Village Health Care
Inspection Findings
F-Tag F0686
F 0686
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Level of Harm - Minimal harm or potential for actual harm
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.
Residents Affected - Few
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.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99) Previous Versions Obsolete
Facility ID:
If continuation sheet
Event ID:
VILLAGE HEALTH CARE in GRESHAM, OR inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in GRESHAM, OR, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from VILLAGE HEALTH CARE or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.