CMS · Oregon Department of Human Services publishes each citation’s tag, official description and scope/severity letter. The surveyor’s written findings are in the Statement of Deficiencies (CMS-2567) for each survey, linked above.
F558Reasonably accommodate the needs and preferences of each resident.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-12-26Record 385254-20241108-F558
F584Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.Scope/severity EStandard
Dignity & rights
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-12-26Record 385254-20241108-F584
F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Scope/severity EStandard
Abuse & neglect
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-12-26Record 385254-20241108-F600
F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Scope/severity DStandard
Abuse & neglect
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-12-26Record 385254-20241108-F609
F610Respond appropriately to all alleged violations.Scope/severity DStandard
Abuse & neglect
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-12-26Record 385254-20241108-F610
F677Provide care and assistance to perform activities of daily living for any resident who is unable.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-12-26Record 385254-20241108-F677
F679Provide activities to meet all resident's needs.Scope/severity EStandard
Care planning
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-12-26Record 385254-20241108-F679
F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-12-26Record 385254-20241108-F684
F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Scope/severity DStandard
Care planningFalls
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-12-26Record 385254-20241108-F689
F697Provide safe, appropriate pain management for a resident who requires such services.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-12-26Record 385254-20241108-F697
F725Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.Scope/severity EStandard
Staffing
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-12-26Record 385254-20241108-F725
F726Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.Scope/severity EStandard
Staffing
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-12-26Record 385254-20241108-F726
F730Observe each nurse aide's job performance and give regular training.Scope/severity EStandard
Staffing
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-12-26Record 385254-20241108-F730
F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Scope/severity DStandard
Medication
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-12-26Record 385254-20241108-F755
F791Provide or obtain dental services for each resident.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-12-26Record 385254-20241108-F791
F801Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.Scope/severity FStandard
Food & nutrition
Widespread; no actual harm, potential for more than minimal harm.Corrected 2024-12-26Record 385254-20241108-F801
F806Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.Scope/severity DStandard
Food & nutrition
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-12-26Record 385254-20241108-F806
F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Scope/severity EStandard
Food & nutrition
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-12-26Record 385254-20241108-F812
F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Scope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-12-26Record 385254-20241108-F842
F851Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.Scope/severity FStandard
Records
Widespread; no actual harm, potential for more than minimal harm.Corrected 2024-12-26Record 385254-20241108-F851
F880Provide and implement an infection prevention and control program.Scope/severity EStandard
Infection control
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-12-26Record 385254-20241108-F880
F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Scope/severity JHarm
Care planning
Isolated; immediate jeopardy to resident health or safety.Corrected 2023-09-19Record 385254-20230802-F684
F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Scope/severity GHarm
Care planningFalls
Isolated; actual harm that is not immediate jeopardy.Corrected 2023-09-19Record 385254-20230802-F689
F698Provide safe, appropriate dialysis care/services for a resident who requires such services.Scope/severity JHarm
Care planning
Isolated; immediate jeopardy to resident health or safety.Corrected 2023-09-19Record 385254-20230802-F698
F578Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-09-19Record 385254-20230802-F578
F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-09-19Record 385254-20230802-F580
F584Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.Scope/severity EStandard
Dignity & rights
Pattern; no actual harm, potential for more than minimal harm.Corrected 2023-09-19Record 385254-20230802-F584
F585Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-09-19Record 385254-20230802-F585
F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Scope/severity DStandard
Abuse & neglect
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-09-19Record 385254-20230802-F600
F606Not hire anyone with a finding of abuse, neglect, exploitation, or theft.Scope/severity DStandard
Abuse & neglect
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-09-19Record 385254-20230802-F606
F607Develop and implement policies and procedures to prevent abuse, neglect, and theft.Scope/severity DStandard
Abuse & neglect
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-09-19Record 385254-20230802-F607
F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Scope/severity DStandard
Abuse & neglect
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-09-19Record 385254-20230802-F609
F610Respond appropriately to all alleged violations.Scope/severity DStandard
Abuse & neglect
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-09-19Record 385254-20230802-F610
F636Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.Scope/severity EStandard
Care planningRecords
Pattern; no actual harm, potential for more than minimal harm.Corrected 2023-09-19Record 385254-20230802-F636
F655Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admittedScope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-10-13Record 385254-20230802-F655
F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Scope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-09-19Record 385254-20230802-F656
F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Scope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-10-13Record 385254-20230802-F657
F677Provide care and assistance to perform activities of daily living for any resident who is unable.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-09-19Record 385254-20230802-F677
F690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-10-13Record 385254-20230802-F690
F692Provide enough food/fluids to maintain a resident's health.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-09-19Record 385254-20230802-F692
F695Provide safe and appropriate respiratory care for a resident when needed.Scope/severity EStandard
Care planning
Pattern; no actual harm, potential for more than minimal harm.Corrected 2023-09-19Record 385254-20230802-F695
F712Ensure that the resident and his/her doctor meet face-to-face at all required visits.Scope/severity DStandard
Staffing
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-09-19Record 385254-20230802-F712
F727Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.Scope/severity FStandard
Staffing
Widespread; no actual harm, potential for more than minimal harm.Corrected 2023-09-19Record 385254-20230802-F727
F730Observe each nurse aide's job performance and give regular training.Scope/severity FStandard
Staffing
Widespread; no actual harm, potential for more than minimal harm.Corrected 2023-09-19Record 385254-20230802-F730
F758Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.Scope/severity DStandard
Medication
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-09-19Record 385254-20230802-F758
F801Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.Scope/severity FStandard
Food & nutrition
Widespread; no actual harm, potential for more than minimal harm.Corrected 2023-09-19Record 385254-20230802-F801
F806Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.Scope/severity DStandard
Food & nutrition
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-10-13Record 385254-20230802-F806
F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Scope/severity EStandard
Food & nutrition
Pattern; no actual harm, potential for more than minimal harm.Corrected 2023-09-19Record 385254-20230802-F812
F835Administer the facility in a manner that enables it to use its resources effectively and efficiently.Scope/severity FStandard
Records
Widespread; no actual harm, potential for more than minimal harm.Corrected 2023-09-19Record 385254-20230802-F835
F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Scope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-09-19Record 385254-20230802-F842
F843Have an agreement with at least one or more hospitals certified by Medicare or Medicaid to make sure residents can be moved quickly to the hospital when they need medical care.Scope/severity EStandard
Records
Pattern; no actual harm, potential for more than minimal harm.Corrected 2023-09-19Record 385254-20230802-F843
F849Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.Scope/severity DStandard
Records
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-09-19Record 385254-20230802-F849
F865Have a plan that describes the process for conducting QAPI and QAA activities.Scope/severity FStandard
Records
Widespread; no actual harm, potential for more than minimal harm.Corrected 2023-09-19Record 385254-20230802-F865
F867Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.Scope/severity FStandard
Records
Widespread; no actual harm, potential for more than minimal harm.Corrected 2023-09-19Record 385254-20230802-F867
F868Have the Quality Assessment and Assurance group have the required members and meet at least quarterlyScope/severity FStandard
Records
Widespread; no actual harm, potential for more than minimal harm.Corrected 2023-09-19Record 385254-20230802-F868
F880Provide and implement an infection prevention and control program.Scope/severity EStandard
Infection control
Pattern; no actual harm, potential for more than minimal harm.Corrected 2023-09-19Record 385254-20230802-F880
F881Implement a program that monitors antibiotic use.Scope/severity EStandard
Infection control
Pattern; no actual harm, potential for more than minimal harm.Corrected 2023-09-19Record 385254-20230802-F881
F883Develop and implement policies and procedures for flu and pneumonia vaccinations.Scope/severity EStandard
Infection control
Pattern; no actual harm, potential for more than minimal harm.Corrected 2023-09-19Record 385254-20230802-F883
F940Develop, implement, and/or maintain an effective training program for all new and existing staff members.Scope/severity FStandard
Records
Widespread; no actual harm, potential for more than minimal harm.Corrected 2023-09-19Record 385254-20230802-F940
F947Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.Scope/severity FStandard
Staffing
Widespread; no actual harm, potential for more than minimal harm.Corrected 2023-09-19Record 385254-20230802-F947