Below average — CMS composite of the measures below.
The next survey window likely opens around June 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Greystone Health Care Center during CMS and state inspections, most recent first.
Failure to provide timely Medicare coverage notices: the facility did not complete required SNFABNs for several residents and did not provide NOMNCs within the required timeframe for one resident. Records showed multiple residents with diagnoses including COPD, CHF, CKD, DM, and chronic pain syndrome had no documentation of the required CMS forms, and one resident’s NOMNC was signed on the day services ended rather than within the required notice window.
MDS assessments were not coded to reflect PASRR Level II status for four residents. Surveyors reviewed PASRR notices, MDS assessments, and medical records for residents with diagnoses including schizophrenia, bipolar disorder, dementia, psychosis, and intellectual disability, and found the PASRR item was coded “No” despite Level II determinations showing the residents needed special services. The RN MDS Coordinator and DON confirmed the coding was incorrect.
Failure to include a Stage IV pressure ulcer in the care plan. A resident with quadriplegia, DM, severe protein-calorie malnutrition, and severe cognitive impairment had a comprehensive care plan that did not address the pressure ulcer. An RN MDS Coordinator confirmed the ulcer was not included in the resident’s comprehensive care plan.
Failure to revise care plan for trach care: A resident with cerebral palsy, tracheostomy status, and COPD had physician orders for routine trach care, suctioning, saline lavage, trach tie changes, and inner cannula changes, but the comprehensive care plan only addressed impaired respiratory status, oxygen, and securing trach ties. The RN MDS Coordinator and DON confirmed the care plan was not revised to include tracheostomy care.
An unsecured scalpel was found on a resident’s bedside table after wound care, and three residents had medications left out in their rooms instead of being secured. One resident had Nystatin cream on the bedside table without being assessed to self-administer, another had antacid tablets and VapoRub left out despite not being care planned for self-administration, and a third had an insulin glargine pen observed on the dresser after the resident said the nurse had given the dose that morning.
Delayed Breakfast Tray Delivery: A resident with COPD, chronic respiratory failure, atrial fibrillation, and moderate cognitive impairment did not receive a breakfast tray in a timely manner despite being ready for the meal and requesting coffee. Staff observed the breakfast carts being delivered, but the resident remained without a tray while other residents were served; CNA E, CNA M, a Wound Care nurse, an LPN, and the DON later confirmed the tray had not been served timely.
Oxygen therapy was not provided as ordered for two residents with COPD-related respiratory conditions when portable O2 tanks were found empty during observation, despite continuous oxygen orders. In addition, trach care for a resident with tracheostomy status was not performed per policy or order when the RT changed gloves without hand hygiene, did not clean the trach stoma, and used sterile water already attached to suction tubing instead of new single-use sterile saline.
Missed refrigerator temperature checks and expired food were found in residents’ personal refrigerators. Temperature logs for three cognitively intact residents had repeated missing entries, and one resident’s refrigerator contained expired milk. An LPN stated staff were responsible for cleaning the refrigerators, discarding expired items, and documenting daily temperatures, and the DON confirmed those expectations.
Failure to Coordinate Care With Hospice: A resident receiving hospice care had diagnoses including dementia and cerebrovascular disease, with orders to admit to hospice and a care plan noting a terminal prognosis with Amedisys Hospice. Although the facility policy and hospice agreement required regular communication and coordinated care planning, there was no documentation of a coordinated care plan meeting between the facility and hospice, and the SSD and DON confirmed the lack of coordination.
Infection control practices were not followed during medication administration, blood glucose monitoring, and wound care. An RN failed to wash or sanitize hands after glove removal, touched medications with bare hands, and reused a glucometer on two residents without disinfecting it between uses. During wound care, a wound care nurse used scissors to remove soiled dressings and then placed the scissors in a pocket without disinfecting them; the DON confirmed the lapse.
Call lights left out of reach for two residents. One resident with post-polio syndrome, left foot drop, mild cognitive impairment, OA, and osteoporosis was observed yelling for help while in bed with breakfast in front of her, and the call light was on the floor; the resident later needed help opening milk while the call light remained out of reach. Another resident with dementia, gait/mobility issues, impulse disorder, and mild intellectual disabilities was observed in bed twice with the call light out of reach, and an RN confirmed it was not within reach. The DON stated it was her expectation for call lights to be placed within residents' reach.
A resident who was hospitalized for an extended period returned to find personal belongings, including a statue and a decorated tree, missing from their room. Facility staff reported that items left behind were boxed, labeled, and stored, but those unclaimed after 30 days were discarded per previous administrative instruction. The resident's family was not notified prior to the disposal, and the facility lacked a policy on handling personal items after a resident's absence.
The facility failed to follow the manufacturer's instructions for using Virasept disinfectant, as observed when a housekeeper did not maintain the required four-minute wet time on a doorknob. Interviews confirmed the deficiency, highlighting a lapse in the infection prevention and control program.
The facility did not include the resident census, facility name, or actual hours worked by RNs, LPNs, and CNAs on the Daily Staffing Sheets for three consecutive days. This was confirmed by the Staffing/Central Supply Coordinator and the DON during interviews.
The facility failed to maintain kitchen equipment in a sanitary condition, ensure spices were properly sealed, and discard expired food, potentially affecting 92 of 95 residents. Observations revealed unsealed seasoning salt, expired wing sauce, a greasy film with food particles behind the deep fryer, and a leaking pipe under the dirty sink area. The Certified Dietary Manager confirmed these deficiencies, acknowledging that the kitchen areas were not maintained in a clean sanitary manner.
The facility failed to document Durable Power of Attorney (POA) for two residents and did not provide education on Advance Directives to six residents upon admission. Residents had varying cognitive impairments, and interviews confirmed the absence of necessary documentation and education.
The facility failed to properly contain garbage and refuse in all three dumpsters, as observed during an inspection. The facility's policy requires trash to be disposed of in external receptacles with the surrounding area free of debris. However, the dumpster area was found with scattered refuse, including used gloves, plastic cups, wipes, straws, spoons, and a trash-filled plastic bag, confirming it was not maintained in a clean and sanitary condition.
The facility failed to provide hand hygiene assistance to eight residents before meals, as observed on two hallways. CNAs and an LPN delivered meal trays without offering hand hygiene, contrary to the facility's infection control protocols. Staff interviews confirmed this oversight, and the DON acknowledged the expectation for hand hygiene assistance prior to meals.
The facility did not adequately address grievances from residents regarding staff behavior and meal options. Residents complained about staff yelling and cursing in hallways and requested more fresh fruits in meals. The Dietary Manager only added a fresh fruit bar once, and the DON did not address the staff behavior issue, as no staff admitted to it. These grievances were not promptly acted upon, affecting 12 residents.
The facility failed to provide ABNs to three residents after discontinuing their therapy services, contrary to its policy. This omission left residents uninformed about potential costs for continued therapy, preventing informed decision-making. The residents had various medical conditions and were discharged from skilled Medicare services without receiving the required notices.
A facility failed to maintain a safe and sanitary environment for a resident, with issues including a strong urine odor, stained curtains, and unclean personal refrigerators. Observations revealed undated food items and expired milk in the refrigerator. Interviews highlighted confusion among staff regarding responsibilities for cleaning and temperature checks.
The facility failed to submit updated Level 2 PASARRs for two residents after new psychiatric diagnoses were identified. One resident was diagnosed with PTSD and another with an Unspecified Mood Disorder, but neither had a new PASARR submitted following these changes. The PASARR Coordinator confirmed the expectation for referrals after new diagnoses.
The facility failed to maintain clean oxygen equipment for two residents, both of whom had soiled oxygen concentrators beside their beds. Interviews revealed confusion among staff regarding responsibility for cleaning the equipment, with the DON confirming that nursing staff were responsible but had not maintained the equipment in a sanitary condition.
A resident with COPD and other conditions did not receive proper instructions or follow-up care during the administration of an oral inhaler by an LPN. The facility's policy, which includes steps for safe inhaler use and mouth rinsing, was not followed, as confirmed by the LPN and DON.
The facility failed to securely store Schedule II pain medication in one of its medication rooms. During an observation, 27 tablets were found in an unlocked refrigerator, contrary to the facility's policy requiring double-lock storage. This was confirmed by an RN and the DON.
A facility failed to secure a laptop containing electronic health records on a medication cart, resulting in resident information being visible to unauthorized persons. The incident occurred when a laptop screen was left unattended and unlocked in the 100 Hallway, as confirmed by an RN and the DON, who acknowledged the breach of facility policy.
A resident with moderate cognitive impairment and multiple health conditions was found without access to her call light, which was placed in a bedside drawer instead of within her reach. This oversight was confirmed by both a CNA and an LPN, highlighting a failure to adhere to the facility's policy on call light accessibility.
The facility failed to protect residents from abuse, resulting in incidents of inappropriate behavior and physical altercations. A cognitively impaired resident was inappropriately touched by another resident, leading to one-on-one supervision. Another incident involved a physical altercation between two residents, resulting in a skin tear and a facial scratch. Additionally, a resident was hit with a soda can by another resident, though no injuries were reported. These incidents indicate a failure to ensure resident safety.
A resident with multiple diagnoses, including COPD and Major Depressive Disorder, was administered Lorazepam without a valid physician's order. The medication was given after the order had been discontinued, as confirmed by interviews with an RN and an LPN.
Failure to Provide Timely Medicare Coverage Notices
Penalty
Summary
The facility failed to ensure timely and appropriate beneficiary notices were provided for 4 of 6 residents reviewed for Medicare coverage notices. The facility policy titled, Advance Beneficiary Notices, required use of the Skilled Nursing Facility Advance Beneficiary Notice (CMS-10055) for Part A items and services and required a Notice of Medicare Non-Coverage (CMS-10123) when Medicare-covered services were ending, including within two days of the last anticipated covered day. Review of records showed no documentation that either notice was provided for Resident #20, Resident #42, or Resident #103, and no documentation that a SNFABN was completed for those residents. Resident #20 had diagnoses including COPD, acute and chronic respiratory failure, and CHF, and was discharged from the facility. Resident #42 had diagnoses including COPD, heart disease, and hypothyroidism, and the resident's Medicare Part A stay ended while the resident remained at the facility. Resident #60 had diagnoses including DM, CKD, and spinal stenosis; a NOMNC was signed on the same day the Part A stay ended, but it was not provided within two days of the last anticipated covered day. Resident #103 had diagnoses including anxiety disorder, muscle weakness, and chronic pain syndrome, and the Medicare Part A stay ended with no documentation that a NOMNC or SNFABN was provided. The Social Service Director stated she was responsible for completing the CMS forms and confirmed the SNFABN was not completed for Residents #20, #42, #60, and #103, and that the NOMNC was not provided within the required timeframe for Resident #103.
MDS assessments were not coded to reflect PASRR Level II status
Penalty
Summary
The facility failed to accurately code the MDS assessment for PASRR status for 4 residents reviewed for MDS accuracy. CMS RAI Manual guidance cited in the report states that the MDS should accurately reflect the resident’s status and that A1500 should be coded “yes” if PASRR Level II screening determined the resident has a serious mental illness. Surveyors reviewed the medical records, PASRR Level II outcome notices, and annual or significant change MDS assessments for Residents #14, #42, #108, and #12 and found that each assessment was not coded to reflect the resident’s Level II PASRR status. Resident #14 was admitted with diagnoses including schizophrenia, depression, and hypertension. A PASRR Level II outcome notice stated the resident had a Level II PASRR evaluation and needed special services for mental health, with the evaluation remaining good during the stay. The annual MDS showed a BIMS score of 15, indicating cognitive intactness, but the MDS item asking whether the resident was currently considered by the state Level II PASRR process to have a serious mental illness was coded “No.” The LPN/MDS Coordinator reviewed the records during observation and interview and confirmed the MDS had not been coded correctly. Resident #42 was admitted and later readmitted with diagnoses including vascular dementia, bipolar disorder, and COPD. A PASRR Level II outcome notice dated prior to admission stated the resident had a Level II PASRR evaluation and needed special services for mental health, with the evaluation remaining good during the stay. The annual MDS showed a BIMS score of 3, indicating severe cognitive impairment, yet the PASRR item was coded “No.” Resident #108 had diagnoses including dementia, OCD, generalized anxiety disorder, major depressive disorder, impulse disorder, unspecified psychosis, and mild intellectual disabilities; the PASRR notice stated special services were needed for mental health, intellectual disabilities, or a related condition, but the significant change MDS was coded “No” for current Level II PASRR status. Resident #12 had diagnoses including delusional disorder, anxiety disorder, and psychosis; the PASRR notice stated special services were needed for mental health, but the annual MDS was coded “No” despite diagnoses of anxiety disorder, depression, and psychotic disorder being listed on the assessment. The RN MDS Coordinator and DON both confirmed the MDS assessments were not coded correctly to reflect the residents’ Level II PASRR status.
Failure to Include Stage IV Pressure Ulcer in Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan for Resident #40’s Stage IV pressure ulcer. Resident #40 was admitted with diagnoses including quadriplegia, diabetes mellitus, and severe protein-calorie malnutrition, and an admission MDS assessment showed a BIMS score of 00, indicating severe cognitive impairment. Review of the comprehensive care plan revised 7/9/2026 showed that the Stage IV pressure ulcer was not addressed. During an interview on 7/22/2026 at 3:07 PM, the RN MDS Coordinator confirmed that Resident #40 did not have a comprehensive care plan developed for the Stage IV pressure ulcer.
Failure to Revise Care Plan for Tracheostomy Care
Penalty
Summary
The facility failed to revise the comprehensive care plan for one resident to include tracheostomy care interventions within 7 days of the comprehensive assessment. Resident #95 was admitted with diagnoses including cerebral palsy, tracheostomy status, and COPD, and the medical record showed physician orders dated 7/18/2024 for trach change one time a day for routine trach care, suctioning as needed, sterile saline lavage, trach tie changes with baths and as needed, trach care every shift and as needed, and inner cannula changes every shift and as needed. The annual MDS assessment indicated the resident had a BIMS score of 10, showing moderate cognitive impairment, and also confirmed the resident had a tracheostomy. The comprehensive care plan dated 7/18/2026 identified impaired respiratory status related to COPD, trach status, and respiratory failure, with interventions for oxygen as ordered and ensuring trach ties were secured, but it did not reflect tracheostomy care. During interview, the RN MDS Coordinator confirmed the care plan had not been revised to include tracheostomy care, and the DON also confirmed she would expect the care plan to be revised with tracheostomy care and that it had not been revised to reflect the resident's tracheostomy care.
Unsecured sharps and medications observed in resident rooms
Penalty
Summary
The facility failed to ensure the environment was free of accidental hazards when an unsecured scalpel was found on the bedside table in Resident #5’s room. Resident #5 was admitted with diagnoses including Diabetes Mellitus, lack of coordination, muscle weakness, and acute respiratory failure, and a quarterly MDS showed a BIMS score of 15, indicating the resident was cognitively intact. A physician progress note documented that a 15 blade had been used to surgically excise devitalized tissue. During observation, a scalpel was seen on the nightstand beside the resident’s bed, and the resident stated it looked like the one used during wound care to the toe and may have been left there. CNA E also identified the object as a scalpel, and LPN H confirmed it was on the bedside table and removed it for disposal in the sharps box. The facility also failed to secure medications for three residents. Resident #12, who had diagnoses including Delusional Disorder, Anxiety Disorder, and Psychosis and a BIMS score of 15, had a tube of Nystatin Cream on the bedside table even though there was no documentation that the resident had been assessed to self-administer topical medications. Resident #54, who had diagnoses including Diabetes, COPD, and Heart Failure and was not care planned to self-administer medications, had antacid tablets and VapoRub on the bedside table; LPN H removed the items and confirmed the resident had not been assessed to self-administer medications. Resident #111, who had diagnoses including Diabetes Mellitus, CHF, and Depression and a BIMS score of 14, had an insulin glargine pen observed lying on the dresser next to the bed during the time the resident stated the nurse had administered the medication that morning.
Delayed Breakfast Tray Delivery
Penalty
Summary
The facility failed to serve a meal tray timely for one resident during breakfast service. The facility policy titled, Meal Distribution, stated that meals are to be delivered in a timely manner and that nursing staff are responsible for timely delivery of meals to residents. Resident #9 was admitted and readmitted with diagnoses including COPD, chronic respiratory failure, and atrial fibrillation. A quarterly MDS assessment showed a BIMS score of 12, indicating moderate cognitive impairment, and the care plan stated the resident was independent with eating but needed assistance with meal setup as needed. During an interview and observation, Resident #9 stated he was ready to get his breakfast tray and coffee. Breakfast trays were observed on meal carts in the hallway being delivered to residents, but 25 minutes later Resident #9 still had not received a tray while other residents on the hallway had been served. CNA E stated he had not served the resident's tray and did not know who had, CNA M stated someone had taken the resident's breakfast and the resident had refused, and the Wound Care nurse stated she had not delivered the tray. At approximately 45 minutes after meal delivery began, CNA E and CNA N confirmed the resident's breakfast tray was still on the food cart. CNA E then served the tray, heated the breakfast, and provided coffee. CNA E, LPN L, and the DON later confirmed the breakfast had not been served timely.
Oxygen Therapy and Tracheostomy Care Not Performed as Ordered
Penalty
Summary
Oxygen was not administered according to physician orders for 2 residents. One resident with diagnoses including COPD, acute and chronic respiratory failure, and CHF had an order for oxygen at 2 L/min via nasal cannula continuously. During observation, the resident was lying in bed with oxygen tubing in place and a portable oxygen tank secured to the back of the wheelchair at the bedside, but the tank was empty. The resident had no signs of respiratory distress, and the RN confirmed the tank was empty and obtained an oxygen saturation of 95%. Another resident with diagnoses including chronic respiratory failure, COPD, and atrial fibrillation had an order for oxygen at 1 L/min via tracheostomy continuously. During observation, the resident was sitting in a wheelchair with oxygen tubing in place and a portable oxygen tank secured to the wheelchair, but the tank was empty. The RN confirmed the order for continuous oxygen and confirmed the tank was empty, and the resident's oxygen saturation was 98%. Tracheostomy care was not performed appropriately for a resident with diagnoses including cerebral palsy, tracheostomy status, and COPD. The resident had orders for routine trach care, suctioning as needed, sterile saline lavage, trach tie changes with baths and as needed, trach care every shift and as needed, and inner cannula changes every shift and as needed. During observation, the respiratory therapist performed trach care by removing the single-use inner cannula, performing in-line suctioning with single-use sterile water already attached to the tubing, removing gloves, donning gloves again, replacing the inner cannula, removing the old dressing around the trach site, and replacing a clean dressing around the stoma. The observation showed the respiratory therapist did not clean her hands between glove changes, did not clean around the trach stoma, and did not use new single-use sterile saline for suctioning. The therapist later confirmed she had not cleaned around the trach stoma and had not utilized new single-use sterile saline for suctioning, and also confirmed she did not wash her hands when she changed gloves during tracheostomy care. The DON confirmed she would expect hand sanitizing between glove changes, new single-use sterile saline for trach suctioning, and cleaning of the trach stoma when changing the gauze.
Missed Refrigerator Temperature Checks and Expired Food in Resident Refrigerator
Penalty
Summary
The facility failed to check and document daily temperatures for personal refrigerators for Resident #25, Resident #73, and Resident #104, contrary to its policy that housekeeping staff record refrigerator temperatures daily on a temperature log attached to the refrigerator. Review of the temperature logs showed repeated missing entries for Resident #25 and Resident #73 across multiple days in April and May 2026, and similar missing temperature documentation for Resident #104 across the same months. Each of these residents had a quarterly MDS assessment showing a BIMS score of 14 or 15, indicating they were cognitively intact. For Resident #104, an observation and interview in the resident’s room revealed a personal refrigerator containing expired food items, including two cartons of milk that had expired on 6/22/2026 and 7/13/2026. The resident stated she did not know who was responsible for checking refrigerator temperatures, cleaning the refrigerator, or ensuring expired foods were discarded. An LPN stated that all staff were responsible for keeping residents’ personal refrigerators clean, disposing of expired items, and checking temperature logs daily, and the DON later confirmed that residents’ personal refrigerators were to be cleaned, expired food items checked and disposed of when expired, and temperatures checked and documented daily.
Failure to Coordinate Care With Hospice
Penalty
Summary
The facility failed to ensure communication between the facility and hospice services for one resident who was receiving hospice care. The resident was admitted with diagnoses including encounter for palliative care, dementia, and cerebrovascular disease, and the physician's orders directed admission to hospice. The resident's comprehensive care plan documented a terminal prognosis with Amedisys Hospice Care related to end-of-life diagnosis of senile deterioration of the brain, and the quarterly MDS indicated the resident had moderate cognitive impairment and received hospice care. Facility records and interviews showed that, although the facility had a Nursing Facility Services Agreement and a hospice policy requiring coordinated care and regular communication with hospice, there was no documentation of a coordinated care plan meeting between the facility and the hospice provider for the resident. The SSD stated that hospice staff contacted the facility when they wanted to schedule care plan meetings and confirmed there was no documented coordinated care plan meeting for the resident. The SSD later stated a care plan meeting was scheduled with Amedisys hospice and that monthly care plan meetings would occur moving forward, and the DON confirmed the facility failed to ensure coordination of care between the facility and hospice for the resident.
Infection Control Lapses During Medication Administration, Glucometer Use, and Wound Care
Penalty
Summary
The facility failed to ensure infection prevention and control practices were followed during medication administration for two residents with diabetes and during wound care for one resident with quadriplegia, diabetes mellitus, and severe protein-calorie malnutrition. Facility policy required medications to be administered in a manner to prevent contamination or infection, hand hygiene after handling contaminated objects, and blood glucose machines to be disinfected after each use with an approved healthcare disinfectant. The disinfectant label for the wipe used on glucometers identified effectiveness against bloodborne pathogens, including hepatitis B, hepatitis C, and HIV. During observation of medication administration, an RN prepared oral medications for one resident, checked the resident’s blood glucose with a glucometer, and after the resident declined one medication, removed her gloves and left the room without washing or sanitizing her hands. She then placed the glucometer on the medication cart, retrieved the resident’s medication, touched a Lasix tablet with her bare hands, and later administered oral medications and insulin before again leaving the room without washing or sanitizing her hands. The same RN then prepared medications for a second resident, broke a potassium tablet in half with her bare hands, administered the medications, and again failed to wash or sanitize her hands. She then used the same glucometer on the second resident without sanitizing it after the prior use. During wound care for the resident with bilateral leg wounds, the wound care nurse sanitized her hands, applied gloves, and removed soiled dressings using scissors. The nurse then failed to disinfect the scissors and placed the soiled scissors in her pocket. The DON confirmed the wound care nurse did not follow appropriate infection control practices during the wound care observation.
Call lights left out of reach for two residents
Penalty
Summary
The facility failed to ensure call lights were within reach for two residents. Resident #13 had diagnoses including Post-Polio Syndrome, left foot drop, mild cognitive impairment, osteoarthritis, and age-related osteoporosis. The care plan directed staff to encourage use of the call light and place it within reach. A significant change MDS showed a BIMS score of 10, indicating moderate cognitive impairment and a need for substantial to maximal assistance with ADLs and mobility. During observations on 7/21/2026, Resident #13 was yelling out for assistance while lying in bed with breakfast in front of her, and the call light was on the floor out of reach. The resident again requested help opening a milk carton, and the call light remained out of reach until RN B later placed it within reach and opened the milk. Resident #108 was admitted and readmitted with diagnoses including dementia, need for assistance with personal care, other abnormalities of gait and mobility, impulse disorder, and mild intellectual disabilities. The care plan identified the resident as at risk for falls/injury and directed staff to place the call light within reach. A quarterly MDS showed a BIMS score of 9, indicating moderate cognitive impairment. During observations on 7/20/2026, Resident #108 was lying in bed and the call light was out of reach on two separate occasions. RN C confirmed the call light was out of reach. The DON later stated it was her expectation for call lights to be placed within residents' reach.
Failure to Safeguard Resident's Personal Belongings After Hospitalization
Penalty
Summary
A deficiency occurred when the facility failed to ensure a resident's right to retain personal possessions following a hospitalization. The resident, who was cognitively intact and dependent on ventilator and personal care, was hospitalized for approximately one month. Upon return, the resident and their family discovered that personal belongings, including a statue and a small decorated tree, were missing from the resident's room. The family reported the missing items to facility staff, but the items could not be located. The Housekeeping Manager confirmed that some items, such as a journal and devotional book, were found and returned, but the statue and tree were not recovered. Facility staff interviews revealed that housekeeping boxed and labeled resident belongings and stored them on the third floor when a resident left the facility. Items stored for 30 days or more were discarded, following instructions from a previous administrator, due to storage space limitations. The Social Services Director and Social Worker did not recall contacting the resident's family to notify them about the impending disposal of the belongings. The facility did not have a policy regarding the disposal of resident personal items, and the Regional Clinical Director was unaware of the 30-day discard practice.
Failure to Follow Disinfectant Instructions
Penalty
Summary
The facility failed to adhere to the manufacturer's instructions for using a disinfectant, Virasept, on one of the hallways observed. The facility's documentation outlined the importance of following the manufacturer's recommended dwell time for disinfectants to effectively sanitize surfaces. According to the manufacturer's instructions, Virasept requires a surface to remain wet for at least four minutes to be effective. However, during an observation, a housekeeper was seen disinfecting a doorknob with Virasept, but the surface dried within three minutes, and the housekeeper did not reapply the solution to maintain the required wet time. Interviews with the housekeeping manager and the housekeeper confirmed the deficiency. The housekeeping manager stated that the surface must remain wet for four minutes, as per the instructions, and the housekeeper acknowledged that the doorknob was not wet for the required duration. This failure to comply with the manufacturer's instructions for disinfectant use could potentially compromise the facility's infection prevention and control program, particularly in preventing the spread of infectious organisms like Candida auris.
Incomplete Daily Staff Posting Information
Penalty
Summary
The facility failed to ensure that daily staff posting information was complete and accurate for three consecutive days. Specifically, the Daily Staffing Sheets from October 28, 2024, to October 30, 2024, did not include the resident census, the facility name, or the actual number of hours worked by Registered Nurses (RNs), Licensed Practical Nurses (LPNs), and Certified Nursing Assistants (CNAs). This deficiency was confirmed through a review of the facility's policy on required postings, observations, and interviews with the Staffing/Central Supply Coordinator and the Director of Nursing (DON). Both the Staffing/Central Supply Coordinator and the DON acknowledged the omissions in the staffing sheets during interviews conducted on October 30, 2024.
Sanitation and Food Storage Deficiencies in Kitchen
Penalty
Summary
The facility failed to maintain kitchen equipment in a sanitary condition, ensure spices were properly sealed, and discard expired food, potentially affecting 92 of 95 residents. During an observation of the food preparation area, a 12-ounce bottle of salt and pepper seasoning salt was found unsealed and available for use. Additionally, an unopened container of mild wing sauce with an expired date was available for use. The area behind the deep fryer was observed to have a greasy film with food particles, indicating a lack of cleanliness. Further observations revealed a pipe under the dirty sink area actively dripping significant amounts of water into a full bucket of cloudy water, with moist food particles on the wall. The Certified Dietary Manager (CDM) confirmed that the equipment and floors were cleaned daily but acknowledged the presence of the greasy film and food particles behind the deep fryer. The CDM also confirmed the leaking pipe and the presence of the bucket of cloudy water and food particles on the wall. The CDM admitted that the kitchen areas had not been maintained in a clean sanitary manner, and the expired wing sauce and unsealed seasoning salt were confirmed to be available for use.
Failure to Document POA and Provide Advance Directive Education
Penalty
Summary
The facility failed to ensure that Durable Power of Attorney (POA) documents were entered into the medical records for two residents and did not provide education regarding Advance Directives upon admission for six residents. Resident #23, who was admitted with severe cognitive impairment, had a previously formulated POA, but the document was not included in the medical record. Similarly, Resident #86, with moderate cognitive impairment, had family members who chose to execute advance directives, but these documents were also missing from the medical record. Additionally, the facility did not provide education on advance directives to six residents or their representatives upon admission. These residents had varying levels of cognitive impairment, as indicated by their Brief Interview for Mental Status (BIMS) scores, ranging from severe to cognitively intact. Despite this, there was no documentation of education provided to them or their representatives about their rights to formulate an advance directive. Interviews with the Social Services Director and the Admissions Director confirmed these deficiencies. The Social Services Director acknowledged the absence of the POA document for Resident #23 and the lack of execution of advance directives for Resident #86. The Admissions Director confirmed that education on advance directives was not provided to the six residents or their representatives at the time of admission.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to ensure that garbage and refuse were properly contained in all three of its dumpsters. According to the facility's policy titled 'Environment,' revised in September 2017, trash should be properly disposed of in external receptacles, and the surrounding area should be free of debris. However, during an observation and interview conducted on October 28, 2024, at 12:00 PM, the Certified Dietary Manager (CDM) confirmed that the outside dumpster area contained scattered refuse. This included used gloves, plastic medicine cups, plastic drinking cups, used wipes, drinking straws, plastic spoons, and a clear plastic bag filled with trash, indicating that the area was not maintained in a clean and sanitary condition.
Failure to Provide Hand Hygiene Assistance Before Meals
Penalty
Summary
The facility failed to adhere to its infection prevention and control program by not offering hand hygiene assistance to eight residents before meals. This deficiency was observed during meal service on two of the three hallways. The facility's document titled 'Validation Checklist Hand Hygiene' indicated that residents should be offered hand hygiene prior to meals, but this protocol was not followed. Observations on the 300 and 200 Hallways revealed that CNAs and an LPN delivered meal trays to residents without offering hand hygiene assistance. Interviews with the staff confirmed the lack of hand hygiene assistance. CNA F, CNA G, CNA H, and LPN D all acknowledged that they did not offer hand hygiene assistance to the residents before setting up their meal trays. The Director of Nursing confirmed that it was the facility's expectation for residents to be offered hand hygiene assistance prior to meals, indicating a failure to meet the facility's own standards for infection control.
Facility Fails to Address Resident Grievances
Penalty
Summary
The facility failed to address grievances raised by residents during a resident council meeting. The grievances included complaints about staff yelling and cursing in the hallways and a request for more fresh fruits in meals. Despite these concerns being documented in the Resident Council Minutes from August 16, 2024, the facility did not take adequate action. The Dietary Manager acknowledged the request for more fresh fruits but only added a fresh fruit bar once in September, with no further action. The Director of Nursing was aware of the complaints about staff behavior but did not take steps to address the issue, as no staff admitted to the behavior, and she was unaware of ongoing concerns. As a result, the facility did not act promptly on the residents' grievances, affecting 12 residents who attended the October 29, 2024, meeting.
Failure to Provide Advanced Beneficiary Notices
Penalty
Summary
The facility failed to provide Advanced Beneficiary Notices (ABNs) to three residents after their therapy services were discontinued. This failure occurred despite the facility's policy, which mandates timely notices regarding Medicare eligibility and coverage when Medicare-covered services are ending. The absence of these notices meant that the residents were not informed of the potential costs of continuing therapy services, thereby not allowing them to make an informed choice. The residents involved included individuals with various medical conditions such as Chronic Obstructive Pulmonary Disease, Anxiety Disorder, Chronic Diastolic Congestive Heart Failure, and a history of Transient Ischemic Attack. Each resident was discharged from skilled Medicare services on different dates, yet none received the required ABN. The facility's administrator confirmed during an interview that the notices were not provided to the residents prior to their discharge from skilled Medicare services.
Deficiency in Housekeeping and Maintenance Services
Penalty
Summary
The facility failed to provide effective housekeeping and maintenance services to ensure a safe, sanitary, and homelike environment for a resident. Observations revealed a strong urine odor in the resident's room, dark brown substances on the walls, and rust-colored substances around the air conditioning unit. Dried food was found inside the vent area of the air conditioning unit, and stains were observed on the window curtains. The Housekeeping Director confirmed these findings and acknowledged that the room was not in a sanitary condition. Additionally, the facility did not maintain the resident's personal refrigerator in a sanitary condition. Observations showed a dark brown dried liquid substance inside the refrigerator, along with undated food items and expired milk. Interviews with the 2nd Floor Unit Manager and the Housekeeping Director revealed confusion regarding the responsibility for cleaning the personal refrigerators and performing temperature checks. The Administrator admitted to not knowing who was responsible for these tasks, indicating a lack of clarity in the facility's procedures.
Failure to Update PASARR for New Psychiatric Diagnoses
Penalty
Summary
The facility failed to submit a Level 2 Preadmission Screening and Resident Review (PASARR) for two residents following new psychiatric diagnoses. Resident #7 was admitted with diagnoses including Dementia, Bipolar Disorder, and Psychosis. A review of the medical records revealed that Resident #7's PASARR, dated 9/29/2023, did not include a diagnosis of Post Traumatic Stress Disorder (PTSD). A psychiatric evaluation on 12/5/2023 identified PTSD as a new diagnosis, but a new PASARR was not submitted following this change. Similarly, Resident #37 was admitted with diagnoses including Dementia, Muscle Weakness, and Generalized Anxiety. The medical records showed that Resident #37's PASARR, dated 9/26/2023, did not include a diagnosis of Unspecified Mood Disorder. A psychiatric evaluation on 12/20/2023 revealed this new diagnosis, yet a new PASARR was not submitted. During an interview, the PASARR Coordinator confirmed that it was expected for both residents to have been referred for a Level 2 PASARR evaluation after their new diagnoses were identified.
Failure to Maintain Clean Oxygen Equipment
Penalty
Summary
The facility failed to maintain resident-care oxygen equipment in a clean and sanitary condition for two residents observed for oxygen use. Resident #23, who was admitted with diagnoses including Chronic Obstructive Pulmonary Disease (COPD), Stroke, Dementia, Weakness, and Obstructive Sleep Apnea, had a blue 5-liter oxygen concentrator beside their bed that was observed to be soiled with a tan brown-like substance on two separate occasions. Similarly, Resident #50, admitted with Alzheimer's Disease, Heart Failure, COPD, and Dementia, had a black 10-liter oxygen concentrator beside their bed that was also observed to be soiled with a tan brown-like substance on two separate occasions. Interviews with facility staff revealed a lack of clarity regarding responsibility for cleaning the oxygen concentrators. The Respiratory Therapist stated that nursing staff were responsible for cleaning the equipment, while a Registered Nurse on the 2nd floor believed it was the responsibility of the respiratory therapy staff. The Director of Nursing confirmed that nursing staff were responsible for cleaning the concentrators when visibly soiled and acknowledged that the equipment for both residents was not maintained in a clean and sanitary condition. The Respiratory Therapy Manager also stated that nursing staff were responsible for cleaning the oxygen concentrators on the 2nd floor.
Failure to Properly Administer Oral Inhaler
Penalty
Summary
The facility failed to ensure proper administration of an oral inhaler for a resident, identified as Resident #52, who was observed during medication administration. The facility's policy on medication administration for oral inhalations, dated January 2023, outlines specific steps for safe and effective use, including instructing the resident to breathe out before inhaling, pressing the inhaler as the resident breathes in, and having the resident rinse their mouth after using a steroid inhaler. However, during an observation on October 29, 2024, at 7:00 AM, an LPN administered the inhaler to Resident #52 without providing any instructions or ensuring the resident rinsed their mouth afterward. Resident #52, who was admitted with diagnoses including Hemiplegia, Hemiparesis, Morbid Obesity, and Chronic Obstructive Pulmonary Disease, was noted to be cognitively intact with a BIMS score of 15. Despite this, the LPN did not follow the facility's policy, as confirmed in an interview later that day. The Director of Nursing also confirmed on October 30, 2024, that the facility's policy for administering oral inhalations was not adhered to in this instance.
Improper Storage of Schedule II Medications
Penalty
Summary
The facility failed to ensure the proper and secure storage of medications in one of its medication storage rooms. During an observation of the 2nd floor medication room, it was found that 27 oral tablets of a Schedule II pain medication were stored in an unlocked refrigerator. This was confirmed by RN A, who acknowledged that the Schedule II pain medication was not stored under the required double-lock system, as the refrigerator was unlocked. The Director of Nursing also confirmed that the facility's policy for the storage of Schedule II medications was not followed.
Unsecured Electronic Health Records on Medication Cart
Penalty
Summary
The facility failed to secure a device containing electronic health records, leading to a breach of resident-identifiable information. During an observation, it was noted that a laptop screen attached to a medication cart in the 100 Hallway was left unattended and unlocked, displaying resident information visible to unauthorized persons. This incident was confirmed by RN E, who acknowledged that the resident information was accessible to unauthorized individuals. The Director of Nursing stated that the facility's policy required laptop screens on unattended medication carts to be locked, confirming that this expectation was not met when RN E left the laptop screen unlocked.
Resident's Call Light Inaccessible
Penalty
Summary
The facility failed to ensure that a resident's call light was within reach, as required by their policy on call light accessibility and timely response. Resident #50, who was admitted with diagnoses including Malignant Neoplasm of the Lung, Psychosis, and Diabetes, and had a moderate cognitive impairment, was observed asking for her nurse while her call light was found in a bedside drawer, out of her reach. The resident was dependent on assistance for eating, toileting, and dressing. A CNA noted that the call light was placed on the resident's belly earlier in the day, but it was later found in the drawer, which was partially closed. An LPN confirmed the call light's location, indicating a failure to ensure the resident's access to the call system.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect residents from abuse, resulting in incidents involving inappropriate behavior and physical altercations among residents. One incident involved a resident with severe cognitive impairment who was nonverbal and dependent on staff for all activities of daily living. This resident was inappropriately touched by another resident who was cognitively intact. Despite the resident's nonverbal cues indicating distress, the inappropriate behavior was observed by staff, and the resident was placed on one-on-one supervision following the incident. Another incident involved two residents, one of whom had severe cognitive impairment and the other who was cognitively intact. The cognitively impaired resident entered the room of the other resident, leading to a physical altercation where one resident sustained a skin tear and the other a facial scratch. The facility's documentation and interviews confirmed that both residents were harmed during this altercation. A third incident involved a cognitively intact resident who hit another resident with a soda can after the latter touched the former's drink. The resident who was hit did not sustain any injuries and reported feeling safe in the facility. These incidents highlight the facility's failure to protect residents from abuse and ensure their safety, as required by their policies.
Failure to Follow Physician Orders for Medication Administration
Penalty
Summary
The facility failed to ensure physician orders were followed for a resident, identified as Resident #26, among 15 residents reviewed. Resident #26 was admitted with diagnoses including Acute Respiratory Failure, COPD, Major Depressive Disorder, and Dysphagia, and was cognitively intact as per the admission MDS assessment. A physician's order dated June 28, 2024, prescribed Lorazepam 0.5 mg by mouth every 4 hours as needed for anxiety/seizure precaution, with an end date of July 12, 2024. However, the Narcotic Log indicated that Lorazepam was removed from the medication cart and administered to the resident on July 23, 2024, after the order had been discontinued. Interviews with RN K and LPN L confirmed the administration of Lorazepam to Resident #26 without a valid physician's order.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 63 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Blountville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Life Care Center Of Gray | 5.2 mi | ★★★★★ | 0 | 0 |
| Holston Rehabilitation And Care Center | 6.2 mi | ★★★★★ | 13 | 0 |
| Wexford House | 7.3 mi | ★★★★★ | 1 | 0 |
| Nhc Healthcare, Kingsport | 7.4 mi | ★★★★★ | 2 | 0 |
| Waters Of Bristol A Rehabilitation And Nursing | 7.6 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Greystone Health Care Center.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.