Village Health Care
VILLAGE HEALTH CARE in GRESHAM, OR — inspection on November 21, 2025.
Found 1 citation. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Based on interview and record review, it was determined the facility failed to re-evaluate preventative interventions in the presence of new pressure ulcers for 1 of 3 (#1) sampled residents reviewed for skin issues.
This placed residents at risk for developing new pressure ulcers.
Findings include:Resident 1 admitted to the facility in 4/2024, with diagnoses including hemiplegia and hemiparesis following cerebral infarction.Resident 1 no longer resided in the facility and could not be observed or interviewed.Resident 1's 4/21/25 care plan revealed Resident 1 had potential impairment to skin integrity related to history of CVA (stroke) with left sided deficits/neglect, impaired mobility, poor insight to limitations, incontinence, history of weight loss and other comorbidities.
Interventions included avoid scratching, keep body parts from excessive moisture, keep fingernails short, follow facility protocols for treatment of injury, identify and document potential causative factors and eliminate/resolve where possible, off load when in bed, frequent repositioning while in wheelchair and clean after each incontinence episode. Resident 1's 6/12/25 Weekly Skin Audit revealed Resident 1 developed a small, superficial open area on his/her left buttock.Resident 1's 8/29/25 Weekly Skin Audit revealed Resident 1 developed moisture-associated skin damage to his/her coccyx.Resident 1's 9/12/25 Weekly Skin Audit revealed Resident 1 developed un unstageable pressure wound to his/her heel.A review of Resident 1's clinical record found no documented evidence that the facility re-evaluated resident's current care plan interventions to ensure the effectiveness of her/his interventions to prevent additional pressure ulcers.On 10/30/25 at 10:09 AM, Staff 13 (RN) stated weekly skin audits are completed on a shower day and a nurse looks over the resident's skin from head to toe.
Staff stated she recommended a pressure reducing air mattress at some point and notified the RCM and DNS of this recommendation but did not document it.
She stated on 8/29/25 she contacted Resident 1's provider about the new skin issue on his/her coccyx but did not work with Resident 1 again and did not follow up for a recommendation. On 11/3/25 at 8:58 AM, Staff 16 (LPN/Resident Care Manager) stated when a resident had skin breakdown, additional interventions should be implemented but were not for Resident 1. On 11/3/25 at 10:11 AM, Staff 2 (DNS) stated additional interventions should have been developed and implemented to prevent Resident 1's skin breakdown.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.
For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
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