Based on interview and record review it was determined the facility failed to develop and implement a baseline care plan related to fall risk for 1 of 5 sampled residents (#1) reviewed for accidents. This failure, determined to be an immediate jeopardy situation, resulted in Resident 1 having a fall with a head injury with bleeding and transfer to the hospital where the resident died ; and placed other residents at risk for falls. Findings include: Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A hospital History and Physical dated [DATE] indicated Resident 1 fell at home when she/he got up from a chair to a standing position. The resident was found on the floor three hours later and was sent to the hospital. …
F655 citations in Oregon
Baseline care plan · Resident Assessment and Care Planning Deficiencies
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Oregon cites F655 less often than its own record predicts
0.64 times the national share — cited less often here than elsewhere.
Of every deficiency written in Oregon in 2025, this is the portion that was F655.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Oregon surveyors wrote
F655 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 a baseline care plan based on identified health conditions and initial goals for 2 of 7 sampled residents (#s 5 and 11) reviewed for pressure ulcers and abuse. This resulted in Resident 5's development of facility acquired pressure ulcers and placed residents at risk for unmet care needs. Findings include: 1. Resident 5 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 1/4/20 Admission Nursing Evaluation revealed Resident 5 had a sacrum rash. The Baseline Care Plan documented Bathing 1 specify type. The Baseline Care Plan did not identify Resident 5's impaired skin condition or any other conditions and risks affecting the resident's health and safety to meet Resident 5's immediate needs. …
Based on interview and record review it was determined the facility failed to develop a care plan for 1 of 1 sampled resident (#63) reviewed for dialysis. This placed residents at risk for lack of continuity of care. Findings include: The facility's 9/2024 Care Plan - Baseline Plan of Care Policy instructed the facility was to provide direct care givers with accurate information available to properly care for residents and a copy of the Baseline Plan of Care within 48 hours of admission.Resident 63 was admitted to the facility in 7/2026 with diagnoses including end stage renal disease.Resident 63's baseline care plan was initiated on 7/31/26 but was not completed within 48 hours of admission and was missing dietary orders, therapy services, and social services related needs. …
The short window
Recent years
| Year | Share of Oregon citations | vs expected |
|---|---|---|
| 2023 | 0.85% | 1.07× |
| 2024 | 1.21% | 1.76× |
| 2025 | 0.42% | 0.64× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Oregon surveyors cite →
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