Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
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.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 224 citations issued within 25 miles in the last 12 months — including the 4 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Woodburn
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Mt Angel Health And Rehabilitation | 6.9 mi | ★★★★★ | 9 | 0 |
| Marquis Newberg | 11.1 mi | ★★★★★ | 6 | 0 |
| Marquis Wilsonville Post Acute Rehab | 11.6 mi | ★★★★★ | 3 | 0 |
| Marquis Hope Village | 11.6 mi | ★★★★★ | 0 | 0 |
| Chehalem Post Acute | 11.6 mi | ★★★★★ | 3 | 0 |
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