Based on interview and record review it was determined the facility failed to ensure a resident received thickened liquids as ordered for 1 of 4 sampled residents (#40) reviewed for nutrition. This placed residents at risk for aspiration. Findings include: Resident 40 was admitted to the facility in 6/2025 with a diagnosis of heart disease. Resident 40's 9/16/21 Dietary Order Details revealed she/he was to receive mildly thickened liquids. Resident 40's 9/21/25 Progress Notes revealed Staff 29 (LPN) notified Residents 40's medical provider that she/he aspirated during a meal. Resident 40's provider ordered a chest x-ray. Resident 40's 9/21/25 communication form to Resident 40's medical provider revealed she/he aspirated at lunch while drinking Ensure which was not thickened. …
F808 citations in Oregon
Nutrition and Dietary Deficiencies
Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Oregon cites F808 less often than its own record predicts
0.72 times the national share — cited less often here than elsewhere.
Of every deficiency written in Oregon in 2025, this is the portion that was F808.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Oregon surveyors wrote
F808 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.
The short window
Recent years
| Year | Share of Oregon citations | vs expected |
|---|---|---|
| 2023 | 0.16% | 0.78× |
| 2025 | 0.10% | 0.72× |
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