Based on interview and record review, it was determined the facility failed to conduct and complete a comprehensive facility wide assessment to care for its residents competently during day to day operations. This placed residents at risk for unidentified and unmet needs. Findings include:The 10/17/25 Facility Assessment was reviewed. The assessment was not comprehensive and failed to accurately include information on the following:- How the facility assessment was used to address staffing needs and competencies.- Necessary staffing and equipment needed to provide bariatric services.- The ethnic, cultural and religious makeup of the facility resident population.On 8/10/26 at 2:28 PM Staff 1 (Administrator) reviewed the Facility Assessment and acknowledged the assessment was not… …
F838 citations in Oregon
Facility assessment · Administration Deficiencies
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Oregon cites F838 more often than its own record predicts
1.66 times the share F838 takes of citations nationally.
Of every deficiency written in Oregon in 2025, this is the portion that was F838.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Oregon surveyors wrote
F838 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 the facility failed to annually update the facility assessment to include current staffing needs and resources related to COVID-19. This place residents a risk for unmet needs. Findings include: Review of the 6/2018 Facility Assessment revealed the assessment was not updated, as necessary, or at least annually. The assessment was not comprehensive and did not include any changes in staffing since 2019 or reference to facility resources related to COVID-19 requirements. On 5/3/22 at 12:21 PM Staff 13 (Chief Executive Officer) acknowledged the available facility assessment was last updated in 2018 and was not current.
The short window
Recent years
| Year | Share of Oregon citations | vs expected |
|---|---|---|
| 2023 | 0.16% | 0.92× |
| 2024 | 0.08% | 0.39× |
| 2025 | 0.42% | 1.66× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Oregon surveyors cite →
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