Based on interview and record review it was determined the facility failed to ensure a resident with a diagnosed mental disorder and a documented history of trauma received needed care and services to prevent psychosocial decline for 1 of 8 sampled residents (#196) reviewed for allegations of abuse and neglect. This failure, determined to be an immediate jeopardy situation, resulted in Resident 196 experiencing ongoing emotional distress, repeated refusals of care, a lack of dignity, worsening skin conditions, development of pressure ulcers, prolonged periods without incontinent care, repeated falls and neglect. …
F742 citations in Oregon
Quality of Life and Care Deficiencies
Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Oregon cites F742 more often than its own record predicts
1.74 times the share F742 takes of citations nationally.
Of every deficiency written in Oregon in 2025, this is the portion that was F742.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Oregon surveyors wrote
F742 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 develop and implement individualized care plans that addressed the emotional and psychosocial needs of the residents for 2 of 3 residents (#s 15 and 30) reviewed for choices. This placed residents at risk for unmet behavioral and emotional needs and a decrease in their quality of life. Findings includeThe facility's 2/2026 Suicide Threats Policy indicated the following:-Staff shall report any resident threats of suicide immediately to the nurse supervisor who shall immediately assess the situation.-After assessing the resident in more detail, the nurse supervisor shall notify the resident's physician and responsible party and seek further direction from the physician. …
The short window
Recent years
| Year | Share of Oregon citations | vs expected |
|---|---|---|
| 2023 | 0.08% | 0.70× |
| 2024 | 0.15% | 1.21× |
| 2025 | 0.21% | 1.74× |
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