The November inspection at Tigard Rehabilitation and Care found that staff violated federal pressure ulcer care standards, leaving a resident with bone infection at risk for worsening wounds.
Resident 7 arrived at the facility in October with osteomyelitis of vertebrae, a bone infection. On November 1, a certified nursing assistant alerted Staff 26, a licensed practical nurse, about an open sore on the upper part of the resident's buttock.
Staff 26 looked at the wound, cleaned it, and covered it. She initiated a required Skin Integrity Report and notified the resident care manager and physician.
But she did nothing else.
Staff 26 admitted to inspectors she "did not measure the wound, did not obtain orders from the provider, did not document any wound treatment, and did not initiate any house wound orders." No wound care was provided until November 4.
The facility's own clinical protocol required nurses to conduct a full assessment of pressure sores, including location, stage, length, width, depth, presence of leaking fluid or dead tissue, and pain assessment. National guidelines recommend assessing pressure ulcers immediately upon discovery and documenting all physical characteristics.
Two days after the initial discovery, on November 3, someone finally measured the wounds. The resident had developed two separate pressure injuries: one on the left buttock measuring 1.5 by 1.1 centimeters, and another on the coccyx measuring 3.1 by 5 by 0.3 centimeters.
Only then did the physician write treatment orders. The November 3 orders specified washing and drying the wound bed, applying hydrogel to the sacrum and medical honey to the coccyx, then covering both wounds with a large sacral dressing daily.
The director of nursing, Staff 2, told inspectors that when staff discovered new skin issues, they were expected to "assess and measure the wound right away, complete wound care, implement a treatment protocol on the TAR, and place the resident on alert charting."
Staff 2 acknowledged that Resident 7's wound was identified November 1 but "was not comprehensively assessed and measured until November 3." She confirmed no evidence existed in the health record showing wound care was provided during those three days.
The resident's admission assessment, required to be completed by October 29, was never finished. This left staff without baseline documentation of the resident's skin condition upon arrival.
Federal inspectors found the facility failed to ensure newly identified pressure ulcer wounds received comprehensive assessment and proper wound care orders for the sampled resident. The violation placed residents at risk for worsening pressure ulcers.
The inspection was conducted in response to a complaint. Inspectors classified the harm level as minimal but noted the potential for actual harm to residents.
Pressure ulcers can develop rapidly in vulnerable populations, particularly residents with conditions like bone infections that compromise healing. The three-day delay in proper assessment and treatment violated both facility policy and national wound care standards.
Staff 26's failure to follow basic wound care protocols left Resident 7 without appropriate medical intervention during a critical period when early treatment could have prevented deterioration. The resident's bone infection made proper wound care even more essential.
The facility's breakdown occurred at multiple levels: the admitting nurse failed to complete required assessments, the licensed nurse ignored established protocols for wound discovery, and supervisory staff failed to ensure compliance with their own clinical standards.
Resident 7 remained at the facility with ongoing wound care needs, dependent on the same staff who had initially failed to provide appropriate treatment.
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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