Grey Stone Health & Rehab: Wound Care Failures - IN
Inspectors cited Grey Stone Health & Rehabilitation Center for causing actual harm to a resident identified only as Resident J, after finding that staff failed to act on a worsening pressure wound for days and then documented treatments as complete that were never carried out.
The family reported the injury on October 18. What they saw was a deep tissue injury, or DTI, to Resident J's left heel — dark purple and red, with irregular borders, measuring 2 centimeters by 2.5 centimeters. A deep tissue injury is damage occurring beneath the surface of intact skin, where muscle meets bone, and it ranks among the most serious categories of pressure wound. The standard response is immediate: reposition the patient off the site, protect the skin, and place a pressure-relieving surface under them.
Grey Stone's response was to order Skin Prep, a liquid film-forming protectant, applied to her heel every shift. Skin Prep is not recommended for open areas.
A Braden Scale assessment completed that same day, October 18, rated Resident J at moderate risk for pressure ulcers. The assessment did not include any new interventions to stop the DTI from worsening or to prevent additional wounds from forming.
Nothing changed for three days.
On October 21, a wound nurse practitioner examined Resident J and found the injury had progressed. It was no longer a deep tissue injury with intact skin. It was now an open ulcer — unstageable, covered with soft eschar, the dead tissue that forms over serious wounds. The wound bed was 100 percent eschar. The wound NP ordered daily treatment with Santyl, an enzyme preparation used to remove dead tissue, along with positioning devices and a low air loss mattress.
That same day, a nurse note confirmed the wound NP's visit and the new orders. The medication administration record shows heel-floating and a heel protector were also ordered for October 21. Nurses initialed the MAR indicating the air mattress was present.
Inspectors found no air mattress on Resident J's bed on October 21. Or October 22. Or October 23.
The mattress had been ordered. It had been charted as in place. It was not there.
Nurses initialed records for three consecutive days confirming equipment that did not exist in the room. The resident, rated at moderate risk for pressure wounds and already carrying an open, unstageable heel ulcer, spent those nights on a standard mattress.
When inspectors requested the facility's pressure injury policies on October 24, the administrator provided them at 10:20 in the morning. The policies stated that at-risk residents would have their heels offloaded and suspended, that they would be repositioned to avoid pressure on bony prominences, and that pressure redistribution devices would be provided as recommended. The policies stated that new pressure injuries would not develop unless the resident's clinical condition made them unavoidable.
Resident J's clinical condition did not make this unavoidable. Her family caught the injury on October 18. They told staff. The staff documented it. Then, for three days, no meaningful intervention followed. When interventions were finally ordered on October 21, the most critical one — the mattress meant to relieve the pressure destroying her heel — was recorded as present and never placed.
The citation carries a finding of actual harm.
What the records show is a gap between what nurses wrote and what was in the room. What they don't show is who noticed, or whether anyone checked on Resident J's heel during those three days and saw a wound sitting on a standard mattress while the chart said otherwise.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Grey Stone Health & Rehabilitation Center from 2025-10-24 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: July 6, 2026 · Our methodology
GREY STONE HEALTH AND REHABILITATION CENTER in FORT WAYNE, IN was cited for violations during a health inspection on October 24, 2025.
The family reported the injury on October 18.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.