Based on observation, interview, and record review it was determined the facility failed to ensure grievances were followed up timely for 1 of 6 sampled residents (#6) reviewed for environment. This placed residents at risk for unresolved grievances. Findings include: Resident 6 was admitted to the facility in 5/2024 with diagnoses of hemiplegia (total or partial paralysis of one side of the body) and chronic obstructive pulmonary disease (irreversible lung damage which restricts breathing).An 8/10/25 Annual MDS revealed Resident 6 had a BIMS score of 15, indicating intact cognition.An 8/28/25 Resident Council Grievance document indicated two residents including Resident 6 voiced concerns regarding the noise level of two different facility doors near their rooms. …
F585 citations in Oregon
Grievances · Resident Rights Deficiencies
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Oregon cites F585 more often than its own record predicts
2.13 times the share F585 takes of citations nationally.
Of every deficiency written in Oregon in 2025, this is the portion that was F585.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Oregon surveyors wrote
F585 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 observation, interview, and record review, the facility failed to maintain evidence of grievance decisions for a period of no less than 3 years from the date of the grievance decision. This placed residents at risk for grievances not being resolved or documented. Findings include:On 8/17/26, an Entrance Conference letter request for grievances related to call lights, activities of daily living (ADLs), resident rights, and resident safety from 3/1/26 through 5/10/26 was submitted to Staff 1 (Administrator). On 8/17/26 at 11:15 AM, Staff 1 reported the 2026 grievance binder could not be located and was unavailable for review. On 8/21/26 at 10:00 AM, Staff 1 reported the grievance binder was last seen approximately two weeks earlier. …
The short window
Recent years
| Year | Share of Oregon citations | vs expected |
|---|---|---|
| 2023 | 0.85% | 1.40× |
| 2024 | 0.98% | 1.56× |
| 2025 | 1.36% | 2.13× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Oregon surveyors cite →
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