Based on interview and record review the facility administration failed to implement their abuse policy procedures in the areas of identification, investigation, protection, and reporting which resulted in repeated incidents of sexual abuse for 2 of 5 sampled residents (#s 15 and 16) reviewed for abuse. This failure to implement their abuse policy and procedures resulted in Resident 15 and Resident 16 repeatedly engaging in intimate nonconsensual sexual activity. The facility's 3/2023 Freedom from Abuse, Neglect and Exploitation policy including the Abuse Reporting and Responsibilities of Covered Individuals indicated the following: - The facility will provide a safe resident environment and protect residents from abuse . this includes freedom from . sexual or physical abuse. …
F607 citations in Oregon
Abuse-prevention policies · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Oregon cites F607 less often than its own record predicts
0.48 times the national share — cited less often here than elsewhere.
Of every deficiency written in Oregon in 2025, this is the portion that was F607.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Oregon surveyors wrote
F607 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 develop and implement written policies related to required abuse training and reporting of abuse for 2 of 2 sampled residents (#s 16 and 21) reviewed for abuse. This failure resulted in psychosocial harm as evidenced by Resident #16's depressed mood and expression of fear and anxiety. Findings include: The facility's 4/2010 Reporting Abuse to Facility Management policy revealed the following: - It was the responsibility of employees to promptly report incidents or suspected incidents of resident abuse to facility management. …
Based on interview and record review it was determined the facility failed to implement its policy and procedure related to abuse investigations for 1 of 2 sampled residents (#2) reviewed for abuse. This placed residents at risk for reoccurring abuse. Findings include: The facility's 4/1/26 Abuse Protection of Residents Policy indicated the facility must implement written policies that prohibit and prevent abuse and to investigate any such allegations. Resident 2 admitted to the facility in 10/2025 with diagnoses including left hip dislocation and cognitive communication deficit. …
The short window
Recent years
| Year | Share of Oregon citations | vs expected |
|---|---|---|
| 2023 | 0.23% | 0.31× |
| 2024 | 0.08% | 0.10× |
| 2025 | 0.31% | 0.48× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Oregon surveyors cite →
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