Greenbriar Nursing Center
GREENBRIAR NURSING CENTER in EATON, OH — inspection on November 20, 2025.
Found 1 citation. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Review of the weekly skin assessment for Resident #75 dated 08/11/25 revealed resident has previously identified skin areas/abnormalities.
Review of the weekly skin assessment for Resident #75 dated 08/18/25 revealed has previously identified skin areas/abnormalities with coccyx pressure noted.
Review of the weekly wound assessment for Resident #75 dated 08/18/25 revealed resident had pressure ulcer to sacrum classified as unstageable.
Wound measurements documented were 7.0 cm x 4.0 cm x 0.
Wound description was documented as resident was admitted from the hospital with DTI, unstageable to coccyx, 100 percent slough with no drainage noted.
Wound status was stable, treatment plan documented for cleanse with soap and water, pat dry, apply wound gel and dry dressing daily.
Review of the wound NP visit notes for Resident #75 dated 08/18/25 revealed coccyx wound pressure and staged as unstageable.
Coccyx wound measures 7.4 cm x 4.0 cm x 0.1 cm.
Wound had scant amount of serous drainage.
Adherent slough (dead non viable tissue) present on wound was documented as covering 100 percent of wound.
Treatment plan documented for wound gel and bordered foam dressing everyday and as needed.
Recommendations documented included continue wound gel to help soften slough and promote debridement.
Air mattress was ordered per nursing.
Review of the weekly wound assessment for Resident #75 dated 08/25/25 revealed resident had pressure ulcer to sacrum classified as unstageable.
Wound measurements documented were 7.0 cm x 4.0 cm x 0.
Review of the physician orders for Resident #75 revealed an order dated 08/12/25 to area on coccyx, cleanse with soap and water, pat dry, apply wound gel, cover with dry dressing, change daily and as needed for soiling and dislodgement. An order for moon boots to bilateral feet when in bed every day and night initiated on 08/11/25.
Review of the monthly medication administration record (MAR) and treatment administration record (TAR) for July 2025 for Resident #75 was silent for any wound treatment orders to the coccyx/sacrum.
Review of the MAR and TAR record for August 2025 for Resident #75 revealed an treatment order dated 08/11/25 was documented to area on coccyx, cleanse with soap and water, pat dry and apply calcium alginate cover with dry dressing and change everyday.
Order was discontinued on 08/12/25. An order dated 08/12/25 was initiated for area to coccyx cleanse with soap and water, pat dry, apply wound gel, cover with dry dressing and change every day.
Interview on 09/30/25 at 3:05 P.M. with Licensed Practical Nurse (LPN) #101 revealed that monitoring skin treatments and rounding with Wound NP verified the facility did not have any documentation that the stated barrier cream which was documented on the weekly skin assessment on 08/01/25 was being applied as ordered. LPN #101 verified July and August 2025 MAR/TAR did not contain any orders for coccyx/sacrum wound care until 08/12/25. LPN #101 further stated the orders for Resident #75's skin breakdown were just missed.
This deficiency represents non-compliance investigated under Complaint Number OH002593689.
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