Based on interview and record review it was determined the facility failed to ensure the care plan was revised for 1 of 4 sampled residents (#24) reviewed for accidents. This placed residents at risk for lack of interventions to prevent accidents. Findings include:Resident 24 was admitted to the facility in 12/2025 with diagnoses including diabetes and osteoarthritis. The 5/6/26 Quarterly MDS revealed Resident 24 had a BIMS assessment score of 14 (cognitively intact).The 12/12/25 admission MDS and associated CAA revealed Resident 24 required assistance with mobility due to the resident's weakness and pain with an increased risk for falls and injuries. …
F656 citations in Oregon
Comprehensive care plan · Resident Assessment and Care Planning Deficiencies
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Oregon cites F656 less often than its own record predicts
0.61 times the national share — cited less often here than elsewhere.
Of every deficiency written in Oregon in 2025, this is the portion that was F656.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Oregon surveyors wrote
F656 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 | 2.49% | 0.69× |
| 2024 | 1.59% | 0.47× |
| 2025 | 2.10% | 0.61× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Oregon surveyors cite →
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