Greenbrier Health Center

• Fine

  CMS changed the fine from October 8, 2025 from $26,685 to $17,345.

• Star rating

  The CMS overall star rating changed from 1 of 5 to 2 of 5.

• Star rating

  The CMS staffing star rating changed from 1 of 5 to 2 of 5.

• Star rating

  The CMS quality measures star rating changed from 4 of 5 to 5 of 5.

• Star rating

  The CMS health inspection star rating changed from 2 of 5 to 1 of 5.

• Star rating

  The CMS overall star rating changed from 2 of 5 to 1 of 5. CMS changed how it scores this rating for many homes at once.

• Star rating

  The CMS quality measures star rating changed from 5 of 5 to 4 of 5.

CMS lists this as a standard inspection and a complaint inspection.

Severity J is the highest of CMS's four levels. CMS uses it when residents' health or safety is at serious risk right away.

60 of 924 Ohio homes (6%) got a citation at the immediate jeopardy level in 2025.

• Citation F0689. Severity J: immediate jeopardy, isolated.

  The rule CMS cited: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

  CMS lists it as corrected on November 4, 2025.

  CMS has cited this home for F0689 3 times since 2023.

• Citation F0606. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Not hire anyone with a finding of abuse, neglect, exploitation, or theft.

  CMS lists it as corrected on November 4, 2025.

• Citation F0761. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

  CMS lists it as corrected on November 4, 2025.

  CMS has cited this home for F0761 2 times since 2024.

• Citation F0804. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

  CMS lists it as corrected on November 4, 2025.

  CMS has cited this home for F0804 2 times since 2024.

• Citation F0813. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Have a policy regarding use and storage of foods brought to residents by family and other visitors.

  CMS lists it as corrected on November 4, 2025.

• Citation F0921. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

  CMS lists it as corrected on November 4, 2025.

  CMS has cited this home for F0921 2 times since 2024.

• Citation F0569. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.

  CMS lists it as corrected on November 4, 2025.

• Citation F0677. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Provide care and assistance to perform activities of daily living for any resident who is unable.

  CMS lists it as corrected on November 4, 2025.

  CMS has cited this home for F0677 2 times since 2023.

• Citation F0684. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Provide appropriate treatment and care according to orders, resident’s preferences and goals.

  CMS lists it as corrected on November 4, 2025.

  CMS has cited this home for F0684 3 times since 2023.

• Citation F0725. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

  CMS lists it as corrected on November 4, 2025.

• Citation F0791. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Provide or obtain dental services for each resident.

  CMS lists it as corrected on November 4, 2025.

• Citation F0880. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Provide and implement an infection prevention and control program.

  CMS lists it as corrected on November 4, 2025.

  CMS has cited this home for F0880 4 times since 2020.

• Citation F0578. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

  CMS lists it as corrected on November 4, 2025.

• Citation F0582. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

  CMS lists it as corrected on November 4, 2025.

• Citation F0656. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

  CMS lists it as corrected on November 4, 2025.

• Citation F0657. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

  CMS lists it as corrected on November 4, 2025.

• Citation F0686. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide appropriate pressure ulcer care and prevent new ulcers from developing.

  CMS lists it as corrected on November 4, 2025.

• Citation F0690. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

  CMS lists it as corrected on November 4, 2025.

  CMS has cited this home for F0690 3 times since 2024.

• Citation F0693. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.

  CMS lists it as corrected on November 4, 2025.

  CMS has cited this home for F0693 2 times since 2024.

• Citation F0695. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide safe and appropriate respiratory care for a resident when needed.

  CMS lists it as corrected on November 4, 2025.

  CMS has cited this home for F0695 2 times since 2024.

• Citation F0698. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide safe, appropriate dialysis care/services for a resident who requires such services.

  CMS lists it as corrected on November 4, 2025.

• Citation F0759. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure medication error rates are not 5 percent or greater.

  CMS lists it as corrected on November 4, 2025.

• Citation F0760. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure that residents are free from significant medication errors.

  CMS lists it as corrected on November 4, 2025.

  CMS has cited this home for F0760 2 times since 2023.

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CMS lists this as a standard inspection.

• Citation K0923. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Have proper medical gas storage and administration areas.

  CMS lists it as corrected on November 4, 2025.

• Citation K0741. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.

  CMS lists it as corrected on November 4, 2025.

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CMS fine of $17,345 on October 8, 2025.

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• Star rating

  The CMS overall star rating changed from 1 of 5 to 2 of 5.

• Star rating

  The CMS quality measures star rating changed from 4 of 5 to 5 of 5.

CMS lists this as a complaint inspection.

• Citation F0697. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide safe, appropriate pain management for a resident who requires such services.

  CMS lists it as corrected on March 13, 2025.

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• Star rating

  The CMS overall star rating changed from 2 of 5 to 1 of 5. CMS changed how it scores this rating for many homes at once.

• Star rating

  The CMS quality measures star rating changed from 5 of 5 to 4 of 5. CMS changed how it scores this rating for many homes at once.

CMS lists this as a complaint inspection.

• Citation F0660. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Plan the resident's discharge to meet the resident's goals and needs.

  CMS lists it as corrected on February 20, 2025.

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CMS lists this as a complaint inspection.

• Citation F0689. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

  CMS lists it as corrected on August 21, 2024.

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CMS lists this as a complaint inspection.

• Citation F0690. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

  CMS lists it as corrected on August 15, 2024.

• Citation F0550. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

  CMS lists it as corrected on August 15, 2024.

  CMS has cited this home for F0550 2 times since 2024.

• Citation F0921. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

  CMS lists it as corrected on August 15, 2024.

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• Star rating

  The CMS overall star rating changed from 3 of 5 to 2 of 5.

• Star rating

  The CMS health inspection star rating changed from 3 of 5 to 2 of 5.

CMS lists this as a complaint inspection.

• Citation F0624. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Prepare residents for a safe transfer or discharge from the nursing home.

  CMS lists it as corrected on April 30, 2024.

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CMS lists this as a complaint inspection.

• Citation F0804. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

  CMS lists it as corrected on March 12, 2024.

• Citation F0812. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

  CMS lists it as corrected on March 12, 2024.

• Citation F0880. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Provide and implement an infection prevention and control program.

  CMS lists it as corrected on March 12, 2024.

• Citation F0550. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

  CMS lists it as corrected on March 12, 2024.

• Citation F0584. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

  CMS lists it as corrected on March 12, 2024.

  CMS has cited this home for F0584 2 times since 2023.

• Citation F0690. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

  CMS lists it as corrected on March 12, 2024.

• Citation F0810. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Provide special eating equipment and utensils for residents who need them and appropriate assistance.

  CMS lists it as corrected on March 12, 2024.

• Citation F0551. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Give the resident's representative the ability to exercise the resident's rights.

  CMS lists it as corrected on March 12, 2024.

• Citation F0684. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide appropriate treatment and care according to orders, resident’s preferences and goals.

  CMS lists it as corrected on March 12, 2024.

• Citation F0693. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.

  CMS lists it as corrected on March 12, 2024.

• Citation F0695. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide safe and appropriate respiratory care for a resident when needed.

  CMS lists it as corrected on March 12, 2024.

• Citation F0761. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

  CMS lists it as corrected on March 12, 2024.

• Citation F0805. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.

  CMS lists it as corrected on March 12, 2024.

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• Star rating

  The CMS health inspection star rating changed from 4 of 5 to 3 of 5.

• Star rating

  The CMS quality measures star rating changed from 4 of 5 to 5 of 5.

• Fine

  CMS changed the fine from March 28, 2023 from $15,000 to $9,750.

CMS lists this as a standard inspection and a complaint inspection.

Severity G is the second-highest of CMS's four levels. It means a resident was harmed.

85 of 924 Ohio homes (9%) got a citation at the actual harm level in 2023.

• Citation F0684. Severity G: actual harm, isolated.

  The rule CMS cited: Provide appropriate treatment and care according to orders, resident’s preferences and goals.

  CMS lists it as corrected on November 13, 2023.

• Citation F0584. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

  CMS lists it as corrected on November 13, 2023.

• Citation F0880. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Provide and implement an infection prevention and control program.

  CMS lists it as corrected on November 13, 2023.

• Citation F0580. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

  CMS lists it as corrected on November 13, 2023.

• Citation F0677. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide care and assistance to perform activities of daily living for any resident who is unable.

  CMS lists it as corrected on November 13, 2023.

• Citation F0689. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

  CMS lists it as corrected on November 13, 2023.

• Citation F0757. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure each resident’s drug regimen must be free from unnecessary drugs.

  CMS lists it as corrected on November 13, 2023.

• Citation F0760. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure that residents are free from significant medication errors.

  CMS lists it as corrected on November 13, 2023.

• Citation F0851. Severity C: potential for minimal harm, widespread.

  The rule CMS cited: Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.

  CMS lists it as corrected on November 13, 2023.

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CMS lists this as a standard inspection.

• Citation K0511. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Have properly installed electrical wiring and gas equipment.

  CMS lists it as corrected on November 13, 2023.

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CMS lists this as a standard inspection.

• Citation F0644. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

  CMS lists it as corrected on March 13, 2020.

• Citation F0880. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide and implement an infection prevention and control program.

  CMS lists it as corrected on March 13, 2020.

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CMS lists this as a standard inspection.

• Citation K0161. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Use approved construction type or materials.

  CMS lists it as corrected on March 13, 2020.

• Citation K0211. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Keep aisles, corridors, and exits free of obstruction in case of emergency.

  CMS lists it as corrected on March 13, 2020.

• Citation K0222. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.

  CMS lists it as corrected on March 13, 2020.

• Citation K0311. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Have an enclosure around a vertical opening shaft.

  CMS lists it as corrected on March 13, 2020.

• Citation K0521. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

  CMS lists it as corrected on March 13, 2020.

• Citation K0918. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Have generator or other power source capable of supplying service within 10 seconds.

  CMS lists it as corrected on March 13, 2020.

• Citation K0353. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Inspect, test, and maintain automatic sprinkler systems.

  CMS lists it as corrected on March 13, 2020.

• Citation K0363. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Install corridor and hallway doors that block smoke.

  CMS lists it as corrected on March 13, 2020.

• Citation K0372. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

  CMS lists it as corrected on March 13, 2020.

• Citation K0911. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Meet requirements for the installation and maintenance of electrical systems.

  CMS lists it as corrected on March 13, 2020.

• Citation K0920. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Ensure proper usage of power strips and extension cords.

  CMS lists it as corrected on March 13, 2020.

• Citation E0004. Severity C: potential for minimal harm, widespread.

  The rule CMS cited: Develop and maintain an Emergency Preparedness Program (EP).

  CMS lists it as corrected on March 13, 2020.

• Citation E0013. Severity C: potential for minimal harm, widespread.

  The rule CMS cited: Develop Emergency Preparedness policies and procedures.

  CMS lists it as corrected on March 13, 2020.

• Citation E0024. Severity C: potential for minimal harm, widespread.

  The rule CMS cited: Establish policies and procedures for volunteers.

  CMS lists it as corrected on March 13, 2020.

• Citation E0029. Severity C: potential for minimal harm, widespread.

  The rule CMS cited: Develop a communication plan.

  CMS lists it as corrected on March 13, 2020.

• Citation E0033. Severity C: potential for minimal harm, widespread.

  The rule CMS cited: Establish methods for sharing information.

  CMS lists it as corrected on March 13, 2020.

• Citation E0036. Severity C: potential for minimal harm, widespread.

  The rule CMS cited: Establish emergency prep training and testing.

  CMS lists it as corrected on March 13, 2020.

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