Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Greenbriar Nursing Center during CMS and state inspections, most recent first.
A facility failed to notify the physician of severe orthostatic BP changes for a resident with dizziness, and failed to notify the resident's family of changes in condition and new orders after an abnormal chest x-ray, cough, congestion, and new CT and prednisone orders. The DON confirmed the lack of documented family notification, and an NP stated she was not notified of the abnormal BP readings.
A resident with pulmonary fibrosis and CHF had an abnormal chest x-ray, and an NP ordered an outpatient chest CT with contrast. The CT was not scheduled in a timely manner, no CT results were found in the chart, and staff interviews confirmed the appointment had been missed and the scheduler had not arranged it until later. The DON and Regional RN also confirmed the results were unavailable, and the facility policy required timely submission of ordered radiology services.
A resident admitted with multiple comorbidities and an unstageable deep tissue injury did not receive timely wound care treatment. Although assessments documented the need for a barrier cream and wound care, there were no corresponding orders or documentation of treatment in the MAR/TAR until several days after admission. An LPN confirmed that wound care orders were missed, resulting in a delay in initiating appropriate skin care interventions.
The facility failed to ensure accurate PASARR documentation for three residents, omitting key mental health diagnoses and services. A resident's PASARR did not include schizoaffective disorder, another resident's PASARR lacked several psychiatric diagnoses and services, and a third resident's PASARR omitted bipolar disorder. These omissions were confirmed by facility staff.
A facility failed to monitor a resident on anticoagulant medication for bruising and bleeding, as required by physician orders and facility policy. The resident, who had a history of stroke, experienced frequent nosebleeds and large bruises, which were not documented or reported to the physician. Interviews confirmed the lack of monitoring and documentation, leading to a deficiency in care.
Failure to Notify Physician and Family of Change in Condition
Penalty
Summary
The facility failed to notify the physician of abnormal orthostatic blood pressure readings for one resident who had complaints of multiple dizzy spells over several days. The resident had diagnoses including pulmonary fibrosis and CHF, and the record showed a severe orthostatic change on the morning of the reading, with BP dropping from 126/72 lying to 77/47 sitting and 79/53 standing. New physician orders had been placed for orthostatic BP monitoring and a basic metabolic panel, but there was no documentation that the physician was notified of the abnormal orthostatic results. The facility also failed to notify the resident's family of changes in condition and new physician orders. The record showed the resident had been assessed for acute cough and congestion, had an abnormal chest x-ray showing interstitial nodular fibrosis, and received new orders for an outpatient chest CT with contrast and prednisone 20 mg daily for five days. The DON verified there was no documented family notification for the resident's changes in condition, abnormal x-ray results, or new orders, and stated the resident did not want family notified, but this was not documented in the medical record. The facility policy stated the resident, attending physician, and representative are to be notified of changes in the resident's medical or mental condition.
Delayed CT Scheduling and Missing Results
Penalty
Summary
The facility failed to schedule a CT scan and obtain the results in a timely manner for one resident with pulmonary fibrosis and congestive heart failure. The resident was admitted with diagnoses including pulmonary fibrosis and CHF, and the care plan addressed altered respiratory status and difficulty breathing with interventions to obtain and monitor labs and diagnostic work as ordered. After a chest x-ray showed interstitial nodular fibrosis, the NP assessed the resident and ordered an outpatient chest CT with contrast, but there were no CT results in the medical record. During interviews, the NP confirmed he ordered the CT after the abnormal chest x-ray and stated he did not know the CT had not been performed until later; he said he would have re-assessed the resident if staff had notified him the test could not be completed sooner. The DON and Regional RN confirmed the CT results were not available in the record, and the Regional RN stated nursing expected to call for results if they were not received within 48 hours. The transporter/scheduler confirmed the CT appointment had been missed and that he had not called to schedule the CT until later, stating he had only recently learned how to run the order report to identify appointments needing scheduling. The facility policy required nurses to submit timely requests for practitioner-ordered services, including radiology.
Failure to Timely Initiate Pressure Ulcer Treatment on Admission
Penalty
Summary
The facility failed to ensure timely initiation of skin care treatments for a resident who was admitted with a pressure ulcer. Upon admission, the resident had multiple diagnoses including hypertension, type 2 diabetes mellitus with diabetic neuropathy, peripheral vascular disease, and congestive heart failure. The resident was cognitively impaired and required supervision or minimal assistance with daily activities. Medical records indicated that the resident was at risk for pressure ulcers and had an unstageable deep tissue injury present on admission, but there was no documentation of pressure ulcer care, dressings, or topical ointments in the initial care plan or hospital discharge orders. Weekly skin and wound assessments documented the presence and progression of the pressure ulcer, including measurements and descriptions of the wound. Although a treatment plan for a zinc-based barrier cream was noted in the assessment, there was no evidence that this treatment was ordered or administered. The medication and treatment administration records for the relevant months were silent regarding wound care orders until several days after admission, when orders for wound gel and dressings were finally initiated. The wound nurse practitioner was notified and evaluated the wound, recommending specific treatments and interventions, but these were not implemented until after a delay. Staff interviews confirmed that the facility did not have documentation of the prescribed barrier cream being applied as indicated in the assessment, and that wound care orders were missed upon admission. The LPN verified that there were no wound care orders in the medication or treatment records until well after the resident's admission, resulting in a lack of timely wound care for the resident's pressure ulcer.
Inaccurate PASARR Documentation for Residents
Penalty
Summary
The facility failed to ensure that the Preadmission Screening and Resident Review (PASARR) documents for three residents accurately reflected their mental health diagnoses and services. Resident #02's PASARR did not include a diagnosis of schizoaffective disorder, despite the resident having multiple mental health conditions, including anxiety disorder and major depressive disorder. This omission was confirmed by the facility's Administrator during an interview. Similarly, Resident #61's PASARR lacked documentation of several psychiatric diagnoses, such as psychotic disorder with delusions, anxiety disorder, and major depressive disorder, as well as the psychiatric services the resident was receiving. This was also confirmed by the Administrator. Additionally, Resident #63's PASARR failed to include a diagnosis of bipolar disorder, which was confirmed by Social Worker #31. These deficiencies indicate a lack of accurate and comprehensive documentation in the PASARRs for these residents.
Failure to Monitor Anticoagulant Side Effects
Penalty
Summary
The facility failed to properly monitor a resident receiving anticoagulant medication for signs of bruising and bleeding, which are potential side effects of the medication. The resident, who was cognitively intact and required assistance with activities of daily living, had a history of stroke and was on Eliquis, an anticoagulant. Despite physician orders to monitor for signs and symptoms of bleeding and report them, there was no documentation of such monitoring in the resident's medical record from late December to late February. Observations revealed the resident had frequent nosebleeds and large bruises on both hands, which were not documented or reported to the physician as required by the facility's policy. Interviews with the resident and the Director of Nursing confirmed the presence of frequent nosebleeds and large bruises, as well as the lack of documentation and physician notification. The facility's policy on anticoagulant medications required assessment for adverse reactions such as bruising and bleeding, with any findings to be reported and documented. The failure to adhere to these protocols resulted in a deficiency in monitoring the resident's condition while on anticoagulant therapy.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Eaton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Vancrest Health Care Center Of Eaton | 0.2 mi | ★★★★★ | 12 | 0 |
| Maple Gardens Rehabilitiation And Nursing Center | 1.5 mi | ★★★★★ | 4 | 0 |
| Arbor Trace Health & Living Community | 11.6 mi | ★★★★★ | 1 | 0 |
| Forest Park Health Campus | 12.6 mi | ★★★★★ | 12 | 0 |
| Brookhaven Nursing & Rehabilitation Center | 13.1 mi | ★★★★★ | 7 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.