Based on interviews and record review it was determined the facility failed to protect the resident's right to be free from involuntary seclusion by facility administration for 1 of 3 sampled residents (# 12) reviewed for abuse. This failure resulted in Resident 12 experiencing psychosocial harm with suicidal ideation, increased depression symptoms, heightened anxiety, and fear of losing her/his home. Findings include: Resident 12 was admitted to the facility in 11/2015 with diagnoses including quadriplegia (a form of paralysis that affects all four limbs, plus the torso), contractures of the right and left hand, right elbow, and lower extremities (fixed tightening of muscle, tendons, ligaments, or skin which prevents normal movement of the body part) and a history of traumatic brain… …
F603 citations in Oregon
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Protect each resident from separation (from other residents, his/her room, or confinement to his/her room).
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2024
Oregon cites F603 more often than its own record predicts
1.49 times the share F603 takes of citations nationally.
Of every deficiency written in Oregon in 2024, this is the portion that was F603.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Oregon surveyors wrote
F603 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 interviews and record review it was determined the facility failed to ensure the resident was free from involuntary seclusion by staff for 1 of 3 sampled residents (# 104) reviewed for involuntary seclusion. This placed residents at risk for mistreatment. Findings include:Resident 104 was admitted to the facility in 2025 with diagnoses including hip fracture and dementia. Resident 104's 12/2025 Care Plan did not include interventions to keep the resident at the nurse's station all night to prevent falling. On 12/12/25, the State Survey Agency received a call from Witness 1 (Former Staff). Witness 1 stated on 12/6/25 she was notified that Staff 6 (LPN) forced Resident 104 to stay up in her/his wheelchair most of the night on 12/5/25. …
What else Oregon surveyors cite →
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