Based on observation, interview and record review it was determined the facility failed to ensure a call light was accessible to a resident for 1 of 13 residents (#54) reviewed for staffing. This placed residents at risk for delayed care. Findings include: Resident 54 was admitted to the facility in 11/2026 with a diagnosis of a stroke. Resident 54's Care Plan revised 3/25/26 indicated she/he was at risk for falls and staff were to remind her/him to activate the call light for assistance. Observation on 6/23/26 at 8:23 AM revealed Resident 54's call light was not within reach. Staff 1 (Administrator) entered Resident 54's room and secured her/his call light within her/his reach. On 6/24/26 at 9:12 AM Resident 54 was observed in bed. Resident 54's call light was not on her/his bed. …
F919 citations in Oregon
Call system · Environmental Deficiencies
Make sure that a working call system is available in each resident's bathroom and bathing area.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Oregon cites F919 less often than its own record predicts
0.47 times the national share — cited less often here than elsewhere.
Of every deficiency written in Oregon in 2025, this is the portion that was F919.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Oregon surveyors wrote
F919 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 | 0.78% | 1.78× |
| 2024 | 0.08% | 0.17× |
| 2025 | 0.21% | 0.47× |
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