed to have smoking contracts and she was working on obtaining them. admission Director #69 revealed all residents were supposed to have a locked cabinet for their smoking paraphernalia. Review of the undated Resident Smoking Guidelines policy revealed to store smoking materials in a secure area when not in use by the resident/patient for both independent and supervised smokers. Smoking materials will be returned to the facility staff upon completion of smoking.

This deficiency represents non-compliance investigated under Complaint Number 2620111.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/08/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Greenbrier Health Center

6455 Pearl Rd Parma Heights, OH 44130

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

observation, record review and interview, the facility failed to provide Resident #119 with timely incontinence care. This finding affected one (Resident #119) of eleven residents reviewed for incontinence care. Findings include:Review of Resident #119's medical record revealed the resident was admitted on [DATE REDACTED] with diagnoses including hemiplegia and hemiparesis following a cerebral infarction affecting the right dominant side, chronic obstructive pulmonary disease and diabetes.Review of Resident #119's Quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE REDACTED] revealed the resident exhibited intact cognition, was frequently incontinent of bowel and bladder and required substantial/maximal assistance with toileting hygiene.Review of Resident #119's Activities of Daily Living (ADL) Self-Performance Care Plan revealed an intervention dated 05/09/25 which indicated the resident required substantial/maximal assistance with toileting hygiene.Observation on 09/22/25 at 9:45 A.M. of Certified Nursing Assistant (CNA) #687 of Resident #119's incontinence care revealed the resident's incontinence brief was saturated with urine and the resident's buttocks (right and left) appeared a deep red. The bedsheets beneath the resident had a large dried yellow stain underneath the resident.Interview on 09/22/25 at 9:52 a.m. with Resident #119 with CNA #687 in attendance revealed the resident was last changed on 09/21/25 around 8:00 P.M. and no one came in to check on her or change her incontinence brief. The resident stated she did not put

the call light on because staff never came.Interview on 09/23/25 at 6:13 A.M. with Licensed Practical Nurse (LPN) #680 revealed Resident #119 was checked and provided incontinence care this morning around 5:30 A.M., which should be performed every two hours.Interview on 09/23/25 at 6:14 A.M. with CNA #602 revealed she worked from 7:00 P.M. to 7:00 A.M. on 09/21/25 into 09/22/25 and again on 09/22/25 into 09/23/25. CNA #602 revealed she checked and changed Resident #119 around 6:00 A.M. on 09/22/25 and did not notice a large yellow stain on the sheets which appeared dried.Review of the Perineal Care - Male and Female policy dated 2018 to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the residents' skin condition.This deficiency represents non-compliance investigated under Complaint Number 1338813, 1338811, 1338810 and 1338808.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/08/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Greenbrier Health Center

6455 Pearl Rd Parma Heights, OH 44130

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0725 Level of Harm - Minimal harm or potential for actual harm

on her residents, CNA #717 stated she prioritized her incontinent residents but rounded on residents generally twice in the 12-hour shift. CNA #717 expressed showers were also difficult to complete on the floor as many residents required a second person to be bathed or transferred and when they were short staffed, there was not a second person readily available to do so.

Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/08/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Greenbrier Health Center

6455 Pearl Rd Parma Heights, OH 44130

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759

Ensure medication error rates are not 5 percent or greater.

Level of Harm - Minimal harm or potential for actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

observation of medication administration, interview, record review, and review of the instructions for insulin pen-injections, the facility failed to ensure medications were administered as ordered resulting in a medication errors rate of 6.7 percent (%). This affected two residents (Resident #87 and #138) out of five residents observed for medication administration. The facility census was 123.Findings include:1. Record

review for Resident #138 revealed an admission date of 05/20/25. Diagnosis included diabetes mellitus with diabetic chronic kidney disease.Review of the quarterly Minimum Data Set (MDS) dated [DATE REDACTED] revealed Resident #138 was cognitively intact. Resident #138 received insulin injections daily. Review of the Care Plan dated 06/02/25 revealed Resident #138 had diabetes with diabetic neurological complications.

Interventions included to administer insulin injections per medical providers orders.Review of the physician orders for Resident #138 dated 08/28/25 revealed orders for Insulin Lispro subcutaneous (sq) solution pen-injector 100 units per ml, inject four units sq with meals for blood sugar. Observation on 09/23/2025 at 11:38 A.M. of medication administration with Licensed Practical Nurse (LPN) #721 prepare and administer insulin to Resident #138 revealed LPN #721 removed the Lispro insulin pen from the medication cart. LPN #721 placed the needle on the pen and dialed in four units. Observation revealed LPN #721 did not prime

the pen. LPN #721 then administered the insulin to Resident #138.Interview on 09/23/2025 at11:42 A.M. with LPN #721 confirmed she did not prime the insulin pen prior to administration to Resident #138 and revealed she didn't need to prime the insulin pen. LPN #721 revealed she worked all areas of the facility.2.

Record review for Resident #87 revealed an admission date 07/22/25. Diagnosis included type two diabetes mellitus with hyperglycemia.Review of the admission MDS dated [DATE REDACTED] revealed Resident #87 was cognitively intact. Resident #87 received insulin injections daily.Review of the Care Plan dated 08/01/25 revealed Resident #87 had diabetes. Interventions included to administer insulin injections as ordered.Review of the physician orders for Resident #87 revealed an order dated 07/26/25 for insulin Glargine Solostar sq solution pen-injector 100 units per ml inject 34 unit sq in the morning for diabetes.

Observation on 09/24/25 at 8:35 A.M. of medication administration for Resident #87 revealed LPN #800 removed the Glargine Solostar pen-injector from the medication carts. LPN #800 primed the pen injector then placed the needle on the pen injector. LPN #800 then dialed in 34 unit on the pen injector and administered the insulin to Resident #87. LPN #800 confirmed she primed the insulin pen injector prior to putting the needle on and confirmed she did not prime the injector after putting the needle on. LPN #800 revealed she had worked all areas of the facility. Review of the Instructions for Use insulin kwik-pen revised 07/2023 revealed the priming process should be performed before every injection to ensure the correct dose is delivered. Without priming, you may inject air instead of insulin leading to an underdose. To prime, attach a needle, dial two units, tap to remove air, press the dose knob, you should see a drop or stream of insulin appear at the needle tip. If no insulin appears, repeat. Once a drop of insulin appears , your pen is primed and ready. You can now dial the correct dose for your injection.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/08/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Greenbrier Health Center

6455 Pearl Rd Parma Heights, OH 44130

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

tablet 875-125 mg from the facility medication dispensary revealed one antibiotic was removed on 07/27/25, one tablet on 07/28/25, two tablets on 07/29/25, two tablets on 07/30/25, one tablet on 07/31/25, one tablet on 08/01/25 and one tablet on 08/02/25.Review of the Medication Administration Policy dated 09/2025 revealed the purpose of the policy was to provide guidance for general medication administration to be provided by personnel recognized as legally able to administer. Medications would be charted when given and administered within the time frame of one hour before up to one hour after the time ordered.This deficiency represents non-compliance investigated under Complaint Numbers 2596048, 1338812 and

1. 1338809. Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/08/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Greenbrier Health Center

6455 Pearl Rd Parma Heights, OH 44130

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many

FORM CMS-2567 (02/99) Previous Versions Obsolete

cap five mg, give two caps by mouth at bedtime for insomnia, Buspirone hcl oral tablet 10 mg, give one tablet by mouth two times a day for anxiety, and Levetiracetam oral tablet 750 mg, give two tablets every morning and at bedtime for epilepsy. Interview on 09/24/25 at 3:58 P.M. with Resident #61 revealed a nurse had left medications in his room for him to take later and revealed one nurse had a habit of doing it, LPN #692.Interview on 09/24/2025 at 4:02 P.M. with Director of Nursing (DON) revealed there was a concern with LPN #692 but was unable to recall the date. DON revealed the morning the complaint was made, (Resident #61) said meds were left at the bedside. DON confirmed LPN #692 worked the night shift 12 hours 7:00 P.M. to 7:00 A.M.; DON revealed on that day, she called LPN #692 on the phone because she had already left for the day. LPN #692 revealed she did set them down for him to take them and went into

the hall. He did not take them according to the nurse.Interview and record review of Resident #61's medical

record on 09/25/2025 at 9:26 A.M. with DON confirmed there was no documentation in the medical record of the medications left at the bedside. DON confirmed the medications were documented as administered.Interview on 09/25/2025 at 10:41 A.M. with Administrator revealed, Resident #61's sister had concerns with medications, as they said they were being left at the bedside so he notified the DON and told her what the sister had said. Interview on 09/25/2025 at 10:25 A.M. with Certified Nursing Assistant (CNA) #717 revealed she had seen medications left at residents' bedside when no nurses were around and revealed it occurred occasionally on different residents.Phone interview on 09/26/2025 at 4:20 P.M. with Resident #61's Responsible Party revealed his aunt saw medications left in Resident #61's room first hand.

Resident #61's Responsible Party revealed he had the text still in his phone and revealed the date was Tuesday 07/08/25 when his two aunts texted him at 10:45 A.M. they found medications on the resident's table from the night before. They spoke to LPN #690 and she admitted it.Phone interview on 09/29/25 at 3:34 P.M. with LPN #690 confirmed on 07/08/25 in the morning she spoke with Resident #61's Responsible Party on the phone. LPN #690 confirmed the conversation included LPN #692 leaving Resident #61's night time medications at the bedside. LPN #692 revealed on the morning of 07/08/25 she took the medications left at Resident #61's bedside which was left by LPN #692 from the evening medications the night before and disposed of them. LPN #690 confirmed Resident #61 never received the medications.Interview on 09/29/2025 at 4:30 P.M. with DON revealed if medications were not administered, the family and MD need to be notified. DON confirmed there was no documentation of notification to the physician of missed medications on 07/07/25 or 07/08/25 for Resident #61. DON confirmed the Medication Administration

Record (MAR) for Resident #61 reflected medications were consumed the evening of 07/07/25 and signed by LPN #672.Review of the staff file for LPN #692 revealed an Employee Corrective Action Form dated 07/01/25 with LPN #692's name and the Violation Statement hand written Medication Storage, Resident Preferences education. The form included the employee (LPN #692) signature and dated 07/01/25.This deficiency represents non-compliance investigated under Complaint Number 1338813.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/08/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Greenbrier Health Center

6455 Pearl Rd Parma Heights, OH 44130

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many

FORM CMS-2567 (02/99) Previous Versions Obsolete

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and

the public.

Based on observation and staff interviews, the facility failed to ensure the facility was maintained a clean and sanitary environment. This had the potential to affect all 123 residents residing in the facility.Findings include:An environmental tour was conducted on 09/29/25 between 8:00 A.M. and 8:45 A.M. The following concerns were observed and verified by Housekeeping Director #999 at the time of discovery:The handrails

in the hallways throughout the facility were noticeably chipped, scuffed, and rough to the touch.The light fixtures in the hallways throughout the facility contained noticeable areas of dust, dirt, and dead insects inside the fixtures.Resident #52's light fixture above the bed was missing a light bulb.The rooms of Residents #27, #32, #52, #84, and #139 had multiple water-stained ceiling tiles.The privacy curtains in the rooms of Residents #76, #85, and #104 were noticeably stained.The walls in the rooms of Residents #12, #14, #82, and #107 were severely scuffed.The wall-unit air conditioners in the rooms of Residents #114 and #127 displayed a clean filter indicator light, and the filters were coated with dust.The bathroom doors in

the rooms of Residents #14, #74, #82, and #107 were severely damaged and scraped.The protective cover to the heat pipe in the rooms of Residents #45 and #64 was completely detached.The protective wood wall covering in the rooms of Residents #59 and #125 had a noticeable hole/gouge.The wheelchairs utilized by Residents #28 and #62 were extremely dirty, with significant accumulations of food, dirt, and other debris.Resident #123's room had a visible crack in the wall.The cover to the wall telephone line outside Resident #27's room was missing, exposing the live telephone wire.This deficiency represents non-compliance investigated under Complaint Number 2603578.

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