Based on observation, interview, and record review it was determined the facility failed to ensure physician ordered diets were provided as ordered for 3 of 5 sampled residents (#s 3, 39 and 57) reviewed for nutrition. This deficient practice was determined to be an immediate jeopardy situation. Resident 57 was provided food not prepared according to their physician ordered diet texture, and this resulted in a severe coughing episode and risk of choking and/or aspiration. Staff were aware the food they were providing the resident was not appropriate. Findings include: 1. …
F805 citations in Oregon
Food in a form residents can eat · Nutrition and Dietary Deficiencies
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Oregon cites F805 less often than its own record predicts
0.34 times the national share — cited less often here than elsewhere.
Of every deficiency written in Oregon in 2025, this is the portion that was F805.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Oregon surveyors wrote
F805 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 cut up foods for 1 of 4 sampled residents (# 84) reviewed for food. This placed residents at risk for unmet individualized food needs. Findings include:Resident 84 was admitted to the facility in 12/2024 with diagnoses including stroke and chronic pain. The 6/13/25 revised Care Plan revealed Resident 84 was dependent on staff for meeting physical needs due to physical limitations.The 11/17/25 revised Care Plan revealed Resident 84 had an ADL self-care performance deficit due to residual right-side weakness from a history of stroke.The 12/26/25 Annual MDS indicated Resident 84 had upper and lower impaired range of motion on one side and required set-up assistance for eating.The 12/30/25… …
The short window
Recent years
| Year | Share of Oregon citations | vs expected |
|---|---|---|
| 2023 | 0.08% | 0.22× |
| 2024 | 0.30% | 0.84× |
| 2025 | 0.10% | 0.34× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Oregon surveyors cite →
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