Resident #28 arrived at Timberland Ridge Nursing & Rehabilitation in October with three existing pressure wounds. The most serious was a stage 3 pressure ulcer on the left ankle measuring 2 centimeters by 1 centimeter with a depth of 0.2 centimeters. Stage 3 wounds involve full-thickness skin loss with damage to subcutaneous tissue that may extend into underlying muscle.
The resident also had a stage 1 pressure wound on the sacrum measuring 5 centimeters by 4 centimeters and a deep tissue injury on the right ankle measuring 2 centimeters by 2.5 centimeters. Deep tissue injuries are localized areas of damage to skin and underlying soft tissue caused by intense or prolonged pressure.
Federal inspectors found no evidence of physician orders or wound care treatments for any of these three pressure wounds from October 3 through October 5. The facility's medication administration records, treatment administration records, and physician orders contained no documentation of care during this period.
Two additional wounds developed while the resident was at the facility. Blisters formed on both feet — a right plantar foot blister measuring 2.9 centimeters by 1.9 centimeters with moderate serous drainage, and a left plantar foot blister measuring 3.5 centimeters by 3.5 centimeters.
Registered Nurse and Wound Nurse #902 confirmed during an October 27 interview that wound care orders and treatments were not in place for the resident's pressure wounds during the three-day period.
The resident's care plan from October 10 stated staff should assess for pain and provide treatments per physician's orders. But those orders were missing for the critical first days after admission.
Resident #28 was admitted with diagnoses including muscle weakness, abnormalities of gait and mobility, and cerebral palsy. The resident's admission assessment revealed severe cognitive impairment.
The facility's own skin assessment policy, revised in March 2024, states that residents with pressure injuries "shall receive necessary treatment and services to promote healing, prevent infection, and prevent new injuries from developing which was consistent with professional standards of practice."
The policy also declares the facility's intent "to provide necessary care to prevent the development of pressure injuries unless the resident's clinical condition demonstrates that the development was unavoidable."
Yet this resident developed two facility-acquired foot blisters while existing wounds went without ordered care.
The inspection was conducted in response to a complaint. Federal inspectors classified the violation as causing minimal harm or potential for actual harm, but noted it represented non-compliance with federal standards for pressure ulcer care.
Pressure ulcers develop when sustained pressure cuts off blood flow to skin and underlying tissue. Stage 1 wounds show non-blanchable redness. Stage 3 wounds involve full-thickness skin loss that may extend into muscle. Deep tissue injuries can appear as purple or maroon areas that may evolve into open wounds.
The three-day gap in wound care occurred during a critical period when prompt treatment could have prevented deterioration. Without proper physician orders, nursing staff could not provide the specialized treatments needed for healing.
The facility failed one of four residents reviewed for wound care during the inspection. The violation specifically affected Resident #28, whose complex medical conditions required careful attention to skin integrity.
Federal regulations require nursing homes to provide appropriate pressure ulcer care and prevent new ulcers from developing. Facilities must ensure physician orders are in place and followed for all wound treatments.
The inspection found the facility's actual practices contradicted its written policies on pressure injury prevention and treatment. While the policy promised necessary care consistent with professional standards, the resident experienced a three-day treatment gap immediately after admission.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Timberland Ridge Nursing & Rehabilitation from 2025-10-29 including all violations, facility responses, and corrective action plans.
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