Above average — CMS composite of the measures below.
The next survey window likely opens around December 2026
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 Greenbrier Nursing & Rehabilitation Center Of Pale during CMS and state inspections, most recent first.
A resident with hemiplegia, prior stroke, and diabetes, who required extensive assistance with ADLs, returned from the hospital after a 12‑lead EKG with electrodes still adhered to the skin. Facility records showed CNAs documented bed baths and a nurse documented a weekly skin assessment with no skin issues or devices noted, while the resident reported inadequate bed baths and that EKG electrodes remained on her body for about a week. A hospital RN later observed the same electrodes still in place at a subsequent appointment, and facility staff acknowledged they did not identify or remove the electrodes during bathing or skin assessment, contrary to the facility’s bed bath policy requiring residents to be clean and comfortable.
A resident with COPD, dementia, CHF, and severely impaired cognition, who required extensive assistance with ADLs and had a communication deficit, was receiving incontinent care from a CNA assisted by another CNA when the primary CNA dropped a glove and exclaimed “God damn it” in the resident’s room. Although the resident showed no immediate reaction and later reported not hearing that specific incident, she stated that staff frequently held personal conversations and that profanity was commonly heard in the hallway near her room. Facility records showed the same CNA had previously cursed in front of another resident in that resident’s room and had been coached on appropriate behavior, despite a facility policy requiring residents be treated with respect and dignity in an environment that supports quality of life.
Two residents with bowel and bladder incontinence and significant ADL assistance needs were not provided timely incontinence and personal care. One resident with diabetes, Parkinson’s disease, and dementia, care-planned for frequent incontinence checks every two hours, reported being left wet for hours and was observed visibly soiled with urine and feces when CNAs first checked her several hours into the shift; the CNA stated she relied on the resident to request changes. Another resident with diabetes, weakness, disorientation, and a humerus fracture, care-planned for assistance with hygiene, bathing, and toileting, experienced repeated delays in staff response to call lights, including waits of 25 minutes or more that resulted in incontinence episodes or required a family member to assist with toileting. A LVN reported not routinely supervising CNAs despite expectations for two-hour rounding, while leadership stated CNAs were expected to provide incontinence care as needed, and facility policy required appropriate treatment and services for incontinent residents.
Infection control failures were observed during resident care involving EBP, incontinent care, and perineal care. Staff did not consistently perform hand hygiene, did not remove a dirty brief before placing a clean one, and did not wear a gown for a resident on EBP during direct care. The residents involved included one with a feeding tube and diabetes, one with severe cognitive impairment and total incontinence, and one with cystitis who needed extensive toileting and hygiene assistance.
A resident with dementia and occasional urinary incontinence was repeatedly observed in wet clothing and soiled linens with a strong ammonia odor, indicating lapses in timely incontinent care and linen changes. Staff interviews revealed inconsistent rounding and care practices, despite facility policy requiring regular checks and assistance.
A CNA failed to follow infection control protocols while providing incontinent care to a resident with dementia and diabetes, including not performing hand hygiene, not changing gloves, and cleaning from dirty to clean areas instead of clean to dirty, contrary to facility policy.
Two residents with significant cognitive and physical impairments were found to be double briefed with saturated briefs and ammonia odor present, despite care plans and facility policy requiring frequent checks and single brief use. Staff interviews confirmed that double briefing was not permitted, yet it occurred, and residents reported not being changed for extended periods.
A CNA failed to follow infection control protocols for a resident on contact precautions, entering the room without PPE and not performing hand hygiene. The resident had diabetes and hypertension and required contact precautions for wound healing. The facility lacked a specific policy, relying on signage for guidance, leading to improper practices and potential infection risk.
Failure to Provide Adequate Bathing and Skin Assessment Resulting in Prolonged Retention of EKG Electrodes
Penalty
Summary
Surveyors identified a deficiency in which the facility failed to provide treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident’s choices for one resident. The resident was an older female with hemiplegia/hemiparesis, cerebral infarction, and type 2 diabetes, who required moderate to total assistance with all ADLs except eating and had no documented skin integrity concerns. Her care plan included assistance with personal hygiene and bathing. Hospital discharge records showed she had a 12‑lead EKG on 4/13/26, and facility task records indicated she received assistance with bathing on 4/14/26 and 4/15/26, and a weekly skin assessment was documented on 4/15/26 with no alterations in skin integrity and no mention of EKG electrodes. During interview, the resident reported she had only received seven showers since admission and that the bed baths she did receive were inadequate and did not get her clean. She stated that after the EKG on 4/13/26, the electrodes remained on her body for about a week and that she did not receive a proper bed bath while the electrodes were adhered to her chest. A hospital RN later reported that when the resident arrived for a scheduled appointment on 4/16/26, EKG electrodes were still adhered to her skin and were believed to be the same ones applied on 4/13/26. Facility documentation showed CNAs had charted bathing assistance during this period. CNA A, who typically bathed the resident, stated that the resident often requested basic “wash ups” (face, neck, arms, hands) instead of showers, and that these were charted as bed baths per what she said she had been told by administration, though she could not specify who. CNA A could not recall specifically bathing the resident between 4/13/26 and 4/16/26 but stated that if it was charted, she did it, and acknowledged she did not notice any EKG electrodes and should have removed them if providing an appropriate bed bath. LVN D, who completed the weekly skin assessment on 4/15/26, reported that she assessed all of the resident’s skin, did not note any EKG electrodes, and stated she should have seen and removed them to perform a proper skin assessment. The facility’s bed bath policy stated that the resident will be clean and free of dryness, irritation, or pruritus and will verbalize a feeling of comfort and well‑being, but the skin assessment policy could not be produced when requested.
Use of Profanity During Resident Care Undermining Dignity and Respect
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident was treated with respect and dignity and cared for in an environment that promoted quality of life. The resident was an elderly female with COPD, dementia, congestive heart failure, and a documented communication deficit related to being hard of hearing. Her MDS showed severely impaired cognition with a BIMS score of 5 and a need for varying levels of assistance with ADLs, including maximal assistance for bathing and lower body dressing. During an observation of incontinent care provided by one CNA with assistance from another CNA, the primary CNA dropped a glove on the floor and audibly exclaimed “God damn it” while in the resident’s room. The CNA then put on a new glove and continued care. The resident did not appear to react at that time and did not show any observable emotional response during the incident. In interviews following the event, the assisting CNA reported not hearing any profanity during the care and stated she had not heard staff use profanity in or around resident care areas. The CNA who used the profanity acknowledged she had not realized she said it during care but agreed that profanity should not be used around residents because it could be offensive even if not directed at them. The resident later stated she did not hear the specific profanity during that episode of care but reported that such language “happens all the time,” describing frequent personal conversations among staff and hearing profanity in the hallway near her room, though she could not identify specific staff or details. Record review showed that the same CNA had previously been documented as cursing in front of another resident in that resident’s room, and had received coaching to be mindful of others and not to curse, as well as attending a customer service in‑service. The facility’s resident rights policy stated that each resident has a right to a dignified existence and to be treated with respect and dignity in a manner and environment that promotes maintenance or enhancement of quality of life.
Failure to Provide Timely Incontinence and ADL Care
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary ADL and incontinence care to residents who were unable to perform these tasks independently, resulting in unmet needs for nutrition, grooming, and personal and oral hygiene. One resident with Type 2 diabetes, Parkinson’s disease, dementia, and bowel and bladder incontinence had a care plan requiring frequent incontinence care, application of moisture barrier after each episode, and checks every two hours with toileting assistance as needed. The resident reported being left in wet briefs for hours, waking early in the morning and not being checked until mid-morning. On observation, the resident was found visibly soiled with urine and feces when CNAs provided incontinence care nearly three hours after the CNA’s shift began. The CNA acknowledged not checking on the resident until that time and stated she relied on the resident to notify staff when wet or soiled, despite the resident’s documented incontinence and cognitive impairment. Another resident with a right humerus fracture, Type 2 diabetes, weakness, disorientation, and frequent bowel and bladder incontinence had an MDS indicating intact cognition and a need for supervision with eating and oral hygiene, and substantial assistance with other ADLs. The resident’s care plan included assistance with personal hygiene, bathing, and toileting. Responsible parties for this resident reported multiple episodes of delayed response to call lights for toileting and incontinence needs, including one instance where they waited 25 minutes after activating the call light, then an additional 6 minutes after notifying the nurse’s station, during which the resident experienced an incontinence episode. Another responsible party reported timing a 25-minute period with no staff response and ultimately assisting the resident to the restroom personally, and described similar incidents without specific details. A LVN stated she expected CNAs to round at least every two hours and assist with incontinence care but did not routinely supervise CNAs, stating it was not her job, while the DON and ADM both stated expectations that CNAs round every two hours and provide incontinence care as needed. The facility’s perineal care policy required incontinent residents to be identified, assessed, and provided appropriate treatment and services.
Infection Control Failures During Resident Care
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program for residents and staff reviewed for infection control. The deficiency involved three residents and four staff members during observed care activities, including incontinent care, perineal care, and care for a resident on enhanced barrier precautions (EBP). The report states that these failures could place residents at risk of exposure to infectious diseases due to improper infection control practices. Resident #57 was a female with diabetes who had a baseline care plan indicating she was on EBP, with gown and gloves required for high-contact activities such as hygiene, toileting/incontinent care, and enteral feeding care. During an observation, CNA A and CNA B provided incontinent care without applying a gown before entering the room and providing direct care. Both CNAs later stated they had been trained on EBP and understood it was used for residents with devices such as feeding tubes, catheters, or wounds. Resident #8 was a male with diagnoses including cerebral infarction, expressive language disorder, hypertension, and gastrostomy status. He had severe cognitive impairment, required substantial to maximal assistance with personal hygiene, and was always incontinent of urine and bowel. During observed incontinent care, CNA B and CNA D donned gowns in the hallway but did not wash or sanitize their hands before putting on gloves and beginning care. CNA D placed the dirty brief between the resident’s thighs and later rolled a clean brief underneath the resident before the dirty brief had been removed. CNA D also changed gloves without performing hand hygiene between glove changes, and CNA B later acknowledged that the dirty brief should have been removed before the clean brief was placed and that hand hygiene should have been performed before care started. Resident #21 was a cognitively intact female with cystitis who required substantial to maximum assistance for toileting and personal hygiene. During observed perineal care, CNA C washed her hands upon entering the room but changed gloves three times during care without performing hand hygiene between glove changes. CNA C stated she had not been watched by state before and did not know why hand hygiene should be performed between glove changes. The DON stated she was responsible for infection control training and that hand hygiene should be done before care, after care, and before gloves were donned, and that staff should never touch clean items with dirty gloves.
Failure to Provide Timely Incontinent Care and Linen Changes
Penalty
Summary
A male resident with dementia, type 2 diabetes, and a psychotic disorder was admitted to the facility and assessed as requiring varying levels of assistance with activities of daily living, including partial assistance with personal hygiene and supervision with toileting. The resident was noted to be occasionally incontinent of bladder and always continent of bowel. Despite care plan interventions for supervision and assistance, the resident was observed on multiple occasions to be left in visibly wet clothing and soiled linens, with a strong odor of ammonia present in his room and on his person. On two separate days, the resident was seen sitting in a wheelchair and lying in bed with wet clothing and soiled sheets, with observations of yellow and brown stains and persistent strong odors. Staff interviews revealed inconsistencies in rounding practices, with one CNA stating she rounded every 30 minutes to 2 hours, while another CNA delayed rounding due to other duties and reported that the resident refused care when offered. The resident himself was unable to recall when staff last checked on him and believed he was dry, despite evidence to the contrary. Facility policy required incontinent residents to be identified, assessed, and provided with appropriate treatment and services, including regular checks for wet or soiled linens and provision of perineal care. Interviews with nursing staff and administration confirmed that CNAs were expected to round at least every two hours and address incontinent care needs, but observations and staff statements indicated these expectations were not consistently met for this resident.
Failure to Follow Infection Control Protocols During Incontinent Care
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) failed to follow proper infection prevention and control procedures while providing incontinent care to a male resident with dementia, type 2 diabetes, and a psychotic disorder. The resident required varying levels of assistance with activities of daily living and was occasionally incontinent of bladder. During the observed care, the CNA did not wash or sanitize her hands before beginning care, donned gloves, and cleaned the resident from the rectal (dirty) area to the urethral (clean) area, contrary to facility policy which requires cleaning from clean to dirty. The CNA also assisted the resident with dressing without changing gloves or performing hand hygiene during the process. Interviews with the CNA and other staff confirmed that the CNA had received training on infection control and incontinent care, and that facility policy required hand hygiene and changing gloves when soiled. The facility's perineal care policy specifically instructs staff to perform hand hygiene and to clean from the urethral area to the rectal area to avoid contamination. Documentation showed the CNA had attended recent in-services and coaching, but the observed care did not comply with established infection control protocols.
Failure to Provide Appropriate Incontinent Care and Improper Use of Double Briefing
Penalty
Summary
Surveyors identified that the facility failed to provide appropriate incontinent care for two residents who were always incontinent of bladder and frequently or always incontinent of bowel. Both residents were observed on separate occasions to be wearing two incontinent briefs (double briefed) at the same time, which is not in accordance with their care plans or facility policy. In both cases, the briefs were saturated with yellow liquid, and there was an odor of ammonia present in the residents' rooms. The residents reported not being changed for extended periods and expressed discomfort due to being wet. Resident #1 had a history of Parkinson's Disease, dementia, and functional quadriplegia, requiring extensive assistance with activities of daily living and was always incontinent of bladder. Resident #2 had dementia, morbid obesity, and muscle weakness, also requiring total or substantial assistance and was always incontinent of bowel and bladder. Both residents' care plans specified frequent checks and incontinent care, but observations and interviews revealed lapses in timely care and the inappropriate use of double briefs. Staff interviews indicated that double briefing was not an accepted practice and was not supposed to occur, yet both residents were found in this condition. The facility's policy and staff expectations required rounding and incontinent care at least every two hours, but these were not consistently followed, as evidenced by the residents' reports and the surveyors' observations.
Infection Control Deficiency Due to Improper PPE Use
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by the actions of a Certified Nursing Assistant (CNA) who did not adhere to contact precaution protocols for a resident. The resident, a cognitively intact female with type 2 diabetes and hypertension, was on contact precautions due to wound healing. Despite the presence of a sign indicating contact precautions and a PPE box outside the resident's room, the CNA entered the room without donning personal protective equipment (PPE) or performing hand hygiene. The CNA was observed touching the resident's bedsheets without gloves and exiting the room without washing hands or using hand sanitizer. Interviews with the Director of Nursing (DON) and the CNA revealed that the facility lacked a specific policy for contact precautions, relying instead on signage as a guide. The DON acknowledged the expectation for staff to follow proper infection control procedures, including hand hygiene and PPE use, to prevent the spread of infections. The CNA admitted to forgetting the resident was on contact precautions and recognized the risk of infection or cross-contamination due to improper practices. The facility's procedure sign for contact precautions outlined the necessary steps for PPE use and hand hygiene, which were not followed in this instance.
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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 Palestine
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Legacy At Town Creek | 3.6 mi | ★★★★★ | 2 | 0 |
| Trucare Living Centers | 4 mi | ★★★★★ | 3 | 0 |
| Avir At Town Creek | 5.1 mi | ★★★★★ | 15 | 0 |
| Avir At Elkhart | 11.9 mi | ★★★★★ | 1 | 0 |
| Avir At Jacksonville | 23.1 mi | ★★★★★ | 1 | 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.