French Prairie Nursing & Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Woodburn, Oregon.
- Location
- 601 Evergreen Road, Woodburn, Oregon 97071
- CMS Provider Number
- 385117
- Inspections on file
- 29
- Latest survey
- February 27, 2026
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at French Prairie Nursing & Rehabilitation Center during CMS and state inspections, most recent first.
A resident admitted with COPD had physician orders for BID doses of Combivent, Symbicort, and apixaban. Review of the MAR showed the evening doses of all three medications were not administered as ordered, and the Interim DNS confirmed they were missed. This failure to follow the medication orders placed residents at risk for not receiving medications as prescribed and potential side effects.
Several residents expressed dissatisfaction with the meals, citing issues such as cold food, poor taste, and dry texture. Staff, including CNAs and LPNs, confirmed frequent complaints and noted that residents often ordered outside food due to the unpalatable meals. A test tray review with the Administrator revealed a cold, bland fish filet served without sauce.
The facility did not provide alternative meals to residents unless requests were made at least two hours in advance, as confirmed by multiple staff and resident interviews. Residents who did not like the main meal or requested alternatives outside the advance notice period were often unable to receive suitable options, despite the facility's alternative menu. This practice placed residents at risk of not receiving nourishing meals.
A resident with dementia and agitation physically struck a CNA and then alleged abuse by the CNA. An LPN assessed the resident and reported the allegation to management, but the facility did not report the abuse allegation to the State Agency within the required two-hour timeframe, and no investigation was initiated the same day.
A resident with dementia and a history of physical behaviors struck a CNA during care and subsequently alleged that the CNA had abused them first. The LPN notified management, but the facility's investigation was incomplete, lacking witness statements, investigation notes, and a summary, as confirmed by nursing leadership.
The facility did not maintain adequate nursing staff, leading to prolonged call light response times, delayed medication administration, missed meals, and incomplete care such as incontinence care and showers. Staff and family interviews, public complaints, and facility records all confirmed frequent staffing shortages, especially on nights and weekends, with state minimum staffing ratios for CNAs unmet on numerous days. One resident requiring substantial assistance reported long waits for care, and staff acknowledged that assignments were not made timely and inexperienced staff were orienting each other.
Facility administration did not ensure effective use of resources, resulting in chronic insufficient staffing, delayed resident assistance, and incomplete facility assessments. A resident with epilepsy did not receive seizure medication on time, leading to a seizure and hospitalization, with no incident report completed or follow-up with the responsible LPN.
A facility-wide assessment was found to be incomplete, lacking accurate information on how staffing needs and resident acuity were addressed, and failing to account for high agency staff usage. The Administrator confirmed the assessment was not comprehensive and did not contain accurate staffing data.
A resident with epilepsy and dementia experienced a seizure and was sent to the hospital, but the emergency contact was not notified by facility staff. The family member only learned of the incident from hospital staff, and facility leadership confirmed the lack of notification.
A resident with epilepsy and dementia did not receive scheduled anti-seizure medications on time when an LPN administered them several hours late and delayed documentation. The resident, who had no prior seizures in the facility, subsequently experienced multiple seizures and required hospitalization. The DNS was informed after a family member raised concerns, and no incident report or staff follow-up occurred.
The facility did not consistently post accurate and complete nurse staffing information, with multiple days showing blank or incorrect entries for daily census, staff numbers, and hours worked. This issue was confirmed by the Administrator.
Several residents with ongoing diarrhea and abdominal symptoms were not promptly assessed or reported to a physician, resulting in delayed c-diff diagnoses. Staff were observed not following required infection control protocols, such as washing hands with soap and water after caring for residents on contact precautions, and instead used alcohol-based hand rubs. Some staff were unclear about proper procedures, and others did not comply due to workload, leading to potential cross-contamination and an Immediate Jeopardy situation.
The facility did not maintain adequate CNA staffing levels, as evidenced by multiple shifts falling below state minimum requirements and numerous reports of long call-light response times. Residents needing assistance with lifts, ADLs, and eating experienced delays, and staff interviews confirmed high acuity and inability to complete all care tasks. Family and resident interviews, as well as direct observations, highlighted frequent and significant delays in care due to insufficient staffing.
The facility did not ensure RN coverage for at least eight consecutive hours per day on multiple occasions, as confirmed by review of staffing reports and administrator acknowledgment. This resulted in periods without required RN oversight, but no specific resident details were provided.
Annual performance reviews were not completed for four CNAs, as confirmed by interviews and record reviews. The Administrator and Regional RN could not provide documentation of these required evaluations when requested.
A resident with major depressive disorder was administered bupropion and desvenlafaxine daily without informed consent being obtained prior to the start of these medications. Consent forms detailing the risks and benefits were signed only after the medications had already been given, as confirmed by the DNS.
A resident with recent fractures and documented cognitive intactness was found to have been self-administering vitamins and eye drops brought from home without an interdisciplinary assessment or physician order, contrary to facility policy. Staff confirmed the absence of a required evaluation despite the resident's ongoing use of these medications.
A resident with severe cognitive impairment and multiple chronic conditions experienced two prolonged episodes of constipation without timely administration of prescribed bowel care medications or physician notification, as required by facility protocol. Documentation and monitoring were lacking, and staff could not provide evidence that the bowel care protocol was followed.
A resident with diabetes and bilateral cataracts did not receive follow-up for recommended cataract surgery after an eye exam, as the facility failed to schedule or address the surgery due to staff turnover and lack of a unit manager. The resident remained aware of the need for surgery but reported no further communication or action from staff.
A resident receiving regular dialysis treatments did not receive required post-dialysis assessments on multiple occasions, as confirmed by both the resident and staff interviews. Nursing staff failed to consistently assess and document the resident's condition and dialysis access site after each treatment, despite physician orders requiring these assessments.
A resident with a right ankle fracture and oral thrush did not receive prescribed Magic Mouthwash for throat pain over a period of several days because the medication was not available. An LPN contacted the pharmacy and provider about the missing medication, but the pharmacy did not receive necessary information from the facility to compound the medication, resulting in a significant delay in delivery. The DON confirmed the resident did not receive the medication as ordered.
A nurse administered two crushed medications together via a feeding tube to a resident with swallowing difficulties, contrary to facility policy requiring separate administration. This contributed to a medication error rate above the acceptable threshold.
A resident with multiple sclerosis and slow transit constipation did not have a physician-ordered stool sample collected for an IFOBT colorectal cancer screening test. Staff interviews revealed a lack of communication between charge nurses and CNAs regarding the need for sample collection, and the LPN was unsure if the order was properly relayed. The sample was not obtained as required by the physician's order.
A facility failed to notify a resident's representative in writing before a room change, as required by policy. The resident, who was severely cognitively impaired and had a spouse with POA, was moved after testing positive for COVID-19 without the spouse being informed. This led to conflict with the new roommate. Staff confirmed the notification protocol was not followed.
Two residents in a LTC facility were neglected by staff, resulting in one being left naked and covered in waste on the floor, and another falling after attempting to use the bathroom without assistance. Staff failed to provide proper care and timely response, leading to undignified and unsafe conditions for the residents.
An LPN in a facility failed to adhere to professional standards, resulting in the neglect of two residents. One resident with dementia was left naked and covered in waste on the floor, while another resident with muscle weakness and a hip fracture was left unchanged and fell in the bathroom. The LPN did not assess or document the incidents, and the facility's investigation confirmed neglect of care.
The facility failed to adequately assess and monitor pressure ulcers for three residents, leading to a risk of worsening wounds. A resident with diabetes and dementia had multiple wounds that were not properly assessed or treated. Another resident admitted to hospice care developed a pressure ulcer that was not monitored for several months. A third resident with a Stage 4 sacral ulcer had inconsistent and incomplete wound assessments. Staff acknowledged the deficiencies in monitoring and treatment.
Failure to Administer Ordered Respiratory and Anticoagulant Medications
Penalty
Summary
Facility staff failed to administer medications according to physician orders for one resident. The resident was admitted with diagnoses including chronic obstructive pulmonary disease and had admission orders dated 12/26/25 for Combivent 1 puff BID, Symbicort 2 puffs BID, and apixaban 5 mg BID. Review of the December 2025 MAR showed that the evening doses of Combivent, Symbicort, and apixaban were not administered on 12/26/25 as ordered. In an interview on 2/27/26 at 9:39 AM, the Interim DNS confirmed that these medications were not given as ordered on that date. This failure to administer the ordered evening doses of respiratory inhalers and an anticoagulant placed residents at risk for not receiving medications as ordered and potential side effects, as identified through interview and record review.
Unpalatable and Improperly Served Meals
Penalty
Summary
The facility failed to ensure that meals provided to residents were palatable, attractive, and served at a safe and appetizing temperature. Multiple residents reported dissatisfaction with the food, describing it as cold, unpalatable, or unappetizing, with specific complaints including cold breakfast, dry chicken, and food described as 'nasty.' Staff members, including CNAs and LPNs, confirmed that residents frequently complained about the quality and taste of the meals and often resorted to ordering food from outside delivery services. During a test tray observation with the Administrator, a fish filet was found to be cold, bland, and served without any sauce, further confirming the issue.
Failure to Provide Timely Alternative Meals to Residents
Penalty
Summary
The facility failed to provide residents with alternative meals and snacks in accordance with their needs, preferences, and requests. Observations and interviews revealed that residents were required to request alternative meals at least two hours in advance, otherwise they had to wait until the end of meal service or were unable to receive an alternative meal at all. Staff members, including dietary, CNA, and LPN personnel, consistently stated that alternative meals could only be provided if requested well in advance, and some staff indicated that residents were not able to request alternatives at all. One resident reported being unable to get an alternative meal if they did not like what was served, and another stated they had only received a second tray once despite multiple requests. On one occasion, a resident requested a hamburger as an alternative meal, but the cook was unable to provide it because it was not on the product list and the request was not made two hours in advance. The facility's alternative menu listed several options, but staff confirmed that these were not always available unless pre-ordered. These practices placed residents at risk of not receiving nourishing meals, as the facility did not accommodate requests for alternative meals outside of the specified advance notice period.
Failure to Timely Report Alleged Abuse to State Agency
Penalty
Summary
The facility failed to report an allegation of abuse to the State Agency within the required two-hour timeframe for one resident diagnosed with dementia and agitation. On the day of the incident, a CNA was physically struck by the resident, after which the resident alleged that the CNA had abused them first. The LPN assessed the resident and reported the allegation to facility management, but no staff initiated an investigation or ruled out the allegation within the mandated timeframe. The State Agency did not receive the facility's report of the abuse allegation until several hours after the incident, exceeding the required reporting window.
Failure to Thoroughly Investigate Abuse Allegation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse involving a resident with dementia and agitation who had a care plan indicating a history of verbal and physical behaviors toward staff, requiring care to be provided in pairs. On the date of the incident, a CNA was physically struck multiple times by the resident during care. Shortly after, the resident admitted to hitting and kicking the CNA but also alleged that the CNA had abused them first. The LPN on duty notified facility management of the abuse allegation. The facility's investigation into the incident was incomplete, lacking staff witness statements, investigation notes, and a summary of the incident. Both the Director of Nursing Services and the Regional Director of Clinical later confirmed that the investigation was not thorough or complete. The documentation did not provide sufficient detail or evidence to demonstrate that the allegation of abuse was appropriately investigated.
Failure to Provide Sufficient Nursing Staff Resulting in Delayed Care and Unmet Resident Needs
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of all residents, as evidenced by multiple observations, interviews, and record reviews. On several occasions, residents experienced long call light response times, with documented waits of up to 33 minutes for assistance with basic needs such as toileting and receiving water. Family members and residents reported delays in medication administration, missed meals, and untimely incontinence care. Staff interviews confirmed ongoing shortages of CNAs, CMAs, and nurses, particularly on night and weekend shifts, resulting in incomplete care tasks such as showers, vital signs, and restorative care. Staff also reported that assignments were not made timely, residents were not divided evenly, and inexperienced staff were orienting each other. Public complaints submitted to the State Agency corroborated these findings, with allegations of untimely toileting assistance, long call light response times, and inaccurate reporting of CNA hours. Facility records showed that state minimum staffing ratios for CNAs were not met on 46 out of 115 days reviewed. Staff responsible for scheduling indicated that staffing decisions were based on minimum state requirements, and upper management determined when additional staff were needed based on acuity. However, there was acknowledgment from both staff and administration of ongoing staffing challenges and frequent call-ins, especially on weekends. One resident, admitted with a history of repeated falls and depression, required substantial assistance with transfers and toileting. This resident filed a grievance regarding insufficient night shift staffing and long call light response times, which was substantiated by facility records showing a CNA shortage on the reported date. The Director of Nursing Services stated she was not involved in staffing assessments, and the administrator confirmed that no facility assessment for staffing levels based on resident acuity was available.
Failure to Ensure Effective Administration, Sufficient Staffing, and Timely Medication Administration
Penalty
Summary
Facility administration failed to use resources effectively and efficiently, resulting in insufficient staffing, lack of a comprehensive facility assessment, and significant medication errors. Observations over multiple days revealed delayed responses to call lights, staff appearing rushed, and residents waiting for assistance, leading to resident frustration. Facility documentation and interviews with residents and staff confirmed ongoing concerns about inadequate staffing, with reports of staffing levels below state minimums and not adjusted for resident acuity. Staff reported these issues to administration, but no changes were made, and the facility assessment did not accurately address staffing needs or the high use of agency staff. Additionally, a resident with epilepsy did not receive scheduled seizure medication on time, with a dose administered over two hours late. Subsequently, the resident experienced an active seizure and was sent to the hospital. The DNS became aware of the incident only after a family member raised concerns, and no incident report was completed, nor was the responsible LPN interviewed about the event. These failures contributed to the facility not attaining or maintaining the highest practicable well-being of residents.
Incomplete Facility Assessment for Staffing and Acuity
Penalty
Summary
The facility failed to conduct and complete a comprehensive facility-wide assessment to determine the necessary resources for competent resident care during both routine operations and emergencies. Review of the facility assessment dated 3/24/25 revealed it was not comprehensive and did not accurately include information on how the assessment was used to address staffing needs or resident acuity, nor did it reflect the high usage of agency staff. During an interview, the Administrator acknowledged that the assessment lacked accurate and comprehensive information related to staffing. No additional information was provided to address these deficiencies.
Failure to Notify Responsible Party of Resident's Change in Condition
Penalty
Summary
The facility failed to notify a resident's responsible party of a significant change in condition for one resident who was admitted with diagnoses including epilepsy and dementia. According to the clinical record, the resident experienced an active seizure and was subsequently sent to the hospital by emergency services. Documentation showed that the on-call staff and the administrator were notified, but there was no evidence that the resident's emergency contact, a family member, was informed of the seizure or hospitalization. The family member later confirmed that she was unaware of the incident until contacted by hospital staff. Facility leadership acknowledged that the emergency contact was not notified regarding the resident's change in condition and hospitalization.
Significant Medication Error Leads to Resident Seizures and Hospitalization
Penalty
Summary
A deficiency occurred when a resident with epilepsy and dementia did not receive prescribed anti-seizure medications (levetiracetam, lamotrigine, and zonisamide) at the scheduled time. The physician's order required these medications to be administered twice daily at 8:00 AM and 8:00 PM. On one occasion, an LPN administered the medications significantly late, at approximately 10:30 PM, and did not document the administration until 11:47 PM. Prior to this incident, the resident had no recorded seizures in the facility. Following the late administration, the resident experienced multiple seizures, including one lasting about ten minutes, and was subsequently sent to the hospital via ambulance. The DNS became aware of the incident after a family member raised concerns about the timing of medication administration. The DNS confirmed that timely administration of anti-seizure medications is important and noted that the facility was not conducting routine lab monitoring for levetiracetam levels. No incident report was completed, and the DNS did not discuss the event with the LPN involved.
Failure to Accurately Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post accurate and complete nurse staffing information as required, as evidenced by a review of Direct Care Staff Daily Reports from June 2025 through September 23, 2025. On 47 separate days, portions of the required staffing forms were either left blank or contained inaccurate information, including the daily census, the number of working staff, and staff hours worked. This deficiency was confirmed during an interview with the Administrator, who acknowledged the incomplete and inaccurate reports for the identified dates.
Failure to Implement and Enforce C-Diff Infection Control Precautions
Penalty
Summary
The facility failed to identify, assess, treat, and implement appropriate contact precautions for residents exhibiting symptoms of Clostridioides difficile (c-diff), as well as failed to ensure staff followed proper infection control practices. Multiple residents with persistent loose stools and diarrhea were not assessed in a timely manner, and there was no evidence that physicians were contacted regarding these symptoms. In several cases, residents were only diagnosed with c-diff after being sent to the hospital, despite ongoing symptoms documented in their records. Staff were observed not following required infection control protocols for c-diff, including not washing hands with soap and water after providing care to affected residents. Instead, staff frequently used alcohol-based hand rubs (ABHR), which is not the recommended practice for c-diff. Some staff members were unclear about the correct hand hygiene procedures, and others cited being too busy to follow proper protocols. Contact precaution signage was present, but staff either misunderstood or did not adhere to the requirements, leading to potential cross-contamination between residents and clean areas such as linen closets. Interviews with staff and review of records revealed a lack of consistent assessment and communication regarding residents with repeated loose stools. The Director of Nursing Services (DNS) acknowledged that staff were not following appropriate infection control practices and that there were concerns about staff understanding and compliance with c-diff precautions. These failures resulted in an Immediate Jeopardy situation, as determined by surveyors, due to the risk of exposure and spread of c-diff among all residents.
Removal Plan
- Identify and assess residents with suspected c-diff. Place affected residents on contact precautions with appropriate signage and review by a physician.
- Sanitize or remove shared equipment from use by affected residents.
- Monitor affected residents.
- Inservice staff on c-diff precautions and infection control practices.
- Inservice oncoming staff prior to their shift.
- Inservice nurses on assessing residents with signs and symptoms of c-diff.
- Conduct PPE competency testing.
- Conduct infection control audits and monitoring.
- Report to QAPI.
- Governing body review.
- Retrain and discipline non-compliant staff members.
Insufficient Staffing Resulting in Delayed Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the care needs of residents across all three halls reviewed, resulting in delayed and unmet care needs. Direct Care Staff Daily Reports showed that the facility did not meet state minimum CNA staffing requirements on multiple dates over two separate periods. The facility assessment indicated ongoing analysis of staffing needs, but records and interviews revealed persistent shortages. Residents requiring assistance with mechanical lifts, two-person ADL support, and eating were affected, and several residents exhibited behaviors that required additional attention. Staff interviews confirmed that high acuity and inadequate staffing made it difficult to complete all required tasks, with CNAs reporting being overworked and unable to respond promptly to resident needs. Observations and interviews documented numerous instances of prolonged call-light response times, with some residents waiting over an hour for assistance. In one case, a call-light was obstructed from view, further delaying response. Family members and residents reported frequent long wait times, particularly in the evenings, and staff were observed to be visibly stressed and hurried. The scheduling coordinator acknowledged reliance on census-based staffing, use of agency and PRN staff, and efforts to fill shifts when staff called off, but the administrator confirmed ongoing staffing shortages and long call-light wait times.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to ensure that a registered nurse (RN) was present for at least eight consecutive hours per day, seven days a week, as required. Review of Direct Care Staff Daily Reports for the periods of August and September 2024, and March to April 2025, identified thirteen specific dates when there was no RN coverage. This deficiency was confirmed by the facility administrator during an interview, who acknowledged the absence of required RN coverage on the identified dates. No information was provided regarding specific residents affected, their medical history, or their condition at the time of the deficiency.
Failure to Complete Annual CNA Performance Reviews
Penalty
Summary
The facility failed to complete annual performance reviews for four sampled certified nurse aides (CNAs) who were reviewed for sufficient and competent nurse staffing. The Administrator and Regional RN were unable to provide documentation of annual performance reviews for these CNAs, despite requests for records and hire dates. This deficiency was identified through interviews and record reviews, which confirmed that the required evaluations had not been conducted for the identified staff members.
Failure to Obtain Informed Consent Prior to Psychotropic Medication Administration
Penalty
Summary
The facility failed to obtain informed consent prior to administering psychotropic medications to a resident admitted with major depressive disorder. Physician orders for bupropion and desvenlafaxine were initiated, and the resident received these medications daily as documented in the medication administration records. However, the signed consents outlining the risks and benefits of these medications were not obtained until several weeks after administration had begun. This was confirmed by review of the medical record and acknowledged by the Director of Nursing Services.
Failure to Assess Resident for Self-Administration of Medications
Penalty
Summary
A deficiency occurred when the facility failed to assess a resident for self-administration of medications as required by its policy. The resident, who was admitted with a left arm and left lower leg fracture following a motor vehicle accident and was documented as cognitively intact, had several bottles of vitamins and eye drops on the bedside table. The resident reported that these items were brought in by family and had been self-administered for several weeks without staff intervention or assessment. Despite the facility's policy requiring an interdisciplinary team assessment and documentation before allowing self-administration of medications, no such evaluation was found in the resident's clinical record. Staff confirmed that the resident had been in possession of and using these medications without the required assessment or physician order. The deficiency was identified through observation, interview, and record review, with staff acknowledging the oversight in not completing the necessary evaluation.
Failure to Administer Bowel Care and Follow Physician Orders
Penalty
Summary
The facility failed to administer bowel care medication and follow physician orders for bowel management for one resident with severe cognitive impairment and diagnoses including dementia and multiple sclerosis. The facility's constipation protocol required specific interventions and physician notification if more than four days passed without a bowel movement. However, the resident experienced two separate periods of extended constipation—one lasting seven days and another lasting five days—without consistent administration of prescribed bowel care medications or documentation that the physician was notified as required. Review of the medication administration records showed that the resident received a Dulcolax suppository only after seven days without a bowel movement, and there was no evidence of bowel care medication being given during the second episode. Additionally, there was no documentation of monitoring, implementation of the bowel protocol, or physician notification for either occurrence. Interviews with nursing staff confirmed that the protocol was supposed to be followed, but no evidence was provided to show that it was implemented for this resident.
Failure to Provide Follow-Up for Cataract Surgery Recommendation
Penalty
Summary
The facility failed to ensure that a resident received appropriate follow-up for vision treatment and services as recommended by an eye care professional. The resident, who had a history of diabetes and was diagnosed with bilateral age-related cataracts, was advised to undergo cataract surgery according to an eye exam summary. However, there was no documentation that the facility scheduled or followed up on the recommended surgery. The resident, who was cognitively intact, reported that their vision was poor and that no one had discussed the surgery with them since the initial recommendation. Staff interviews revealed that the responsibility for scheduling follow-up visits typically fell to the unit manager, but due to staff turnover and the absence of a unit manager, the follow-up was not completed.
Failure to Complete and Document Post-Dialysis Assessments
Penalty
Summary
A resident with end-stage renal disease and dependent on dialysis was admitted to the facility and had physician orders specifying dialysis treatments three times weekly, with a requirement for post-dialysis assessments upon return to the facility. The resident's medical record review showed that the last documented post-dialysis assessment was completed on 3/24/25, with no evidence of assessments on thirteen subsequent dialysis dates. The resident confirmed that nursing staff did not assess them after returning from dialysis. Interviews with staff revealed that the agency RN reviewed paperwork and entered new orders upon the resident's return from dialysis but did not consistently document or perform post-dialysis assessments. The LPN Unit Manager acknowledged the lack of documentation for the required assessments and stated that nursing staff were expected to assess the resident, including the dialysis access site, and document these findings after each dialysis session.
Failure to Provide Timely Pharmaceutical Services for Pain Management
Penalty
Summary
The facility failed to provide timely pharmaceutical services for a resident admitted with a right ankle fracture and oral thrush, who had an order for Magic Mouthwash to be administered four times daily for throat pain. According to the medication administration record, the mouthwash was not available from 4/10/25 to 4/23/25, and the resident did not recall receiving it during this period. An agency LPN reported contacting both the pharmacy and the provider on two occasions to notify them that the medication was unavailable. The facility pharmacist stated that the pharmacy had reached out to the facility on 4/14/25 to clarify the medication ratios needed to compound the mouthwash but did not receive a response, resulting in the medication not being delivered until 4/25/25. The Director of Nursing acknowledged that the resident did not receive the ordered medication as prescribed.
Medication Error Rate Exceeds Acceptable Threshold Due to Improper Administration
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as required by policy, resulting in a 7.69% error rate with 2 errors out of 26 observed medication administration opportunities. During medication administration, a nurse crushed and combined two medications—metoprolol tartrate and atorvastatin calcium—before administering them together via a feeding tube to a resident who was unable to swallow following a stroke. The facility's policy, dated March 2023, specified that crushed medications should not be combined for administration, whether given orally or through a feeding tube. The nurse acknowledged not being aware of this policy and administered the medications together, contrary to the physician's orders and facility protocol. The Director of Nursing confirmed that medications should be given separately with flushes between each.
Failure to Obtain Ordered Laboratory Stool Sample
Penalty
Summary
The facility failed to obtain required laboratory samples for one resident who had an active physician order for a stool sample to complete an IFOBT test for colorectal cancer screening. The resident, admitted with multiple sclerosis and slow transit constipation, had an order for the test starting in November 2024. Interviews revealed that certified nursing assistants (CNAs) were responsible for collecting stool samples when notified by the charge nurse, but one CNA did not recall being informed that a sample was needed for this resident. An LPN stated that collecting the sample was challenging due to the need for three separate samples and was unsure if the need for collection was communicated to CNAs. The LPN Unit Manager expected charge nurses to communicate such orders at the start of each shift, and the Director of Nursing Services (DNS) expected physician orders to be followed in a timely manner or the physician to be notified if not completed. Despite these expectations, the sample was not collected as ordered.
Failure to Notify Resident's Representative of Room Change
Penalty
Summary
The facility failed to notify a resident's responsible party in writing prior to a room change, as required by their Room Move Notification policy. This policy mandates that both the resident and their representative be informed in advance of a room move and receive a written explanation if the move is initiated by the facility. In this case, Resident 4, who was admitted with dementia and had a power of attorney (POA) for finances and care held by their spouse, was moved to another room after testing positive for COVID-19. However, there was no documentation indicating that the spouse, who was also the decision maker, was contacted or provided with written documentation regarding the room change. The deficiency was further highlighted when the spouse, referred to as Witness 4, confirmed not being notified of the room change, which subsequently led to conflict between Resident 4 and the new roommate. Staff 3, identified as the Social Service Director (SSD), acknowledged that the facility's protocol was not followed, as the resident's representative was neither notified nor provided with the necessary written documentation. This oversight placed the resident at risk for adjustment difficulties and delayed the responsible party's notification related to changes in room location.
Neglect of Residents in LTC Facility
Penalty
Summary
The facility failed to protect the rights of two residents, identified as Resident 17 and Resident 18, from neglect and deprivation of services. Resident 17, who had a history of dementia and a fractured femur, was found naked and covered in urine and feces on the floor of their room. Staff 7 (CNA) and Staff 8 (LPN) were responsible for the resident's care but left the resident on the floor for an extended period, citing the resident's combative behavior as the reason. The facility's investigation confirmed that the neglect occurred, as the resident was left in an undignified and unsafe condition, with a skin tear and signs of cold exposure. Resident 18, diagnosed with muscle weakness and a hip fracture, was also neglected. The resident was left unchanged for an extended period, with urine and dried feces on their body. The resident attempted to go to the bathroom without assistance due to a lack of timely response to their call light, resulting in a fall. Staff 8 failed to assess the resident's condition or document the incident, leaving the resident on the floor until the shift change. The facility's investigation substantiated the neglect by both Staff 7 and Staff 8, as the resident was left in a humiliating and unsafe condition. The facility's administration, including Staff 1 (Administrator) and Staff 2 (DNS), acknowledged the failures in providing proper incontinent care and ensuring the safety of both residents. The incidents highlighted a lack of appropriate response and care from the staff, leading to the residents being left in undignified and potentially harmful situations. The facility's investigation confirmed the neglect and the failure to adhere to professional standards of care.
Neglect of Care for Two Residents by LPN
Penalty
Summary
The facility failed to ensure that Staff 8, an LPN, adhered to professional standards of practice, resulting in the neglect of two residents. Resident 17, who had a history of dementia and falls, was found naked and covered in urine and feces on the floor of their room. Staff 8, along with Staff 7, left the resident in this condition for an extended period, citing the resident's combative behavior as the reason. Staff 8 did not assess the resident's needs or consider one-to-one care, and failed to document the incident. The resident was eventually assisted by Staff 11, who found the resident cold and with a skin tear, and administered medication to calm the resident. Resident 18, diagnosed with muscle weakness and a hip fracture, was also neglected by Staff 8 and Staff 7. The resident was left unchanged with urine and dried feces and was found on the floor in the bathroom after attempting to go to the bathroom without assistance. Staff 8 did not respond to the resident's call light in a timely manner and failed to assess or document the resident's condition after the fall. The incident report was incomplete, lacking an assessment of the resident's injuries and other necessary details. The facility's investigation substantiated the neglect of care for both residents. Staff 8 admitted to not documenting the incidents or assessing the residents, and acknowledged that leaving Resident 17 in such a condition violated professional standards of care. The facility's administration confirmed the failure to provide proper incontinent care and ensure the safety of the residents.
Failure to Monitor and Assess Pressure Ulcers
Penalty
Summary
The facility failed to adequately assess and monitor pressure ulcers for three residents, leading to a risk of worsening wounds. Resident 22, who was readmitted with diabetes and dementia, had an unstageable coccyx wound and a deep tissue injury on the right malleolus. However, the facility did not complete assessments for the right heel and failed to provide measurements or descriptions for the coccyx wound. Hospital records later revealed additional wounds on the right foot and heel, which were not monitored or treated as per the facility's records. Staff acknowledged the lack of comprehensive weekly assessments and the absence of treatment orders for certain wounds. Resident 15, admitted with dementia and later to hospice care, developed a right heel unstageable pressure ulcer, but the facility did not conduct weekly wound assessments or monitoring from June to September. Similarly, Resident 13, with diabetes and a Stage 4 sacral pressure ulcer, had inconsistent and incomplete wound assessments. The facility failed to provide detailed wound characteristics or measurements, and assessments were not conducted regularly. Staff confirmed the lack of consistent monitoring for Resident 13's pressure ulcer.
Latest citations in Oregon
A resident with acute respiratory failure and heart failure had a documented Full Code status and a POLST specifying Attempt Resuscitation/CPR and Full Treatment. During night rounds, two CNAs found the resident not breathing, cool to the touch, with yellow skin and no pulse, but did not initiate CPR or call a code blue, instead going to notify an LPN. The LPN assessed the resident, confirmed absence of vital signs, noted the body was cold with mottling and no rigor mortis, and contacted the DNS, physician, and 911 for the coroner’s number, but did not start CPR or activate a code blue. No lifesaving measures were attempted despite facility policy requiring CPR for unresponsive residents without a valid DNR and the resident’s clearly documented full code status, leading surveyors to cite Immediate Jeopardy and substandard quality of care.
A resident with respiratory failure and pneumonia, who was Full Code and not on hospice, was found during routine rounds and suspected to be deceased. Nursing staff assessed the resident, noted there was no rigor mortis, confirmed death, and did not initiate a code blue or any resuscitation efforts despite the resident’s Full Code status. The facility later treated this as a potential neglect incident but did not report it to the State Agency within the required two-hour timeframe, as confirmed by the regional QA director.
A resident with chronic pain and a left below-knee amputation, who required supervision or touching assistance with ADLs, was discharged after returning from an outing shortly after midnight. Although discharge instructions noted the need for assistance and assistive devices, there was no documentation of referrals for medical equipment or home health services. Facility staff documented that the resident was discharged because they were out past midnight and believed Medicare would not cover the stay, did not issue a NOMNC, and recorded the discharge as voluntary despite the resident later reporting they had been “kicked out” and were sleeping on a friend’s couch with difficulty getting around. Staff interviews revealed no financial issues and indicated the resident had originally been scheduled for discharge at a later date.
A resident with a hip fracture and anxiety reported to social services that a CNA had been rough, told the resident to take themself to the bathroom, and instructed them not to get out of bed until a specified early morning time. The allegation was received by facility staff in the late afternoon, but the incident report was not submitted to the State Agency until the following day, exceeding the required 2-hour reporting timeframe acknowledged by the DNS. The deficiency concerns this untimely reporting of an abuse allegation, despite the CNA’s denial of any abuse.
A resident with hemiplegia, previously evaluated as not appropriate to self-administer any medications, was found to have open tubes of antifungal cream, anti-itch cream, hydrocortisone cream, and a medicated pain roll-on (DMSO) stored in a bedside drawer. Record review showed there were no MD orders for several of these topical products and no order permitting self-administration. An RN case manager confirmed the absence of orders, and the resident reported self-administering the medications, demonstrating a failure to ensure medications were administered only as ordered and in accordance with the resident’s assessed ability.
A resident with hemiplegia, previously evaluated as not appropriate to self-administer medications, was found with open containers of anti-itch cream, hydrocortisone cream, and a medicated pain roll-on (DMSO) in a bedside drawer. Record review showed no MD orders, no documented indication for use, and no monitoring for these medications. An RN case manager confirmed there were no orders and that staff did not administer or monitor the creams, while the resident reported self-administering them.
The facility failed to investigate multiple staff-reported allegations that one cognitively intact, wheelchair-using resident engaged in sexually inappropriate behaviors toward three other residents with significant cognitive and neurological impairments. Staff reported finding a resident with a ripped brief, crying and resisting care, and suspected sexual contact; they also reported that the alleged aggressor tried to take another resident into a shower room for sexual acts, attempted to video and kiss that resident, and encouraged a third resident to remove their top while present with a phone. CNAs, social services, and other staff stated they informed the administrator, DNS, HR, and unit management about these incidents and behaviors, but the administrator acknowledged that no investigations were conducted, despite being aware of the reports.
A resident with multiple sclerosis, care planned as dependent on two staff and requiring a Hoyer lift for transfers, was instead transferred by a CNA using a stand-pivot method without the lift or a second staff member. The CNA reported she had not read the resident’s care plan and described performing the transfer by giving the resident a “giant bear hug” and making several attempts to move the resident from chair to bed. The resident reported right flank pain and stated the transfer caused three broken ribs, although an x-ray later showed no rib fractures or dislocation and no visible injury was noted.
A resident with multiple sclerosis was admitted with physician orders for PT and OT, but review of the clinical record showed no documentation that these therapies were ever provided. The resident reported not receiving any therapy since admission, and the Director of Rehabilitation confirmed that no therapy services had been delivered during this period despite active orders, resulting in a failure to provide ordered rehabilitative services.
A dependent resident with dementia and a history of stroke, identified on the MDS as requiring staff assistance for showers, did not consistently receive scheduled bathing, and one CNA falsely documented that bathing had been provided. CNA task reports showed missed or undocumented baths on scheduled days, and an internal investigation confirmed that a bath recorded as completed on one date had not actually occurred. Staff interviews indicated that if bathing was not documented it usually did not occur, and that scheduled bathing was expected to be provided by staff.
Failure to Initiate CPR for a Full Code Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide CPR in accordance with a resident’s documented full code status. The facility’s Emergency Procedure CPR policy, initiated in 2001, required staff trained in CPR to initiate resuscitation on unresponsive residents who were not breathing unless there was a valid DNR order or clear signs of irreversible death such as rigor mortis. The policy further specified that if a resident’s DNR status was unclear, CPR should be started and continued until a DNR was confirmed. Resident 3 had been admitted with diagnoses including acute respiratory failure and heart failure and had a care plan and POLST on file indicating Full Code/Attempt Resuscitation and Full Treatment, including use of intubation, advanced airway interventions, mechanical ventilation, and transfer to hospital or ICU if indicated. On the night of the incident, a CNA (Staff 5) documented last vital signs for the resident at approximately 10:45 PM, with oxygen saturation of 92% on one liter of oxygen. At 2:00 AM, the resident was observed sleeping, breathing, and with a dry brief. Around 4:00 AM, Staff 5 and another CNA (Staff 8) entered the resident’s room and observed that the resident was not breathing, had yellow skin color, was cool to the touch, and had no palpable pulse. Both CNAs concluded the resident was deceased and went to notify the LPN (Staff 4) instead of initiating CPR or calling a code blue, despite having recent CPR training and later stating that, in retrospect, they would have started CPR and called for a code blue. When Staff 4 (LPN) entered the room, she assessed the resident and found no pulse, blood pressure, or respirations, noted the body was cold, with some mottling on the lower legs, pale/yellowish skin color, and no rigor mortis. Staff 4 did not initiate a code blue or CPR and instead contacted the DNS (Staff 2) and the physician, and then called 911 to obtain the coroner’s phone number. No lifesaving measures were attempted by any staff, despite the resident’s documented full code status and the facility policy requiring CPR in the absence of a valid DNR or signs of irreversible death. The DNS later stated she expected staff to call a code blue immediately, start CPR, call 911, and verify the resident’s code status. Surveyors determined that the facility failed to provide CPR according to the resident’s code status, placing all residents with full code status at risk and constituting substandard quality of care, with the noncompliance cited as Immediate Jeopardy and Past Noncompliance.
Removal Plan
- Administrator, DNS and nursing staff would be re-educated on the code blue process, how to locate a resident's code status in PCC and the POLST on file, and the importance of following individual resident care plans and orders.
- Resident code status would be cross-referenced with the PCC order, POLST scanned in binder, care plan, and resident dashboard.
- DNS or designee would monitor resident code status preferences for new admissions/returning admissions from hospitalizations.
- DNS or designee would audit code status for all new admissions and readmissions from hospitalization or ED visits, and share audit results with the QAPI committee to ensure substantial compliance is maintained.
- DNS or designee would complete a mock code.
- DNS or designee would complete mock codes.
Failure to Timely Report Alleged Neglect Involving Lack of CPR for Full Code Resident
Penalty
Summary
The facility failed to timely report an allegation of potential neglect related to CPR to the State Agency for one resident. The resident was admitted in February 2026 with diagnoses including respiratory failure and pneumonia and had a Full Code status, was not on hospice, and therefore was to receive CPR if found unresponsive. According to the facility’s investigation dated six days after the resident’s death, staff found the resident during routine rounds and suspected the resident was deceased, notified the nurse, and the nurse confirmed the resident was deceased. The investigation documented that at the time of the nurse’s assessment the resident did not have rigor mortis, yet the nurse did not initiate a code blue or any resuscitation interventions despite the Full Code status. The incident, which occurred on an identified date, was not reported to the State Agency until a later identified date, and the Regional Director of Quality Assurance confirmed that the facility did not report the incident within the required two-hour timeline. This failure to timely report the allegation of potential neglect involving the lack of CPR initiation for a Full Code resident constituted the deficiency identified by surveyors.
Failure to Ensure Safe and Orderly Discharge After Late Return from Outing
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe and orderly discharge for a resident who was admitted with chronic pain, a left below-knee amputation, and post-surgical aftercare needs. An admission MDS completed shortly after admission documented that the resident was cognitively intact but required supervision or touching assistance with toileting, transfers, and bathing. Discharge instructions indicated the resident was being discharged home and that the resident’s current physical status required assistance and assistive devices, yet there was no documentation of referrals for needed medical equipment or a home health referral. The facility’s records did not show that these services or equipment were arranged prior to discharge. On the night in question, a nursing note documented that the resident returned to the facility after an outing at 12:23 AM, after the facility had notified the police because the resident’s location was unknown. The resident reported having been out with friends and being unaware of any concern. A social services note stated that because the resident was out past midnight, the resident was discharged from the facility, and a NOMNC was not issued because the resident left prior to the scheduled discharge and on their own initiative. A discharge summary documented that discharge instructions were reviewed with the resident, who refused to sign and was leaving voluntarily, and the voluntary consent form included a handwritten statement that the resident refused to sign. Later, the resident stated they had been “kicked out” for coming back late and were sleeping on a friend’s couch, finding it difficult to get around. Staff interviews showed there were no financial issues documented, that staff believed Medicare would not cover the resident if out past midnight, and that the resident had been scheduled for discharge several days later, while a regional director later characterized the situation as a clerical error and confirmed a normal discharge should have been completed.
Failure to Timely Report Alleged Abuse to State Agency
Penalty
Summary
The facility failed to timely report an allegation of abuse to the State Agency after a resident reported that a CNA had been rough and verbally directive with them. The resident, who had been admitted with diagnoses including a hip fracture and anxiety, stated that the CNA was “kind of rough,” told the resident to take themself to the bathroom, and instructed the resident not to get out of bed until 6:00 AM. The resident reported this allegation of abuse involving the CNA to the social services staff member at 4:00 PM on 1/29/26. According to the facility’s investigation documentation, the allegation was received by staff at 4:00 PM on 1/29/26, and the Facility Reported Incident form was not received by the State Agency until 2:13 PM on 1/30/26. The DNS acknowledged that the facility became aware of the allegation at 4:00 PM on 1/29/26 and that it should have been reported to the State Agency within two hours but was not. The CNA denied abusing the resident or any resident, but the deficiency centers on the delay in reporting the allegation to the State Agency within the required timeframe.
Failure to Prevent Unauthorized Self-Administration of Non-Prescribed Medications
Penalty
Summary
Surveyors identified that a resident was self-administering non-prescribed topical medications despite a documented determination that they were not appropriate to self-administer any medications. The resident, admitted with hemiplegia, had a Self-Medication Administration Evaluation dated 11/13/25 indicating they were not appropriate to self-administer medications. During an observation on 3/19/26 at 7:50 AM with a RN case manager, open tubes of antifungal cream, anti-itch cream, hydrocortisone cream, and a medicated pain roll-on (DMSO) were found in the resident’s bedside table drawer. Review of the clinical record showed there were no physician orders for the anti-itch cream, hydrocortisone cream, or DMSO, and the resident did not have an order to self-administer any medications. The RN case manager confirmed the lack of orders for these medications, and at 8:10 AM the resident stated they did self-administer the medications found in their room. This constituted a failure by the facility to ensure the resident did not self-administer non-prescribed medications and to provide treatment and care according to physician orders and the resident’s evaluated ability to self-administer medications.
Unmonitored Self-Administration of Topical Medications Without Physician Orders
Penalty
Summary
The facility failed to ensure a resident’s drug regimen was free from unnecessary drugs by not providing adequate monitoring, indication for use, or physician orders for multiple medications. A resident admitted with hemiplegia in May 2024 had a self-medication administration evaluation dated 11/13/25 indicating they were not appropriate to self-administer any medications. During an observation on 3/19/26, an RN case manager found an open tube of anti-itch cream, hydrocortisone cream, and a medicated pain roll-on (DMSO) in the resident’s bedside table drawer. Record review showed no physician orders, no documented indication for use, and no monitoring for these medications. The RN case manager confirmed the resident did not have orders for the anti-itch cream, hydrocortisone cream, or DMSO, and that staff did not administer or monitor these medications. The resident stated they self-administered the medications found in their room, despite the prior evaluation determining they were not appropriate to self-administer any medications.
Failure to Investigate Multiple Allegations of Sexual Abuse
Penalty
Summary
The deficiency involves the facility’s failure to investigate multiple allegations of sexual abuse involving three residents. Resident 102, who had cognitive loss equivalent to a young child, legal blindness, and was non-verbal, was reportedly found with a ripped brief, crying, and resisting a brief change. Staff reported concerns that another resident, Resident 105, had performed or attempted to perform sexual acts on Resident 102. Staff members, including CNAs and social services, stated they informed facility management, including the Administrator and DNS, about the torn brief, Resident 102’s distress, and concerns that Resident 105 was being sexually inappropriate with multiple residents. Despite these reports and discussions in morning meetings, the Administrator acknowledged that no investigation was completed, believing the incident was based on staff assumptions. The facility also failed to investigate allegations involving Resident 103, who had Alzheimer’s disease and Parkinson’s disease. Staff reported that Resident 105 attempted to take Resident 103 into a shower room to perform sexual acts, and that a staff member intervened. The complainant later spoke with Resident 103, who stated that Resident 105 was “sick” and made bad comments. Other staff reported to human resources, the DNS, and the Administrator that Resident 105 attempted to take a resident into a shower room to unclothe the resident, and that Resident 105 attempted to video Resident 103, expressed a desire to kiss Resident 103, and get the resident into a shower room. The Social Service Director confirmed she reported these concerns to the Administrator, who stated he was aware of the incident but that no investigation was completed. A third failure to investigate involved Resident 108, who had Huntington’s disease and dementia. A staff member reported observing Resident 105 telling Resident 108 to take off their shirt and gesturing for them to do so, and stated they completed a written statement and gave it to the unit manager. Another CNA reported hearing that Resident 105 and other residents were laughing and encouraging Resident 108 to remove their top, and also reported observing Resident 105 rubbing other residents’ backs more physically than appropriate. Social services reported being told that Resident 108 was removing their top while Resident 105 was in the dining room with a phone, and that Resident 105 admitted to the behavior but described it as innocent. The Administrator stated he was aware of Resident 108 removing their shirt while Resident 105 was present, yet confirmed that no investigation was completed for this incident. These failures to investigate led surveyors to determine that the facility did not respond appropriately to alleged violations of sexual abuse for the three residents.
Removal Plan
- Residents 102, 103, and 108 received head-to-toe skin assessments completed by RCMs with no observed findings.
- Resident 105 was placed on one-to-one observations pending investigations.
- Staff 1 (Administrator) and Staff 2 (DNS) were re-educated on the facility's abuse policy, reporting, and thorough investigations.
- Social Services will interview all interviewable residents regarding abuse.
- Nurses will complete a head-to-toe assessment on all non-interviewable residents.
- All staff, including agency staff, will be re-educated on the facility's abuse policy and reporting.
Failure to Follow Care-Planned Hoyer Lift Transfer Requirements
Penalty
Summary
The deficiency involves the facility’s failure to follow a resident’s care plan interventions for transfers, resulting in a transfer being performed without required equipment and assistance. A resident admitted in February 2026 with multiple sclerosis had a 2/25/26 ADL care plan indicating the resident was dependent on two staff members for transfers and required use of a Hoyer (mechanical) lift. Despite this, on 2/28/26 a CNA (Staff 3) performed a stand-pivot transfer without the Hoyer lift and without a second staff member. The resident later reported that Staff 3 gave a “giant bear hug” and made several attempts to transfer the resident from chair to bed, after which the resident reported right flank pain and stated the transfer caused three broken ribs. An x-ray on 3/10/26 showed no rib fractures or dislocation, and the resident was assessed to have no visible injury. During interview, Staff 3 confirmed she had completed a stand-pivot transfer with the resident and acknowledged she had not read the resident’s care plan, and the Administrator confirmed that the resident had been care planned for a two-person Hoyer lift transfer at the time of the incident.
Failure to Provide Ordered Rehabilitative Services
Penalty
Summary
The facility failed to provide ordered rehabilitative services to a resident with multiple sclerosis. The resident was admitted in February 2026 with admission orders dated 2/24/26 for both physical therapy and occupational therapy. Review of the resident’s clinical record showed no documented evidence that any therapy services were provided as ordered. In an interview on 3/11/26 at 10:58 AM, the resident reported not having received any therapy since admission. During a separate interview on 3/11/26 at 10:40 AM, the Director of Rehabilitation confirmed that the resident had not received any therapy services from the date of admission through 3/11/26, despite the existing orders for physical and occupational therapy. This failure to implement the physician’s orders for rehabilitative services for this resident placed the resident at risk for a decline in range of motion.
Failure to Provide and Accurately Document Scheduled Bathing for a Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a dependent resident received required assistance with activities of daily living (ADLs), specifically bathing, and inaccurate documentation that bathing had been provided. The resident, admitted in 10/2025 with dementia and stroke, had a 10/21/25 admission MDS indicating severe cognitive impairment and dependence on staff for showers. The facility’s 12/2025 CNA task report showed the resident was scheduled for bathing on day shift on Wednesdays and Sundays. On 12/24/25, the task report was blank for bathing, and on 12/28/25, the report documented that the resident received bathing and was dependent on staff for assistance. However, a 12/29/25 facility investigation determined the resident did not receive a bath on 12/28/25 and that it had been falsely documented that bathing occurred. A Facility Reported Incident form dated 12/31/25 further documented that on 12/28/25, a CNA (Staff 5) noted providing bathing to the resident but did not provide any type of bathing. Additional record review showed that the resident’s 3/2026 CNA task report contained no documentation that any type of bathing was provided on 3/11/26. Attempts to contact Staff 5 on 3/16/26 and 3/17/26 were unsuccessful. During interviews, another CNA (Staff 7) stated that on 12/28/25 she observed Staff 5 lay the resident down and, when she asked about bathing, Staff 5 said she would complete the resident’s bathing in the evening; Staff 7 stated she could not perform the resident’s bathing in the evening because she moved to a different hall on evening shift. Another CNA (Staff 21) stated that usually if bathing was not documented in the resident’s record, bathing did not occur. The Regional Nurse (Staff 31) stated that staff should provide scheduled bathing to residents.
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