Based on observation, interview and record review it was determined the facility failed to ensure a resident with a diagnosed mental disorder and documented history of suicide attempts received the necessary behavioral health care and services needed to prevent suicide attempts for 1 of 5 sampled residents (# 52) reviewed for unnecessary medications. This failure, determined to be an immediate jeopardy situation, resulted in Resident 52 attempting suicide and placed residents at risk for avoidable accidents and death. …
F740 citations in Oregon
Behavioral health services · Quality of Life and Care Deficiencies
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Oregon cites F740 more often than its own record predicts
3.19 times the share F740 takes of citations nationally.
Of every deficiency written in Oregon in 2025, this is the portion that was F740.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Oregon surveyors wrote
F740 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 provide necessary behavioral health services for 1 of 1 sampled resident (#32) reviewed for behavior. This failured resulted in Resident 32 continuing to experience untreated mental health symptoms, including expressing statements of wanting to die and socially isolating her/himself. Findings include:Resident 32 admitted to the facility in 4/2026 with diagnoses including anxiety disorder, obsessive-compulsive disorder, attention deficit hyperactivity disorder, post-traumatic stress disorder, major depressive disorder, and bipolar disorder.A 4/30/26 admission MDS revealed Resident 32 had a score of 19 on the Patient Health Questionaire-9 (an assessment of depression symptoms), which indicated she/he… …
Based on observation, interview, and record review it was determined the facility failed to address behavioral health needs timely for 1 of 1 sampled resident (#69) reviewed for mood and behavior. This placed residents at risk for lack of behavioral health care. Findings include: Resident 69 was admitted to the facility in 10/2019 with diagnoses including chronic pain and major depressive disorder. The 10/29/25 Annual MDS revealed Resident 69 had minimal depressive symptoms. The 4/28/26 IDT (Interdisciplinary Team) Care Plan Conference Evaluation revealed Witness 1 (Family Member) was not present. The 5/1/26 Quarterly MDS revealed Resident 69 had a PHQ-9 (Patient Health Questionnaire) assessment score of 13 (moderate depression) and a BIMS score of 15 (cognitively intact). …
The short window
Recent years
| Year | Share of Oregon citations | vs expected |
|---|---|---|
| 2023 | 0.39% | 1.47× |
| 2024 | 0.23% | 0.92× |
| 2025 | 0.84% | 3.19× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Oregon surveyors cite →
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