F689 in Oregon. Pick another state for the same tag.
Against expectation — 2025
Oregon cites F689 more often than its own record predicts
Versus expected share1.16×
1.16 times the share F689 takes of citations nationally.
Share of Oregon citations6.39%
Of every deficiency written in Oregon in 2025, this is the portion that was F689.
Oregon6.39%
National5.53%
Share of all citations that were F689.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Oregon surveyors wrote
F689 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, isolatedMay 11, 2026
Based on observation, interview, and record review, the facility failed to ensure residents were adequately supervised and protected from avoidable accidents. Specifically, the facility failed to:(1) Ensure adequate supervision to prevent accidents for 1 of 4 sampled residents (#44), a severely cognitively impaired resident, who was left unsupervised in the community in a high-traffic, [NAME] area for an unknown period of time and was subsequently located and returned to the facility by law enforcement. …
Based on interview and record review it was determined the facility failed to ensure bed brakes were engaged during resident care for fall prevention for 1 of 3 sampled residents (#8) reviewed for accidents. Resident 8 experienced a fall from bed and sustained a skin abrasion, increased lower extremity pain, and a decline in mobility status. Findings include:Resident 8 was admitted to the facility in 10/2024 with diagnoses including hemiparesis (one-sided weakness) following a stroke.An 11/18/25 Quarterly MDS Assessment for Resident 8 demonstrated a BIMS Score of 14, indicating intact cognitive function.An undated fall investigation document revealed Resident 8 suffered a fall to the floor between her/his bed and the wall which occurred while Staff 9 (CNA) was providing personal care and… …
D · No harm, potential for more than minimal, isolatedSeptember 4, 2026
Based on observation, interview and record review it was determined the facility failed to ensure supervision and safety interventions were in place to prevent smoking related accidents for 1 of 1 sampled resident (# 69) reviewed for smoking safety. This placed resident at risk for burns and accidents. Findings include:The facility 9/2024 Smoking Policy indicated the following:- Staff were responsible for ensuring that smoking by residents is done in a safe manner. - Residents were not allowed to give or borrow smoking materials from other residents.- All smoking materials, including cigarettes, electronic cigarettes and lighters were to be locked up, including smoking materials for residents who were assessed to be supervised smokers.Resident 69 was admitted to the facility in 5/2026 with… …
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