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Tigard Rehabilitation: Pressure Ulcer Care Failures - OR
Resident 7 arrived at the facility in October with osteomyelitis of vertebrae, a bone infection....
Latest reports, citations, and penalties from CMS data
Resident 7 arrived at the facility in October with osteomyelitis of vertebrae, a bone infection....
Resident 14's blood glucose level reached 528 by the time testing resumed on October 22, 2025....
The DON explained that air mattresses should be set according to the resident's weight....
The medications included two insulin pens, breathing inhalers and nasal spray belonging to Resident 87....
The wound became infected, requiring antibiotics and specialized dressing changes....
Resident #5's urine culture and sensitivity test was ordered at 1:13 PM on November 12....
Resident #3, who is cognitively intact, shouted for help until the Assistant Director of Nursing came to the dining room....
Staff at Pine Forest Care Center for Rehab & Healthcare discovered Resident #1 outside on the ground at approximately 7:10 AM on October 17, 2025....
When inspectors asked whether wound assessment fell within an LPN's scope of practice, Staff E responded: "I never really thought of that, I am not sure....
The complaint investigation at Willard Care Center revealed a pattern of undocumented family communications across multiple residents....
Federal inspectors who watched nurses distribute medications over two days in November found a 7.14% error rate on the facility's first and second floors....
The incident occurred at Northgate Care Center on October 17, when the nurse approached a resident sitting in a recliner chair following a fall....
The resident told investigators that CNA #2 became upset when asked to be gentler during care on August 21, 2025....
The October 29 incident involved a resident who had been admitted just days earlier with congestive heart disease, anxiety, and Type 2 diabetes....
Resident 1's urine test came back abnormal....
State inspectors found the violations during a November 14 visit to Aperion Care Midlothian....
Federal inspectors found that staff violated basic wound care protocols by leaving the patient vulnerable to infection....
The resident was admitted on an undisclosed date in April 2025 with multiple diagnoses including heart failure and diabetes....
Resident 9 sat on the edge of their bed without a call light within reach on November 14....
The resident had been refusing medications for days....