F725 in Oregon. Pick another state for the same tag.
Against expectation — 2025
Oregon cites F725 more often than its own record predicts
Versus expected share2.30×
2.30 times the share F725 takes of citations nationally.
Share of Oregon citations1.78%
Of every deficiency written in Oregon in 2025, this is the portion that was F725.
Oregon1.78%
National0.78%
Share of all citations that were F725.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Oregon surveyors wrote
F725 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 23, 2023
1. Based on interview and record review it was determined the facility failed to respond to a residents call lights timely for 4 of 12 sampled residents (#s 32, 39, 41 and 168) reviewed for staffing. This facility's failure was determined to be an immediate jeopardy situation because it resulted in Resident 168's in delay of care, transfer to the hospital, subsequent death and placed all residents at risk for untimely and unmet care needs. Findings include:
1. Resident 168 admitted to the facility on [DATE] with diagnoses including dysphagia (difficulty swallowing) and chronic respiratory failure.
a. …
1. Based on observation, interview and record review it was determined the facility failed to ensure sufficient staffing to meet resident care needs for 1 of 1 facility reviewed for sufficient and competent staffing. This failure resulted in Resident 57 having eight falls in ten months, one with serious injury which resulted in the resident sustaining a fractured hip requiring surgery. Findings include:
The facility's 2/2017 Staffing Policy indicated the following:
-The facility provided sufficient numbers of staff with the skills and competency necessary to provide care and services for all residents in accordance with resident care plans and the facility assessment. …
F · No harm, potential for more than minimal, widespreadSeptember 4, 2026
Based on observation, interview and record review it was determined the facility failed to ensure sufficient nursing staff were available to meet resident needs for 3 of 3 resident halls reviewed for staffing. This placed residents at risk for lack of timely assistance and unmet care needs. Findings include: On 9/3/26 the facility provided lists of residents who:-Required assistance with transfers: 10-Required a mechanical lift with transfers: 10- Required one or two-person assistance with bathing: 21-Required one or two-person assistance with toileting: 20-Required assistance with personal hygiene and dressing: 21These residents resided on all three facility halls. a. …
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