French Prairie Nursing & Rehabilitation Center

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Based on interview and record review it was determined the facility failed to notify a resident's responsible party of a significant change of condition for 1 of 3 sampled residents (#3) reviewed for medication. This placed residents at risk for their responsible party not being informed of the resident's status. Findings include:Resident 3 admitted to the facility in 2025 with diagnoses including epilepsy and dementia.

Resident 3's emergency contact was listed as Witness 7 (Family Member). The 9/14/25 12:01 AM Progress Note by Staff 15 (LPN) indicated Patient found having active seizure. Called 911, resident left facility 00:01 [12:01 AM]. Notified on call. Left message on administrators phone.There was no indication in the clinical

record to indicate Witness 7 was notified of Resident 3's change of condition and hospitalization. On 9/23/25 at 2:23 PM Witness 7 stated she was unaware of Resident 3's seizure or hospitalization until the hospital staff called and told her. On 9/25/25 at 12:55 PM Staff 2 (DNS) acknowledged Resident 3's emergency contact was Witness 7 and she was not contacted regarding the resident's seizures and hospitalization on 9/13/25.

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:

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/24/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

French Prairie Nursing & Rehabilitation Center

601 Evergreen Road Woodburn, OR 97071

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0725 Level of Harm - Minimal harm or potential for actual harm

residents could receive the care they deserve. Staff 1 acknowledged there were two instances when only two CNAs worked a weekend shift and stated he was not aware until the following Monday. Staff 1 was unable to produce any sort of facility assessment for staffing levels based on resident acuity.

Residents Affected - Many

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/24/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

French Prairie Nursing & Rehabilitation Center

601 Evergreen Road Woodburn, OR 97071

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0732

Post nurse staffing information every day.

Level of Harm - Potential for minimal harm

Based on interview and record review it was determined the facility failed to post accurate and complete staffing information for 1 of 1 facility reviewed for required staff postings. This placed residents and the public at risk for incomplete and inaccurate staffing information. Findings includeA review of the Direct Care Staff Daily Reports from June 2025 through 9/23/25 revealed 47 days when portions of the form were left blank or were inaccurate. The incomplete or inaccurate information included daily census, the number of working staff and staff hours worked. The dates included:7/6/257/9/257/22/25 8/1/25 8/5/25 8/10/25 8/11/25 8/12/25 8/13/25 8/14/25 8/15/25 8/16/25 8/17/25 8/21/25 8/22/25 8/23/25 8/24/25 8/25/25 8/26/25 8/27/25 8/28/25 8/29/25 8/30/25 8/31/25 9/1/25 9/2/5 9/3/25 9/4/25 9/5/25 9/6/25 9/7/25 9/8/25 9/9/25 9/11/25 9/12/25 9/13/25 9/14/25 9/15/25 9/16/25 9/17/25 9/18/25 9/19/25 9/20/25 9/21/25 9/22/25 9/23/25On 9/25/25 at 11:15 AM Staff 1 (Administrator) acknowledged the Direct Care Staff Daily Reports were incomplete and inaccurate for the identified dates.

Residents Affected - Many

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/24/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

French Prairie Nursing & Rehabilitation Center

601 Evergreen Road Woodburn, OR 97071

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760

Ensure that residents are free from significant medication errors.

Level of Harm - Minimal harm or potential for actual harm

Based on interview and record review it was determined the facility failed to ensure residents were free from significant medication errors for 1 of 3 sampled residents (#3) reviewed for medication. This placed residents at risk for reduced efficacy of medications. Findings include:Resident 3 admitted to the facility in 7/2025 with diagnoses including epilepsy (a neurological disorder characterized by unprovoked seizures) and dementia. The 8/20/25 physician order indicated Resident 3 was to receive the following medications twice daily for epilepsy:-levetiracetam (antiepileptic drug) 750 mg 3 tablets;-lamotrigine (anticonvulsant medication used to prevent or control seizures) 200 mg 2 tablets;-zonisamide (anticonvulsant medication used to prevent or control seizures) 100 mg 3 tablets. The 9/2025 MAR indicated the following:-Resident 3 was to receive levetiracetam, lamotrigine and zonisamide at 8:00 AM and 8:00 PM.-On 9/13/25 Staff 15 (LPN) administered levetiracetam, lamotrigine and zonisamide to Resident 3 at 11:47 PM (three hours and 47 minutes late). On 9/24/25 at 9:55 AM Staff 15 stated she administered levetiracetam, lamotrigine and zonisamide to Resident 3 on 9/13/25 at 10:30 PM (two and a half hours late) and did not document the administration time until 11:47 PM. Staff 15 stated after she administered the medications at 10:30 PM, Resident 3 was fine and was not having any issues. Staff 15 further stated later on that evening, the CNA staff reported the resident did not look right and when Staff 15 responded to the room the resident was actively having seizures. Staff called 911 and sent the resident to the hospital via ambulance. The 9/14/25 12:01 AM Progress Note by Staff 15 indicated Patient found having active seizure. Called 911, resident left facility 00:01 [12:01 AM]. Notified on call. Left message on administrator's phone.The 9/14/25 4:14 AM Hospital Records indicated on 9/13/25 Resident 3's first seizure episode lasted one to two minutes, followed by another seizure that did not last long, then around 11:40 PM the resident had another seizure that lasted about 10 minutes. When the medics arrived the patient was seizing. A review of Resident 3's clinical record revealed no indication the resident experienced seizures in the facility prior to 9/13/25. On 9/25/25 at 12:55 PM Staff 2 (DNS) stated she became aware of Resident 3's seizure and hospitalization

after Witness 7 (Family Member) made a comment about the resident not receiving her/his medications on time. Staff 2 stated the resident was hospitalized for a few days as a result of the seizure. Staff 2 stated it was important for anti seizure medication to be given timely, especially levetiracetam, because if the resident was at a subtherapeutic level, seizures could occur. Staff 2 stated the facility was not completing labs for routine levetiracetam levels and she did not find labs in the resident's clinical record. Staff 2 stated

she did not talk to Staff 15 about the incident and an incident report was not completed. Staff 2 acknowledged Resident 3 did not have seizures in the facility prior to 9/13/25 when the medication was administered late.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/24/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

French Prairie Nursing & Rehabilitation Center

601 Evergreen Road Woodburn, OR 97071

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0835

Administer the facility in a manner that enables it to use its resources effectively and efficiently.

Level of Harm - Minimal harm or potential for actual harm

Based on interview and record review the facility failed to ensure facility administration used the facility's resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident related to lack of sufficient staffing, lack of a facility assessment, and significant medication errors for 1 of 1 facility reviewed for effective administration.1. Observations on 9/24/25 and 9/25/25 revealed delayed responses to call lights, staff appeared and reported to be rushed, and residents were waiting for assistance from staff and appeared frustrated from the lack of timely assistance.Facility documentation including grievances and Direct Care Staff Daily Reports revealed chronic concerns spread across multiple months related to insufficient staffing, which resulted in delayed assistance or assistance not provided at all.Interviews with residents and witnesses during from 9/22/25 through 9/24/25 revealed concerns related to sufficient staffing including delayed call light times, and lack of assistance. Interviews with facility staff from 9/22/25 through 9/25/25 revealed the facility was often staffed below state minimum staffing ratios, and was not staffed according to resident acuity. Many of the residents required two-person assistance. The lack of staffing to the acuity of residents resulted in outcomes including delayed assistance, improper assistance, lack of assistance and increased stress of staff due to their inability to provide sufficient care. Staff reported the concerns were shared with facility administration, but no changes were made to the staffing levels.On 9/25/25 at 11:15 AM and 1:54 PM Staff 1 (Administrator) acknowledged the ongoing concerns related to insufficient staffing.Refer to F-F725.2. The 3/24/25 Facility Assessment failed to comprehensively and accurately include information how the facility assessment was used to address staffing needs and resident acuity and the high usage of agency staff.On 9/25/25 at 1:54 PM, Staff 1 (Administrator) acknowledged the assessment was not comprehensive and did not have accurate information related to staffing.Refer to F-F838.3. Resident 3 was to receive medications for epilepsy two times a day at 8:00AM and 8:00PM. On 9/24/25 Staff 15 (LPN) did not administer the medication to Resident 3 until 10:30 PM. A 9/14/25 at 12:01 AM a Progress Note indicated Patient found having active seizure. Called 911, resident left facility 00:01 [12:01 AM]. Notified on call. Left message on administrator's phone.On 9/25/25 at 12:55 PM Staff 2 (DNS) stated she became aware of Resident 3 being sent out to the hospital after Witness 7 (Family Member) made a comment about the resident not receiving her/his medications on time. Staff 2 acknowledged the expectation was for seizure medications to be administered on time, as the medications were to prevent seizures. Staff 2 stated she did not to speak to Staff 15 about the incident, and an incident report was not completed. Refer to F-F760.

Residents Affected - Many

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/24/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

French Prairie Nursing & Rehabilitation Center

601 Evergreen Road Woodburn, OR 97071

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0838 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many

FORM CMS-2567 (02/99) Previous Versions Obsolete

Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.

Based on interview and record review, it was determined the facility failed to conduct and complete a comprehensive facility assessment to care for its residents competently during day-to-day operations. This placed residents at risk for unidentified and unmet needs. Findings include:The 3/24/25 Facility Assessment was reviewed. The assessment was not comprehensive and failed to accurately include information on the following:- How the facility assessment was used to address staffing needs and resident acuity.- The high usage of agency staff.On 9/25/25 at 1:54 PM, Staff 1 (Administrator) reviewed the Facility Assessment and acknowledged the assessment was not comprehensive and did not have accurate information related to the area of staffing. No further information was provided.

Event ID:

Facility ID:

If continuation sheet