Based on observation, interview and record review it was determined the facility failed to assess, develop, reassess and implement a person-centered care plan for dementia care needs to ensure resident safety for 4 of 4 sampled residents (#s 1, 2, 3, and 4) reviewed for elopement. As a result, Resident 1 left the faciity on [DATE] without staff knowledge, had an incident involving her/his power wheelchair getting stuck outside on [DATE], and on [DATE] left the facility again, which placed the resident at risk for serious injury. Resident 1 lacked a comprehensive assessment and person-centered care plan for her/his dementia with Lewy bodies. There were no interventions developed and implemented to ensure the appropriate supervision and monitoring were in place to prevent an injury. …
F744 citations in Oregon
Dementia care · Quality of Life and Care Deficiencies
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Oregon cites F744 more often than its own record predicts
1.06 times the share F744 takes of citations nationally.
Of every deficiency written in Oregon in 2025, this is the portion that was F744.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Oregon surveyors wrote
F744 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 interview and record review it was determined the facility failed to ensure staff implemented appropriate dementia cares and competencies and failed to implement care plan interventions for a resident diagnosed with [REDACTED].# 1) reviewed for abuse. This resulted in Resident 1 receiving care against her/his wishes, which resulted in distress and bruising to the resident's right and left wrists and right forearm. This placed residents at risk for the unmet care needs and physical and mental abuse. Findings include: Resident 1 was admitted to the facility in 10/2016 with [DIAGNOSES REDACTED]. Resident 1's 10/2018 Annual MDS revealed the resident was severely cognitively impaired and rarely or never made decisions. …
Based on observation, interview, and record review it was determined the facility failed to comprehensively assess and revise a resident's care plan related to dementia for 1 of 1 sampled resident (#20) reviewed for dementia. This placed residents at risk for unaddressed dementia and behavioral needs. Findings include: Resident 20 was admitted to the facility in 9/2024 with diagnoses including dementia with behavioral disturbances. The 10/2/24 admission MDS indicated revealed a BIMS score of 6, which indicated Resident 20 had severe cognitive impairment. …
The short window
Recent years
| Year | Share of Oregon citations | vs expected |
|---|---|---|
| 2023 | 0.31% | 1.46× |
| 2024 | 0.08% | 0.36× |
| 2025 | 0.21% | 1.06× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Oregon surveyors cite →
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