Based on observations, interview and record review it was determined the facility failed to provide the correct therapeutic diet and supervision during a meal for 1 of 3 samples residents (# 2) reviewed for nutrition. Resident 2 was observed to eat the incorrect diet and was not supervised during her/his meal. This placed Resident 2 at risk for choking on the incorrect diet. Findings included: Resident 2 was readmitted to the facility in 2/2019 with [DIAGNOSES REDACTED]. The 2/9/19 Progress Notes (PN) revealed the resident was readmitted to the facility with a new diet and fluids order, The new diet orders were: -Staff supervision for meals -One on one staff at bedside -The resident required set up for eating and swallow precautions -Nectar thick liquids -Dysphagia 2 diet (moist and soft… …
F692 citations in Oregon
Nutrition and hydration · Quality of Life and Care Deficiencies
Provide enough food/fluids to maintain a resident's health.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Oregon cites F692 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 F692.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Oregon surveyors wrote
F692 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 observation, interview, and record review it was determined the facility failed to maintain acceptable parameters of nutritional status for 2 of 5 sampled residents (#s 52 and 375) reviewed for nutrition. Resident 52 experienced a severe weight loss of over 13 percent in less than three months. Findings include: 1. Resident 52 was admitted to the facility on [DATE] with diagnoses including protein malnutrition and diabetes. Resident 52 had the following weights recorded: -9/1/23 300 pounds -9/10/23 300 pounds -9/25/23 297 pounds -10/26/23 275 pounds -11/7/23 269 pounds -11/8/23 260 pounds This was a 13 percent weight loss which was severe and not gradual. The 9/1/23 care plan indicated to prevent significant weight loss and gain in the next 30 days, 90 days, and 180 days. …
Based on interview and record review it was determined the facility failed to ensure residents received one on one supervision with meals for 1 of 1 sampled resident (#23) reviewed for nutrition. This placed residents at risk for weight loss. Findings include:Resident 23 was admitted to the facility in 2022 with diagnoses including vascular dementia and heart failure. Review of the 11/27/25 Annual MDS dated revealed Resident 23 had a BIMS score of 3 out of 15, indicating severe cognitive impairment.Resident 23's comprehensive care plan, dated 6/2/26, directed staff to provide one on one supervision during meals and ensure food was cut into bite-sized pieces.On 8/18/26 at 12:35 PM, Resident 23 was observed in bed with a meal tray. …
The short window
Recent years
| Year | Share of Oregon citations | vs expected |
|---|---|---|
| 2023 | 1.24% | 0.99× |
| 2024 | 0.61% | 0.51× |
| 2025 | 0.73% | 0.64× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Oregon surveyors cite →
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