F628 in Oregon. Pick another state for the same tag.
Against expectation — 2025
Oregon cites F628 more often than its own record predicts
Versus expected share1.35×
1.35 times the share F628 takes of citations nationally.
Share of Oregon citations1.26%
Of every deficiency written in Oregon in 2025, this is the portion that was F628.
Oregon1.26%
National0.93%
Share of all citations that were F628.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Oregon surveyors wrote
F628 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.
E · No harm, potential for more than minimal, patternAugust 13, 2026
Based on interview and record review, the facility failed to provide required discharge paperwork to residents and failed to ensure safe discharge plans were in place for 3 of 3 sampled residents (#s 1, 2 and 4) reviewed for discharge. This placed residents at risk for unsafe discharge. Findings include: 1. Resident 1 admitted to the facility in 5/2026 with diagnosis including lymphedema. Resident 1 discharged from the facility on 6/24/26. There was no evidence a recapitulation of Resident 1's stay in the facility was provided to Resident 1 at discharge or that written notice of discharge was provided as soon as practicable. Resident 1's Discharge Instructions documented an appointment with a primary care physician on 7/23/26. …
B · No harm, potential for minimal, patternApril 10, 2026
Based on interview and record review it was determined the facility failed to ensure the State Long Term Care Ombudsman Office was notified of resident discharges as required for 1 of 1 facility reviewed for discharge. Findings include: The facility's undated Notice Transfer Discharge Policy & Procedure specified the facility business office will notify the state ombudsman office of all transfers and discharges monthly, or by cadence defined by the state ombudsman's office. On 4/9/26 at 3:14 PM and 3:41 PM Staff 9 (Business Office Manager) stated a list of discharged residents was not sent to the state ombudsman office since 10/2025. …
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