Village Health Care

could access their closets independently for 1 of 1 sampled residents (#23) reviewed for

Findings include: Resident 23 was admitted to the facility in 12/2025 with diagnoses of right and left knee replacements and difficulty walking. Resident 23's quarterly MDS dated [DATE] identified the resident as having intact cognitive function, used a walker and wheelchair for mobility, and required set up and supervision with transfers and walking. A care plan dated 4/1/26 revealed Resident 23 utilized a wheelchair and required one person assistance with walking.

Observations of Resident 23's room on 6/1/26 at 10:48 AM. 6/3/26 at 9:45 AM, and 6/4/26 at 3:02 PM revealed Resident 23 and the roommate's beds were positioned directly facing each other.

Each bed was centered on its assigned wall beneath the overbed light.

The headboards were pushed against the walls, and the footboards were approximately 20 to 24 inches apart from the other.

The closets were located in the corner on the far wall. On 6/3/24 at 9:45 AM Resident 23 was observed attempting to maneuver her/his wheelchair between the two beds but the wheels caught against the foot boards preventing Resident 23 to access her/his closet.On 6/1/26 at 10:48 AM Resident 23 stated she/he could not access her/his closet when in her/his wheelchair because the wheels would become caught on the foot boards of the two beds because they were too close. Resident 23 stated she/he was not supposed to walk on her/his own yet but she/he did not want to have to ask staff and instead would hold onto the footboard to walk to the closet or use the bed remote to raise the bed all the way up to make more room for the wheelchair to fit between the two beds when attempting to get to her/his closet. Resident 23 stated staff were notified multiple times she/he could not access her/his closet, but no changes were made to the room. On 6/3/26 at 9:14 AM Staff 16 (CNA) stated Resident 23 only accessed her/his closet in the morning by transferring out of bed on the closet side of the bed and did not go to the closet after that to his knowledge.

Staff 16 stated Resident 23 was independent with walking and thought she/he could probably get through the space between the beds if she/he wanted to.On 6/4/26 at 9:55 AM Staff 17 (CNA) stated Resident 23 was independent with walking in her/his room but also used a wheelchair.

Staff 17 stated Resident 23's wheelchair did not fit between the two beds, so the resident would lock her/his wheelchair and walked on her/his own to access the closet.

Staff 17 confirmed she was not aware Resident 23 was not yet cleared to walk unassisted and had not reported the wheelchair could not fit between the beds. On 6/4/26 at 10:09 AM Staff 20 (RN) stated he did know if Resident 23 had difficulty accessing her/his closet.On 6/4/26 at 3:02 PM Staff 1 (Administrator) and Staff 18 (Maintenance Director) entered Resident 23's room and confirmed the footboards were too close together and a wheelchair would not fit between them.

Staff 1 stated he felt the current layout of Resident 23's room would not meet the required minimum square footage around beds and Resident 23 should not have been required to put her/himself at risk of falling to access her/his closet.

385068 06/05/2026

Village Health Care 3955 SE 182nd Avenue Gresham, OR 97030

bed-hold policies.

bed-hold notice at the time of hospital transfer for 1 of 1 resident (#76), provide residents with the

Long-Term Care Ombudsman for 2 of 3 residents (#s76 and 78) reviewed for hospitalization and discharge.

This placed residents at risk for lack of being informed, financial responsibilities and Ombudsman advocacy.

Findings include: The facility's 5/2025 Bed Hold Policy indicated: The resident and/or representative is informed of the Bed Hold Policy in writing upon admission, transfer, or leave of absence.

Upon transfer or discharge, the nursing department provides the resident and/or resident representative with a copy of the Notice of Bed Hold Policy.

The facility's 5/2025 Transfer and Discharge Policy indicated: The facility sends a copy of the notice to the State Long-Term Ombudsman.1. Resident 76 was admitted in 4/2026 with diagnoses including streptococcal infection (bacterial infection) and respiratory failure.Resident 76's admission Profile indicated she/he was responsible for themselves.Review of Resident 76's clinical record revealed she/he was transferred to the hospital on 4/26/26. No evidence was found in Resident 76's clinical record to indicate the resident or resident representative was provided with a written Notice of Bed Hold Policy at the time of transfer and no evidence to indicate the State Long-Term Care Ombudsman was notified of the discharge. On 6/3/26 at 1:28 PM, Staff 24 (LPN) stated bed-hold information was provided to residents or resident representatives when residents were transferred to the hospital. On 6/5/26 at 12:26 PM, Staff 1 (Administrator) confirmed the facility did not provide a written Notice of Bed Hold Policy for Resident 76 at the time of the hospital transfer.2. Resident 78 was admitted in 3/2026 with diagnoses including surgical aftercare and morbid obesity.Resident 78's admission Profile indicated she/he was responsible for themselves.Review of Resident 78's clinical record revealed she/he was discharged from the facility following leaving against medical advice (AMA). No evidence was found in Resident 78's clinical record to indicate the State Long-Term Care Ombudsman was notified of the discharge.On 6/5/26 at 12:26 PM, Staff 1 (Administrator) verified the State Long-Term Care Ombudsman had not been notified of Resident 76 or Resident 78's transfer/discharge events.

385068 06/05/2026

Village Health Care 3955 SE 182nd Avenue Gresham, OR 97030

for adverse side effects to medications.

Findings include:Resident 7 was admitted to the facility in

order for metoprolol succinate (a medication used to treat hypertension) indicated the medication was to be held if the pulse was less than 55 beats per minute (bpm).A review of the 5/2026 and 6/2026 MAR revealed no documentation on the MAR of Resident 7's pulse.A review of the pulse record revealed no pulse was taken on 5/1/26, 5/3/26, 5/11/26, 5/14/26, 5/24/26, 5/26/26, 5/27/26, 5/30/26, and 6/1/26.A review of the pulse record revealed Resident 7's pulse was taken after the medications were administered on 5/7/26, 5/8/26, 5/10/26, 5/15/26, and 5/31/26.A review of the pulse record revealed Resident 7's pulse was less than 55 and metoprolol succinate was administered on 5/12/26, 5/18/26, 5/22/26, 5/25/26, and 5/29/26.On 6/4/26 at 10:24 AM, Staff 14 (CMA) stated Resident 7 had orders for metoprolol succinate, hold if her/his pulse was less than 55.

Staff 1 stated she should have checked Resident 7's pulse prior to administering the metoprolol, but Staff 7 stated she could not remember if she checked Resident 7's pulse prior to giving her/his medication.On 6/4/26 at 12:28 PM, Staff 2 (DNS) stated the MAR was not triggering for Resident 7's pulse to be taken prior to the metoprolol succinate being given.

Staff 2 stated it was the expectation for staff to follow physician order, check Resident 7's pulse prior to administering the metoprolol succinate, and to hold the medication if resident 7's pulse was less than 55 bpm.

385068 06/05/2026

Village Health Care 3955 SE 182nd Avenue Gresham, OR 97030

getting up on her/his own. No new interventions were listed but the resident was encouraged to ask

elbow.

The resident had not used her/his call light and was re-educated to call for assistance to prevent re-injury. Resident 3's care plan dated 3/24/26 revealed the resident was at risk for falls and instructed facility staff to encourage the resident to use the call light for assistance, to ensure the resident wore non-skid socks when up, and to provide one person to assist with toileting and transferring.

The care plan was revised on 3/25/26, 4/25/26, and 6/2/26 but did not include new or amended fall prevention interventions.

On 6/1/26 at 11:00 AM Resident 3 stated she/he did not know why she/he fell but believed she/he was approved to walk and transfer independently.

Observations made on 6/1/26 at 11:00 AM, 6/2/26 at 8:15 AM, 6/3/26 at 8:53 AM, and 6/4/26 at 8:52 AM revealed Resident 3 was not wearing non-skid socks.

On 6/3/26 at 8:53 AM Resident 3 was observed to push her/his call light and observed the bedside commode had crumpled toilet paper and yellow liquid in the bowl.

The resident stated she/he wanted staff to empty the bedside commode and confirmed she/he had used the commode without assistance because she/he believed she/he was cleared to do so independently.

On 6/3/26 at 9:33 AM Staff 22 (CNA) stated she believed Resident 3 was independent to transfer and use the toilet on her/his own and was not at risk for falls.

Staff 22 confirmed Resident 3 had not asked for assistance before using the bedside commode earlier.

Staff 22 stated she had not reviewed Resident 3's Kardex (a quick, easy-to-read care plan for CNAs) before working with Resident 3.

After reviewing the Kardex, Staff 22 confirmed Resident 3 was not cleared to complete her/his cares independently.

On 6/4/26 at 10:09 AM Staff 20 (RN) stated staff educated Resident 3 to use the call light to ask for assistance, but the education did not prevent Resident 3 from self-transferring and falling.

On 6/4/26 at 11:04 AM Staff 24 (Former Director of Rehabilitation) confirmed Resident 3 was at high risk for falls and was often non-compliance with asking for assistance.

Staff 24 stated the facility discussed Resident 3's non-compliance multiple times during morning department manager meetings and weekly skilled services review meetings.

Staff 24 stated she did not recall what interventions were put in place but would have recommended frequent checks and moving Resident 3 closer to the nursing station.

On 6/5/26 at 8:36 AM Staff 2 (DNS) stated she determined the effectiveness of fall interventions by monitoring for the absences of no new falls and the team would discuss alternative strategies.

Staff 2 stated she was aware of Resident 3's falls and stated the resident's confirmed current fall preventions interventions were ineffective and no new interventions were not discussed or implemented.

385068 06/05/2026

Village Health Care 3955 SE 182nd Avenue Gresham, OR 97030

Review of Resident 56's 3/2026 Treatment Administration Record (TAR), 4/2026 TAR, 5/2026 TAR, and 6/2026 TAR revealed the resident had not been administered Aspercreme Lidocaine Cream 4% on the following dates:- 3/5/26 AM Dose- 3/5/26 PM Dose- 3/6/26 AM Dose- 3/6/26 PM Dose- 4/21/26 AM Dose- 5/11/26 PM Dose- 5/20/26 AM Dose- 5/26/26 AM Dose- 5/27/26 AM Dose- 5/28/26 AM Dose- 5/29/26 AM Dose- 5/29/26 PM Dose- 5/30/26 AM Dose- 5/30/26 PM Dose- 5/31/26 AM Dose- 5/31/26 PM Dose- 6/1/26 AM Dose On 6/1/26 at 11:22 AM Resident 56 stated the facility had run out of the ordered lidocaine cream for her/his left shoulder pain multiple times with the most recent time occurring the week prior. Resident 23 stated she/he did not know why the facility kept running out of medications and without it her/his left shoulder pain was not managed. On 6/4/26 at 10:05 AM Staff 19 (CMA) stated nurses administered creams.

Staff 19 stated to ensure residents did not run out of medication the expectation was to check the supply regularly and submit a request to have the medication refilled when the supply started to become low. On 6/4/26 at 10:09 AM Staff 20 (RN) stated when Aspercreme Lidocaine 4% was running low the expectation was to notify Staff 21 (Central Supply) since it was an OTC cream.

Staff 20 confirmed Resident 56 missed multiple doses of Aspercreme due to the medication running out but the medication running out but was unsure as to why the facility did not have any available for residents. On 6/4/26 at 3:09 AM Staff 21 stated he checked the medication supply room daily to verify available stock so he could order out of stock supplies.

Staff 21 confirmed Aspercreme Lidocaine 4% had run out multiple times because the facility switched vendors and the new vender did not carry Aspercreme Lidocaine 4%, so he relied on Amazon.com and local stores to purchase the pain cream but the stores did not consistently have it in stock.

Staff 2 stated Staff 21 was responsible for monitoring and tracking medications that required refills, including Aspercreme.

Staff 21 stated she/he was unaware Resident 56 had missed doses of her/his Aspercreme and the medication should not have run out.

385068 06/05/2026

Village Health Care 3955 SE 182nd Avenue Gresham, OR 97030

Based on observation, interview and record review it was determined the facility failed to monitor

at risk for receiving ineffective medications or vaccinations.

Findings include:On 6/5/26, the CDC requires facilities to monitor temperatures in medication refrigerators to maintain a temperature between 36 and 46 degrees Fahrenheit (F).On 6/4/26 at 1:13PM, Staff 3 (Regional Director of Clinical Operations) provided the temperature logs for three medication refrigerators.A review of Station 1's medication temperature log for 5/2026 revealed missing temperatures on 5/1/26, 5/2/26, 5/8/26, 5/11/26, 5/14/26, 5/15/26, 5/16/26, 5/17/26, 5/22/26, and 5/29/26 (10 days).A review of Station 2's medication temperature log for 5/2026 revealed missing temperatures on 5/1/26, 5/2/26, 5/3/26, 5/4/26, 5/5/26, 5/9/26, 5/10/26, 5/16/26, and 5/17/26 (nine days).A review of Station 3's medication temperature log for 5/2026 revealed missing temperatures on 5/1/26, 5/2/26, 5/3/26, 5/4/26, 5/5/26, 5/6/26, 5/8/26, 5/9/26, 5/10/26, 5/16/26, 5/17/26, and 5/24/26 (12 days).On 6/5/2026 at 8:43 AM, Staff 1 (Administrator) stated staff were expected to check the medication refrigerators daily.

Staff 1 confirmed the missing temperatures and stated the facility did not have a back-up temperature monitoring system on the days with blank temperatures.

385068 06/05/2026

Village Health Care 3955 SE 182nd Avenue Gresham, OR 97030

Review of the CDC's Pneumococcal Vaccine Timing for Adults, dated March 2025, revealed there were four types of pneumococcal vaccines available in the United States: pneumococcal conjugate vaccines (PCV15, PCV20, and PCV21) and pneumococcal polysaccharide vaccine (PPSV23).

For adults 65 years or older who have not previously received any pneumococcal vaccine, CDC recommends you give 1 dose of PCV20 or PCV21. If PCV15 is used, this should be followed by a dose of PPSV23 at least one year later.

For adults 65 years or older who have only received PPSV23, CDC recommended 1 dose of PCV20 or PCV21 one year after PPSV23.

The PCV15 dose should be administered at least one year after the most recent PPSV23 vaccination.

For adults 65 years or older who have only received PCV13, CDC recommended PCV20 or PCV21 one year after PCV13.

For adults 65 years or older who have only received PCV13 or PPSV23 after age [AGE] years old, CDC recommended PCV20 or PCV21 at least five years after PCV13 or PPSV23. a. Resident 56 was admitted to the facility in 11/2021 with diagnoses including chronic obstructive pulmonary disease and asthma.

Review of Resident 56's clinical records revealed the resident last received the PPSV23 on 2/27/23 with no documentation of pneumococcal consent after 2/23/24.

There was no documented evidence that Resident 56 was offered or declined PCV15, PCV20, or PCV21.On 6/5/26 at 8:15 AM Resident 56 stated she would have wanted to have been offered the pneumococcal vaccination. b. Resident 7 was admitted to the facility in 4/2024 with diagnoses including chronic heart failure and diabetes.Review of Resident 7's clinical records revealed the resident last received the PCV13 on 7/17/17.

There was no pneumococcal vaccination consent after 7/17/17.

There was no documented evidence that Resident 7 was offered or declined PCV20 or PCV21.Resident 7's 4/30/26 Quarterly MDS indicated the resident had severe cognitive impairment. On 6/4/26 12:46 PM Staff 15 (Infection Preventionist) stated she developed a tracking system when she took over the position approximately ten months early and found residents were past due for vaccinations.

Staff 15 was aware Resident 7 and Resident 56 were due for pneumococcal vaccinations but had not offered the vaccination.

Staff 15 stated she struggled completing the past due vaccinations because of being pulled to other nursing and staffing coordination related tasks.On 6/5/26 at 8:36 AM Staff 2 (DNS) confirmed knowing Staff 15 was working on past due vaccinations but did not confirm knowing specific residents.

Staff 15 stated her expectation was residents are offered pneumococcal vaccinations when due.