Based on observation, interview, and record review it was determined the facility failed to assess a resident prior to implementing bedrails for 1 of 4 sampled residents (#54) reviewed for accidents. This placed residents at risk for entrapment. Findings include: Resident 54 was admitted to the facility in 11/2025 with a diagnosis of a stroke with paralysis to the left side. Resident 54's 11/28/29 Device/Mattress Safety Observation form revealed the type of device was a bed rail, but the form did not identify the length of the rail. The form indicatedResident 54 was able to move in bed but was not able to transfer independently, and the rail was not a restraint. There was no additional information related to the placement of the rail. …
F700 citations in Oregon
Bed rails · Quality of Life and Care Deficiencies
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Oregon cites F700 less often than its own record predicts
0.54 times the national share — cited less often here than elsewhere.
Of every deficiency written in Oregon in 2025, this is the portion that was F700.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Oregon surveyors wrote
F700 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 | 0.08% | 0.21× |
| 2025 | 0.21% | 0.54× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Oregon surveyors cite →
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