Health inspection·November 20, 2025

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure skin care treatments were timely initiated when a resident was admitted with a pressure ulcer. This affected one (#75) of three reviewed for wound care and services. The facility census was 70. Findings include: Medical record for Resident #75 revealed an admission on [DATE] with diagnoses including but not limited to hypertension, type two diabetes mellitus with diabetic neuropathy, peripheral vascular disease, and congestive heart failure. Resident #75 was transferred to the hospital on [DATE] and did not return to the facility. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] for Resident #75 revealed cognitive impairment. Resident #75 required supervision for eating and minimal assistance with bed mobility, transfers and toileting. Resident #75 was coded in section M of the MDS as being at risk for developing pressure ulcers and coded for as having one more unhealed pressure ulcers. Resident #75 was coded with one unstageable deep tissue injury that was present on admission. Resident #75 was not coded with any pressure ulcer care, applications of dressings or topical ointments. Further review of section M revealed it was signed as completed on 08/07/25. Review of the plan of care for Resident #75 dated 08/01/25 was silent for any documentation related to altered skin integrity. Review of hospital discharge orders for Resident #75 dated 07/31/25 was silent for any orders related to impaired skin integrity. Review of the weekly skin assessment for Resident #75 dated 07/31/25 revealed scatter bruising and scabs, buttocks red and skin beginning to peel. Review of the weekly wound assessment for Resident #75 dated 08/01/25 revealed resident had pressure ulcer to sacrum classified as suspected deep tissue injury. Wound measurements documented were 7 centimeters in length, 7.4 cm in width and 0.0 depth. Wound description was documented as resident was admitted from the hospital with this deep tissue injury (DTI) to coccyx, purple in color, top layer of skin peeling and no drainage noted. Wound status was stable, treatment plan documented for zinc-based barrier cream two times a day. Review of the weekly skin assessment for Resident #75 dated 08/05/25 revealed admitted with unstageable to coccyx seen by wound nurse practitioner (NP). Review of the weekly wound assessment for Resident #75 dated 08/11/25 revealed resident had pressure ulcer to sacrum classified as unstageable. Wound measurements documented were 6.5 cm x 4.5 cm x 0. Wound description was documented as resident was admitted from the hospital with this deep tissue injury (DTI) to coccyx, purple in color, top layer of skin peeling and 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 initial wound NP visit for Resident #75 dated 08/11/25 revealed coccyx wound pressure and staged as unstageable. Coccyx wound measures 6.5 cm x 4.5 cm x 0.1 cm. Wound had scant amount of serous drainage. Adherent slough (dead non viable tissue) present on wound was documented as 50 percent of wound area and 50 percent eschar. Treatment plan documented for wound gel and bordered foam dressing everyday and as needed. Recommendations documented included NP was notified by facility on admission of coccyx wound, treatment was Residents Affected - Few Page 1 of 2 365854 365854 11/20/2025 Greenbriar Nursing Center 501 West Lexington Road Eaton, OH 45320

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few initiated upon evaluation today. Will start with wound gel to soften slough and eschar and for chemical debridement. Resident #75 would benefit from low air loss mattress. 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. 365854 Page 2 of 2