The resident, identified as Resident #75 in the September inspection report, arrived at the facility from a hospital with an unstageable pressure ulcer to the tailbone area. The wound measured 7.0 centimeters by 4.0 centimeters and was covered entirely with dead tissue requiring specialized treatment.
Federal inspectors found no wound treatment orders documented on the resident's medication and treatment records for the entire month of July 2025. The facility's own weekly skin assessments from August 1st noted barrier cream should be applied, but Licensed Practical Nurse #101 confirmed during a September 30th interview that no documentation existed showing this treatment was actually ordered or provided.
The wound care gap extended into August. Treatment orders finally appeared on August 11th, directing staff to clean the area with soap and water and apply calcium alginate dressing daily. That order lasted exactly one day.
On August 12th, the facility discontinued the alginate treatment and switched to wound gel therapy. The new orders called for cleaning with soap and water, applying wound gel, and covering with dry dressing daily. Moon boots for both feet were also ordered to prevent further pressure injuries.
By August 18th, a wound care nurse practitioner documented the pressure ulcer had grown slightly to 7.4 centimeters by 4.0 centimeters with a depth of 0.1 centimeters. The wound showed scant serous drainage and remained completely covered with adherent dead tissue. The nurse practitioner recommended continuing wound gel to soften the dead tissue and promote natural removal of the damaged skin.
The practitioner also ordered a low air loss mattress to reduce pressure on the resident's vulnerable skin areas. Weekly assessments from August 11th and 18th had already identified the resident's coccyx pressure concerns and existing skin abnormalities.
Treatment records show the facility's approach shifted multiple times within days. The initial August 11th order specified calcium alginate dressing, a material designed to absorb wound drainage and maintain moisture balance. Within 24 hours, staff switched to wound gel therapy, which works differently by chemically breaking down dead tissue.
The wound remained classified as unstageable throughout the documented treatment period. Unstageable pressure ulcers cannot be properly assessed for depth because dead tissue obscures the wound bed, making them particularly concerning for infection risk and healing complications.
LPN #101's September interview with inspectors revealed the scope of the documentation failure. When asked about monitoring skin treatments and coordination with the wound care nurse practitioner, the licensed practical nurse acknowledged the facility had no records showing barrier cream application despite assessment notes indicating it should be used.
The nurse confirmed that both July and August medication and treatment administration records contained no coccyx or sacrum wound care orders until August 12th. When pressed about the missing documentation, LPN #101 stated the orders for Resident #75's skin breakdown "were just missed."
Weekly wound assessments from August 25th showed the pressure ulcer measurements had returned to 7.0 centimeters by 4.0 centimeters with no depth recorded. The wound description remained consistent with previous documentation, noting the resident had been admitted from the hospital with the existing tailbone injury.
The inspection occurred as part of a complaint investigation numbered OH002593689. Federal regulators classified the violation as causing minimal harm or potential for actual harm, affecting few residents.
Pressure ulcers represent one of the most preventable complications in nursing home care. The wounds develop when sustained pressure cuts off blood flow to skin and underlying tissue, typically over bony areas like the tailbone, hips, and heels. Once formed, they require consistent, documented treatment to prevent infection and promote healing.
The facility's treatment inconsistencies extended beyond missing documentation. Staff changed wound care approaches multiple times within a two-week period, switching from no documented treatment to alginate dressing to wound gel therapy. Each treatment method requires different application techniques and monitoring protocols.
Moon boots, ordered on August 11th for both feet, represent a standard pressure prevention measure. The protective devices keep heels elevated off mattresses and prevent foot drop, a common complication for bedridden residents.
Resident #75's case illustrates the critical importance of treatment documentation in nursing home care. Without proper records, facilities cannot demonstrate they provided ordered care or track treatment effectiveness over time.
The resident remained at Greenbriar Nursing Center with the ongoing pressure ulcer requiring daily wound gel application and dressing changes as of the September inspection.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Greenbriar Nursing Center from 2025-11-20 including all violations, facility responses, and corrective action plans.