Based on interview and record review it was determined the facility failed to ensure a resident who was continent was not checked by CNA staff for incontinence for 1 of 3 sampled residents (#1) reviewed for dignity. This caused Resident 1 to have increased anxiety, persistent anger and tearfulness. Findings include: Resident 1 was admitted to the facility in 2022 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A 4/26/22 Admission Nursing Database indicated Resident 1 was alert, oriented but was agitated. The resident was assessed to be continent of bowel and bladder and independent with transfers, toileting and bed mobility. The resident usually went to bed at 9:00 PM and woke up at 8:00 AM. …
F550 citations in Oregon
Resident rights and dignity · Resident Rights Deficiencies
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Oregon cites F550 less often than its own record predicts
0.44 times the national share — cited less often here than elsewhere.
Of every deficiency written in Oregon in 2025, this is the portion that was F550.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Oregon surveyors wrote
F550 findings written in Oregon, one from each severity band recorded here, most serious first.
Severity is as the surveyor wrote it. Some findings had already been corrected before the survey.
Based on interview and record review it was determined the facility failed to ensure a resident was treated with dignity and respect for 1 of 5 sampled residents (#4) reviewed for dignity and respect. This placed residents for diminished quality of life. Findings include: Resident 4 admitted to the facility in 7/2026 with diagnoses including fracture to the right arm and left wrist. A 7/2/26 Care plan indicated Resident 4 had an ADL deficient due to fractures and required moderate to maximum assistance from 1 female staff member, if present and available, with showering twice weekly. The facility's Incident Report dated 7/17/26, indicated Staff 9 (CNA) told Resident 4 to clean her/his crotch then rinsed and re-cleaned the area roughly with a washcloth. …
The short window
Recent years
| Year | Share of Oregon citations | vs expected |
|---|---|---|
| 2023 | 1.32% | 0.64× |
| 2024 | 1.82% | 0.83× |
| 2025 | 0.94% | 0.44× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Oregon surveyors cite →
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