Based on the immediate jeopardy in the areas of Accident Hazards it was determined the facility was not administered by the management team in an effective and efficient manner. Resident 2 and 16 eloped from the facility and were placed at risk in hazardous environments and avoidable accidents. Findings include: Resident 2 was admitted to the facility in 2/2019 with [DIAGNOSES REDACTED]. Record review indicated Resident 2 eloped from the facility on nine occasions and staff interview indicated the resident eloped on multiple occasions. On 3/17/19 the resident was placed on alert charting to monitor her/him for elopement. After 3/19/19 Resident 2 eloped from the building on more than six occasions before her/his care plan was updated to identify the resident was an elopement risk. …
F835 citations in Oregon
Administration · Administration Deficiencies
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Oregon cites F835 less often than its own record predicts
0.71 times the national share — cited less often here than elsewhere.
Of every deficiency written in Oregon in 2025, this is the portion that was F835.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Oregon surveyors wrote
F835 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 deficient practice in the areas of Freedom from Abuse, Neglect and Exploitation, Investigate/Prevent/Correct Alleged Violations and failure to adhere to Professional Standards of Practice of nursing to identify, assess and intervene for residents' Change of Condition it was determined the facility was not administered by the management team in an effective and efficient manner to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. As a result: Residents 305, 309 and 314 were mentally and verbally abused and Residents 312 and 315 experienced delays in treatment for significant changes of condition requiring hospitalization . Findings include: 1.The facility failed to ensure residents were free from mental and verbal abuse. a. …
Based on interview and record review the facility failed to ensure facility administration used the facility's resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident related to lack of sufficient staffing, lack of a facility assessment, and significant medication errors for 1 of 1 facility reviewed for effective administration.1. Observations on 9/24/25 and 9/25/25 revealed delayed responses to call lights, staff appeared and reported to be rushed, and residents were waiting for assistance from staff and appeared frustrated from the lack of timely assistance.Facility documentation including grievances and Direct Care Staff Daily Reports revealed chronic concerns spread across multiple months related… …
The short window
Recent years
| Year | Share of Oregon citations | vs expected |
|---|---|---|
| 2023 | 0.23% | 0.81× |
| 2025 | 0.21% | 0.71× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Oregon surveyors cite →
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