The resident was admitted on an undisclosed date in April 2025 with multiple diagnoses including heart failure and diabetes. Staff 4, a licensed practical nurse, completed the clinical admission assessment and noted "some redness with a small healing blister" on the resident's front left knee during a full-body skin check.
The next day's care plan identified the resident as having "impaired skin integrity due to a current blister on the left thigh/shin and immobility." Yet a review of the resident's medical record revealed no wound assessment and no monitoring throughout the stay.
The resident was discharged to the hospital on April 22, 2025, for an unrelated condition.
Federal inspectors interviewed Staff 4 on November 13, 2025. The nurse confirmed he had completed the resident's clinical admission assessment, including the full-body skin check that identified the knee blister. Staff 4 said his standard practice was to place monitoring notes on the Treatment Administration Record when skin problems were found.
But when Staff 4 reviewed the resident's TAR during the interview, he acknowledged he had failed to implement any monitoring of the blister.
Staff 25, an LPN and resident care manager, confirmed the following day that no assessments were completed for the resident's knee blister.
The facility's director of nursing services outlined the expected protocol during a November 14 interview. Staff 2 said any skin impairment noted during admission should be documented in the admission progress note, added to the TAR, trigger alert charting, and prompt a risk management note.
None of this happened for the diabetic resident's knee wound.
Staff 2 acknowledged the resident's blister was neither assessed nor monitored during the entire stay at the facility.
The failure violated federal requirements that nursing homes provide appropriate treatment and care according to medical orders and resident needs. Inspectors determined the lapse placed residents at risk for worsening wounds and treatment delays.
For diabetic patients, even minor skin wounds can develop into serious complications without proper monitoring. The resident's combination of diabetes, heart failure, and limited mobility created additional risk factors that made wound surveillance particularly critical.
The inspection, conducted as a complaint investigation, found the facility failed to ensure proper monitoring of non-pressure skin wounds. Inspectors reviewed three residents with such wounds and found monitoring failures affected at least one case.
Federal regulations require nursing homes to assess residents' skin integrity and implement care plans to prevent deterioration. When wounds are identified, facilities must establish monitoring protocols and document changes in condition.
The resident's case demonstrated a breakdown in the facility's wound care system. Despite staff training on proper protocols and the director of nursing's clear expectations, the admission assessment that identified the problem failed to trigger required follow-up care.
Staff 4's acknowledgment that he typically placed monitoring notes on the TAR when skin problems were found, combined with his admission that no such monitoring occurred, highlighted the gap between policy and practice.
The timing proved particularly concerning. The resident's five-day stay was brief, but diabetic wounds can deteriorate rapidly without proper attention. The combination of the resident's underlying conditions and immobility status made consistent wound monitoring essential for preventing complications.
Inspectors classified the violation as causing minimal harm or potential for actual harm, but noted it affected few residents. The finding occurred during a complaint-based inspection conducted in November 2025, suggesting concerns about the facility's wound care practices prompted the federal review.
The case illustrated broader challenges in nursing home wound care, where documentation requirements and clinical protocols must align to ensure resident safety. When admission assessments identify problems but fail to trigger appropriate monitoring, residents face unnecessary risks during vulnerable periods of their care.
Staff 2's detailed description of expected protocols showed the facility had established appropriate policies. The failure occurred in implementation, where individual staff members must translate written procedures into consistent daily practice.
For the diabetic resident with heart failure, the missed monitoring meant potential complications went undetected during a critical period when medical intervention could have prevented deterioration.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Tigard Rehabilitation and Care from 2025-11-17 including all violations, facility responses, and corrective action plans.
Additional Resources
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