Based on interview and record review it was determined the facility failed to ensure resident care equipment was in safe operating condition for 1 of 3 sampled resident (#5) reviewed for falls. This resulted in Resident 5 being sent out to the hospital for uncontrolled pain resulting in a right [MEDICAL CONDITION]. Findings include: Resident 5 admitted to the facility ,[DATE] with [DIAGNOSES REDACTED]. An undated Kardex (a form utilized by CNAs to provide care to residents) indicated Resident 5 was a two person assist with all ADLs including transfers. A Fall Investigation dated [DATE] at 11:00 AM by Staff 36 (Interim DNS) revealed the following: -The resident was sent out to the hospital for uncontrolled pain and agitation. The resident had a right [MEDICAL CONDITION]. …
F908 citations in Oregon
Equipment in safe condition · Environmental Deficiencies
Keep all essential equipment working safely.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Oregon cites F908 less often than its own record predicts
0.23 times the national share — cited less often here than elsewhere.
Of every deficiency written in Oregon in 2025, this is the portion that was F908.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Oregon surveyors wrote
F908 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 maintain essential kitchen equipment for 1 of 1 kitchen reviewed for kitchen services. This placed residents at risk for food borne illnesses. Findings include:The 12/5/07 manufacturer specifications for the Ecolab Model ES-2000 indicated the dishwasher required a minimum wash and rinse temperature of 120 degrees Fahrenheit and a recommended temperature of 140 degrees Fahrenheit.On 5/7/26 at 12:17 PM, an observation of the facility kitchen revealed the dishwasher temperature gauge was hazed and unreadable. Staff 16 (Registered Dietician) acknowledged the gauge was unreadable. She stated Dietary Manager was on vacation. …
The short window
Recent years
| Year | Share of Oregon citations | vs expected |
|---|---|---|
| 2023 | 0.16% | 0.33× |
| 2024 | 0.23% | 0.52× |
| 2025 | 0.10% | 0.23× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Oregon surveyors cite →
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