Licensed Practical Nurse #707 at Greenbrier Health Center documented completing daily wound treatments for Resident #38 on September 23. But when investigators examined the actual dressings, they found dates showing September 22 — proof the treatments never happened.
The resident lives with quadriplegia, diabetes and schizophrenia. Federal inspectors found him with pressure wounds covering his mid-spine, right back, sacrum and left buttock — some measuring up to seven centimeters long and five centimeters wide.
His doctor had ordered daily cleaning and fresh collagen dressings for all wound sites. Staff were supposed to cleanse each area with wound cleanser, apply collagen sheets to the wound base, and secure everything with bordered foam dressing.
Instead, they left old dressings in place while falsifying medication administration records and treatment administration records to show the work was complete.
Licensed Practical Nurse #690, who serves as the facility's wound nurse, confirmed the deception during her September 24 interview with inspectors. She acknowledged that LPN #707 had signed off on treatments as completed, but the physical evidence showed the dressings carried dates from the day before.
The resident's medical records show his cognitive abilities remain intact, meaning he was fully aware his wounds weren't receiving the care his doctors ordered.
Wound progress notes from September 24 documented the extent of his injuries. The mid-spine pressure wound measured 2.1 centimeters long, 1 centimeter wide, and extended 0.3 centimeters deep into his tissue. His right back wound stretched 3.3 centimeters by 4 centimeters, reaching the same 0.3-centimeter depth.
The sacrum wound measured 4.6 centimeters long and 3 centimeters wide. His left buttock bore the largest injury — a gaping wound 7 centimeters long, 5.1 centimeters wide, and extending 0.2 centimeters into his flesh.
All four wounds were classified as stage three, indicating they had eaten through the skin and fat layers to expose underlying tissue. The notes described them as "improving," but that progress depended on the daily care that wasn't happening.
The facility's own wound care policy requires treatment based on each wound's location, stage and drainage. For this resident, that meant daily attention to prevent infection and promote healing in four separate wound sites across his immobilized body.
Federal investigators discovered the falsified records while responding to three separate complaints filed against Greenbrier Health Center. The complaint numbers — 2561886, 1338811 and 1338808 — suggest multiple people reported concerns about care at the facility.
The inspection found the medication administration records and treatment administration records were "inaccurate," a clinical term for documentation that doesn't match the actual care provided. In nursing home regulation, accurate documentation isn't just paperwork — it's the primary way to ensure vulnerable residents receive the treatments their doctors order.
When nurses sign off on treatments they haven't performed, it creates a cascade of problems. Other staff members checking the records assume the work is complete. Doctors reviewing charts make treatment decisions based on false information. And residents like #38 suffer with untreated wounds while everyone believes they're receiving proper care.
The resident was readmitted to Greenbrier Health Center sometime before the inspection, suggesting his condition had deteriorated enough to require hospitalization. His diagnoses of quadriplegia and diabetes make pressure ulcer prevention and treatment critical — people with paralysis can't shift their weight to relieve pressure, and diabetes impairs wound healing.
Stage-three pressure ulcers represent serious medical conditions that can lead to life-threatening infections if left untreated. The wounds require consistent, skilled nursing care to prevent deterioration into stage four, where bone and muscle become exposed.
Federal inspectors classified this as causing "minimal harm or potential for actual harm," but the finding reveals a breakdown in basic nursing care for one of the facility's most vulnerable residents. The investigation covered seven residents reviewed for pressure wounds, meaning this resident represented one-seventh of the cases examined.
The falsified documentation occurred over multiple days, indicating this wasn't a single oversight but a pattern of neglecting ordered treatments while maintaining the appearance of compliance through fraudulent record-keeping.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Greenbrier Health Center from 2025-10-08 including all violations, facility responses, and corrective action plans.