F610 in Oregon. Pick another state for the same tag.
Against expectation — 2025
Oregon cites F610 more often than its own record predicts
Versus expected share1.18×
1.18 times the share F610 takes of citations nationally.
Share of Oregon citations1.78%
Of every deficiency written in Oregon in 2025, this is the portion that was F610.
Oregon1.78%
National1.51%
Share of all citations that were F610.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Oregon surveyors wrote
F610 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.
J · Immediate jeopardy, isolatedMarch 18, 2026
Based on interview and record review it was determined the facility failed to investigate allegations of sexual abuse for 3 of 3 sampled residents (#s 102, 103, and 108) reviewed for allegations of sexual abuse. This placed all residents at risk for sexual abuse and constituted substandard quality of care. A determination was made that the facility's noncompliance placed Residents 102, 103, and 108 in immediate jeopardy, beginning on 3/17/26.On 3/17/26 at 2:12 PM, Staff 14, Staff 15 (Regional Directors of Clinical Service), and Staff 2 (DNS) were notified of the immediate jeopardy (IJ) situation and provided a copy of the IJ template related to the facility's failure to investigate allegations of sexual abuse. …
Based on interview and record review it was determined the facility failed to ensure a thorough investigation was completed related to an allegation of physical abuse for 1 of 1 sampled resident (#25) reviewed for abuse. This resulted in Resident 25 experiencing increased agitation post event and placed residents at risk for continued abuse. Findings include:
Resident 25 admitted to the facility in 2018 with diagnoses including Alzheimer's disease and major depressive disorder.
The 11/30/22 Quarterly MDS indicated Resident 25 was rarely/never understood and staff interviews indicated the resident experienced memory deficits. …
E · No harm, potential for more than minimal, patternAugust 25, 2026
Based on interview and record review it was determined the facility failed to complete thorough investigations for alleged neglect and verbal abuse allegations for 3 of 8 sampled residents (#s 7, 8, and 9) reviewed for elopement and verbal abuse. This placed residents at risk for elopement and continued verbal abuse. Findings include:1. Resident 7 was admitted to the facility in 8/2026 with diagnoses including Alzheimer's disease, dementia and altered mental status. Resident 7's 8/7/26 Brief Interview for Mental Status assessment revealed Resident 7 moderately cognitively impaired. On 8/18/26, the State Agency received a public complaint alleging Resident 7 left the faciity on 8/12/26 and crossed a busy highway. …
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