Based on observation, interview and record review it was determined the facility failed to ensure residents were assessed for safe self-administration of medications for 3 of 3 sampled residents (#s 4, 15 and 30) reviewed for self-administration of medications. This placed residents at risk for unsafe medication administration. Findings include: The Medication Administration/Self-Administration Policy dated 1/2023 indicated: -Residents who desire to self-administer medications are permitted to do so with a prescriber's order and if the nursing care center's interdisciplinary team has determined that the practice would be safe and the mediations are appropriate and safe for self-administration. …
F554 citations in Oregon
Resident Rights Deficiencies
Allow residents to self-administer drugs if determined clinically appropriate.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Oregon cites F554 more often than its own record predicts
2.41 times the share F554 takes of citations nationally.
Of every deficiency written in Oregon in 2025, this is the portion that was F554.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Oregon surveyors wrote
F554 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.
The short window
Recent years
| Year | Share of Oregon citations | vs expected |
|---|---|---|
| 2023 | 1.09% | 1.96× |
| 2024 | 0.68% | 1.25× |
| 2025 | 1.36% | 2.41× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Oregon surveyors cite →
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