Greenbrier Nursing & Rehabilitation Center Of Pale
Inspection Findings
F-Tag F0690
F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
he thought he was dry. He said he was not wet all day like yesterday. He said he could not remember when
a staff member last checked on him.During an observation on 9/9/25 at 5:06 p.m., Resident #1 was observed in his room. He was lying on his bed; his sheets were visibly wet with a brown outer ring approximately the width of half of the sheet and a smaller yellow ring approximately half the size. A strong odor of ammonia was detected from his person and room. His pants were visibly wet around the right hip area. Resident #1 appeared to be sleeping.During an interview on 9/9/25 at 5:08, CNA B said she worked
the 2:00 p.m. to 10:00 p.m. shift and was working on Resident #1's hall that day. She said she did not round
on residents until 3:30 p.m. or 4:00 p.m. because she had to assist residents with showers first. She said
she checked on Resident #1 around 3:00 p.m. and checked his briefs and noted them to be dry. She said
she did see something on his sheets but Resident #1 did not want her to do anything about it.During an
interview on 9/10/25 at 9:00 a.m., LVN C said CNAs were expected to round on residents every 2 hours and part of that rounding should include checking for any incontinent care needs. He said CNAs should go into every room and ask the resident if they need any assistance. During an interview on 9/10/25 at 9:10 a.m., LVN D said CNAs were expected to check on every resident at least every 2 hours. She said CNAs should be checking to see if residents need peri care and providing it. She said CNAs should be checking for wet or soiled linens and changing them. She said if a resident refused care the CNA should report it to
the nurse so they can assist. During an interview on 9/10/25 at 9:30 a.m., the DON said she was ultimately responsible for supervising nursing staff. The DON said CNAs were expected to round every 2 hours and should be checking for and addressing any resident needs including incontinent care and wet or soiled linens. During an interview on 9/10/25 at 9:40 a.m., the ADM said the DON was responsible for supervision of the nursing staff. The ADM said CNAs were expected to round a minimum of every 2 hours, and they should be checking for incontinent care needs and changing soiled linens as part of their regular rounding.Review of the facility's policy titled Perineal Care dated 5/11/22 revealed the following .An incontinent resident of urine and/or bowl (sic) should be identified, assessed, and provided appropriate treatment and services. Skin problems associated with moisture can range from irritation to increased risk of skin breakdown.
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
09/10/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Greenbrier Nursing & Rehabilitation Center of Pale
2404 Hwy 155 Palestine, TX 75803
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-Tag F0880
Federal health inspectors cited GREENBRIER NURSING & REHABILITATION CENTER OF PALE in PALESTINE, TX for a deficiency under regulatory tag F-F0880 during a complaint investigation conducted on 2025-09-10.
Category: Infection Control Deficiencies
The facility was found deficient in the following area: Provide and implement an infection prevention and control program.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 2 deficiencies cited during this inspection of GREENBRIER NURSING & REHABILITATION CENTER OF PALE.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-09-11.
GREENBRIER NURSING & REHABILITATION CENTER OF PALE in PALESTINE, TX inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in PALESTINE, TX, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from GREENBRIER NURSING & REHABILITATION CENTER OF PALE or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.