Based on interview and record review it was determined the facility failed to revise care plan interventions for 3 of 5 sampled residents (#s 1, 2 and 3) reviewed for abuse. Resident 1 and Resident 2 experienced psychosocial harm as evident by feelings of anxiety, intimidation and ongoing emotional discomfort. Resident 1 stated she/he did not feel safe. Findings include: 1. Resident 1 admitted to the facility in 7/2017 with [DIAGNOSES REDACTED]. The Annual MDS dated [DATE] indicated Resident 1 had a BIMS score of 15 which indicated Resident 1 was cognitively intact. Resident 1's care plan last revised on 7/29/19 indicated Resident 1 required moderate assistance with ADLs. The care plan did not indicate Resident 1's preference for female only caregivers. …
F657 citations in Oregon
Care plan timing and revision · Resident Assessment and Care Planning Deficiencies
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Oregon cites F657 less often than its own record predicts
0.45 times the national share — cited less often here than elsewhere.
Of every deficiency written in Oregon in 2025, this is the portion that was F657.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Oregon surveyors wrote
F657 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 revise care plans and involve and inter-disciplinary team in the care planning process for 2 of 7 sampled residents (#s 10 and 13) reviewed for care planning and dental. This placed residents at risk for unmet needs. Findings include: 1. Resident 10 was admitted to the facility in 3/2026 with diagnoses including Post Traumatic Stress Disorder and depression. The 3/31/26 admission MDS indicated Resident 10 had a BIMS score of 15 (cognitively intact). The 4/29/26 comprehensive care plan indicated Resident 10 was to discharge home or another facility. …
The short window
Recent years
| Year | Share of Oregon citations | vs expected |
|---|---|---|
| 2023 | 2.95% | 1.38× |
| 2024 | 2.50% | 1.31× |
| 2025 | 0.84% | 0.45× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Oregon surveyors cite →
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