Based on interview and record review it was determined the facility failed to report allegations of abuse for 3 of 3 sampled residents (#s 1, 2 and 3) reviewed for abuse. This failure to report past abuse allegations resulted in Resident 2's physical, verbal and mental abuse and placed all residents at increased risk of abuse and intimidation. Findings include: 1. Resident 2 admitted to the facility in 5/2023 with COPD (chronic obstructive pulmonary disease), hemiplegia (paralysis on one side) and multiple cancer diagnoses. Resident 2 was on end of life, comfort care measures. The 12/7/23 Written Statements of Staff 5 (CNA) and Staff 6 (CNA) revealed allegations that Staff 3 (RN) abused Resident 1. There was no evidence a FRI (Facility Reported Incident) was sent in to the State Agency. …
F609 citations in Oregon
Reporting alleged violations · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Oregon cites F609 more often than its own record predicts
1.07 times the share F609 takes of citations nationally.
Of every deficiency written in Oregon in 2025, this is the portion that was F609.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Oregon surveyors wrote
F609 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 report allegations of abuse within a two hour period for 2 of 4 residents (#s 3 and 4) reviewed for abuse. This placed residents at risk for abuse. Findings include: The facility's Policy and Guidelines for Implementation: Freedom Form Abuse, Neglect and Exploitation: dated 11/2017 included the following elements: For allegations of abuse, the facility will: Immediately report the allegation to appropriate authorities. 1. Resident 3 was admitted to the facility in 10/2019 with [DIAGNOSES REDACTED]. …
Based on interview and record review the facility failed to report allegations of neglect to the state survey agency within the required timeframe for 1 of 1 sampled resident (#24) reviewed for neglect. This placed residents at risk for continued neglect. Findings include:Resident 24 was admitted to the facility in 10/2025 with diagnoses including cirrhosis of the liver (a long-term scarring of the liver that prevents it from working properly) and type 2 diabetes mellitus (a long-term condition in which the body does not use insulin properly). Resident 24's 10/24/25 Care Plan indicated the resident was incontinent of bladder and was to be offered position changes while in bed approximately every two hours. …
The short window
Recent years
| Year | Share of Oregon citations | vs expected |
|---|---|---|
| 2023 | 1.09% | 0.55× |
| 2024 | 1.82% | 0.80× |
| 2025 | 2.62% | 1.07× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Oregon surveyors cite →
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