Based on interview and record review it was determined the facility failed to complete a Significant Change MDS within the required timeframe for 1 of 1 sampled resident (#2) reviewed for hospice. This placed residents at risk for unassessed needs. Findings include:Resident 2 was admitted to the facility in 1/2026 with diagnoses including diabetes and chronic obstructive pulmonary disorder. An Election of Benefits and Informed Consent document revealed Resident 2 was admitted to hospice services on 5/24/26. The Significant Change MDS was completed on 6/18/26, 11 days after the required 14-day timeframe. On 7/22/26 at 12:27 PM Staff 8 (MDS Coordinator) acknowledged the Significant Change MDS completion date exceeded the required 14-day timeframe.
F637 citations in Oregon
Assessment after a significant change · Resident Assessment and Care Planning Deficiencies
Assess the resident when there is a significant change in condition
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Oregon cites F637 more often than its own record predicts
1.31 times the share F637 takes of citations nationally.
Of every deficiency written in Oregon in 2025, this is the portion that was F637.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Oregon surveyors wrote
F637 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.
The short window
Recent years
| Year | Share of Oregon citations | vs expected |
|---|---|---|
| 2023 | 0.39% | 1.27× |
| 2024 | 0.45% | 2.02× |
| 2025 | 0.31% | 1.31× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Oregon surveyors cite →
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