F658 in Oregon. Pick another state for the same tag.
Against expectation — 2025
Oregon cites F658 less often than its own record predicts
Versus expected share0.18×
0.18 times the national share — cited less often here than elsewhere.
Share of Oregon citations0.31%
Of every deficiency written in Oregon in 2025, this is the portion that was F658.
Oregon0.31%
National1.79%
Share of all citations that were F658.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Oregon surveyors wrote
F658 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.
J · Immediate jeopardy, isolatedDecember 10, 2023
Based on interview and record review it was determined the facility failed to ensure 2 of 2 staff (RNs) adhered to professional standards of nursing practice related to the provision of care for a resident after a fall with potential neck and back injuries. This was determined to be an immediate jeopardy situation which resulted from a lack of assessment of the resident and provision of appropriate neck and spine precautions for 1 of 1 sampled resident (#1) who was injured in a fall resulting in blunt trauma to the back of the resident's head, complaints of neck pain and inability to move extremities. The fall resulted in a cervical spine (neck) fracture and spinal cord injury requiring emergency surgical intervention. …
Based on interview and record review it was determined the facility failed to ensure staff adhered to professional standards during medication administration for 1 of 1 licensed nurse (#3) reviewed for significant medication error. Resident 49 required emergency treatment and was hospitalized for monitoring due to a methadone overdose. Findings include:Resident 49 admitted to the facility in 2021 with diagnoses including COPD and diabetes. Staff 3's employee file indicated on 10/13/25 education was provided regarding where to find crushed medication orders for Resident 49. The education was provided because Staff 3 gave whole medications to the resident and she/he choked on the whole medications. Resident 49's orders were reviewed with Staff 3. …
D · No harm, potential for more than minimal, isolatedJuly 31, 2026
Based on interview and record review it was determined the facility failed to ensure staff provided care and services according to professional standards for 1 of 3 sampled residents (#4) reviewed for medication administration. This placed residents at risk for unsafe medication administration. Findings include:OAR [PHONE NUMBER]Scope of Practice Standards for All Licensed Nurses(1) Standards related to the licensee's responsibility for safe nursing practice. The licensee shall:(a) Practice within the laws and rules governing the practice of nursing at the level the nurse is licensed. …
Deficiency Index is independent and is not affiliated with, endorsed by, or approved by CMS, Medicare, or any government agency. About this data · Report a correction