Citations in Oregon
Statistics, citations and compliance trends for long-term care facilities in Oregon.
Statistics for Oregon (Last 12 Months)
Financial Impact (Last 12 Months)
Latest citations in Oregon
The facility failed to ensure RN coverage for at least 8 consecutive hours on 3 of 46 days reviewed. Review of the Direct Care Staff Daily Reports showed no required RN coverage on three dates, and the Administrator acknowledged the missing coverage.
Ice Machine Drain Lacked Required Air Gap The facility failed to ensure the dual ice and water machine had the required air gap. A flexible drain line was observed entering the kitchen through a wall opening and resting in contact with the kitchen drain, with part of the hose coiled in the drain and discolored with splotchy pink areas. The Maintenance Director confirmed the drain line setup, and staff acknowledged there was no air gap present.
Failure to Follow Contact Precautions: Two residents were on contact precautions, including one with an MDRO UTI and another with C. diff. Staff did not consistently follow posted PPE and hand hygiene instructions, including a CNA entering a room without gown and gloves and CNAs using hand sanitizer instead of soap and water when leaving a resident’s room.
Dirty Resident Room and Respiratory Equipment: A resident with dysphagia, a feeding tube, and a tracheostomy had a room observed with a dirty fan, debris on the mattress, dust and dried debris on the O2 concentrator and trach machine, and a dirty towel on the bed. A family member reported the area by the bed was often dirty from tube feeding, and an LPN Resident Care Manager agreed the room was dirty and needed daily cleaning.
A resident with depression and delusional disorders was prescribed Olanzapine for delusions, but the MAR and care plan showed no targeted behavior monitoring or other behavioral documentation to support the medication’s use or effectiveness. The SS Director and DNS both confirmed the resident was not on behavior monitoring, despite the facility stating residents on antipsychotics were placed on it.
A resident with idiopathic aseptic necrosis of the right femur and ongoing hip pain had a PRN oxycodone order every 4 hours, but the medication was delayed after the resident and CNAs reported the need for pain relief. The LPN stated the dose was not yet due and later said the resident was asleep, while the DNS said the delay occurred after an early morning fire drill and resulted in the resident going 7 hours without PRN pain medication when it could have been given every 4 hours.
RN Coverage Not Maintained
Penalty
Summary
The facility failed to ensure a registered nurse was available for at least eight consecutive hours on 3 of 46 days reviewed for RN coverage. Review of the Direct Care Staff Daily Reports for 1/31/26 through 3/17/26 identified no required RN coverage on 1/31/26, 2/25/26, and 3/17/26. The report states this placed residents at risk for delayed nursing assessments. On 8/6/26 at 3:22 PM, the Administrator acknowledged the dates without the required RN coverage.
Ice Machine Drain Lacked Required Air Gap
Penalty
Summary
The facility failed to ensure an ice machine had the required air gap for 1 of 1 facility ice and water machine reviewed for kitchen sanitation. On 8/6/26 at 11:00 AM, a flexible hose drain line was observed coming into the kitchen through a hole in the wall. The drain hose was resting along the edge of the drain, and approximately six inches were coiled around and in contact with the bottom of the kitchen drain. The drain line was discolored with splotchy pink areas and was connected to the dual ice and water machine on the other side of the wall. On 8/6/26 at 1:17 PM, the Maintenance Director stated he was responsible for maintenance of the machine and confirmed there was a flexible drain line that went through the shared wall and drained into a kitchen drain. Staff 8 acknowledged the drain hose was in contact with the drain floor and side wall and that there was no air gap present. The Dietary Manager was informed of the findings at 1:25 PM.
Failure to Follow Contact Precautions
Penalty
Summary
The facility failed to implement appropriate contact precautions for two residents who were on isolation precautions. One resident had a multidrug-resistant organism urinary tract infection and a care plan dated 7/29/26 directed staff to follow Contact Precautions. A Contact Precautions sign posted by the resident’s door instructed staff to wear gloves and a gown each time they entered the room, but on 8/6/26 a CNA entered the room and delivered a meal without wearing a gown and gloves. The CNA stated PPE was not required when delivering the meal, while the DNS stated staff were to wear the required PPE each time they entered the room. A second resident had Crohn’s Disease and a physician order dated 7/24/26 for vancomycin for C. diff. A Contact Enteric Precautions sign posted by the resident’s door directed staff to wash or gel hands prior to entry, wear a gown and gloves, and use soap and water upon leaving the room. On 8/3/26, a CNA exited the room and used hand sanitizer before leaving instead of washing with soap and water. On 8/4/26, another CNA removed her gown and gloves and sanitized her hands with hand sanitizer when leaving the room, then walked to the nurses station restroom and washed her hands with soap and water. The CNA stated staff were to wash their hands with soap and water after being in the resident’s room, and the DNS stated staff were to wash their hands with soap and water before they exited the room.
Dirty Resident Room and Respiratory Equipment
Penalty
Summary
The facility failed to provide a homelike environment for Resident 6, who was admitted in 2022 with diagnoses including dysphagia and whose annual MDS dated 10/25/25 showed a feeding tube for nutrition and a tracheostomy in place. During observation, the resident’s room contained a small black fan that was very dirty and dusty and appeared not to have been cleaned for a long time. The resident’s room was later observed with a mattress on the floor near the bed that appeared dirty with dried clear debris, an oxygen concentrator with dried clear debris and dust on it, a tracheostomy machine with dried white debris all over it, the black fan covered in dust, and a dirty towel on the resident’s bed. A family member stated the area next to the resident’s bed was dirty and often had liquid on it from the tube feeding and appeared gross. An LPN Resident Care Manager observed the room and agreed it was dirty and needed to be cleaned daily.
Lack of Behavior Monitoring for Antipsychotic Use
Penalty
Summary
The facility failed to ensure behavior monitoring was in place related to the use of an antipsychotic medication for one resident reviewed for unnecessary medications. Resident 8 was admitted with diagnoses including depression and delusional disorders and had a physician order for Olanzapine 5 mg once daily for delusions. Review of the resident’s July 2026 MAR and May 2026 care plan showed no identification or monitoring of targeted behaviors related to antipsychotic use, and the record did not include other behavioral documentation to support the use or effectiveness of the medication. Staff interviews confirmed that the resident was not on behavior monitoring, and the DNS stated that residents receiving antipsychotic medications were placed on behavior monitoring and confirmed this resident did not have it in place.
Delayed PRN Pain Medication Administration
Penalty
Summary
The facility failed to ensure appropriate pain management for Resident 23, who was admitted with diagnoses including idiopathic aseptic necrosis of the right femur, a condition associated with pain, stiffness, and limited mobility. A physician order dated 6/19/26 directed PRN oxycodone every four hours for this condition. On 6/24/26, the resident requested pain medication after having last received oxycodone at 10:38 PM on 6/23/26, making the medication available again at 2:38 AM. According to the incident report, CNAs notified Staff 14 that the resident needed pain medication, but Staff 14 stated the medication was not yet due. The resident later went to the medication cart and again requested pain medication, and the medication was not given until about 4:45 AM, with the incident report noting it was administered at 5:02 AM. Camera review showed a CNA left the resident’s room at about 2:30 AM and went to Staff 14, and the resident was seen at the nurses’ station at about 4:30 AM speaking with Staff 14 before returning to the room. Resident 23 stated the pain medication should have been given around 2:30 AM and that the right hip hurt at all times, with pain rated 7 or 8 out of 10. Staff 14 stated the resident requested the medication too soon and that the resident was asleep when she went into the room around 4:00 AM. Staff 2, the DNS, stated the late PRN medication concern was investigated and determined that Staff 14 waited until after an early morning fire drill to provide the medication, resulting in the resident not receiving the PRN pain medication for seven hours when it could have been given every four hours. Staff 8 stated she notified the nurse two to three times about the resident’s need for pain medication.
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Compliance trends in Oregon
Data through Jul 2026Comparisons below measure the most recent period Aug 2025 – Jul 2026 against the prior period Aug 2024 – Jul 2025 (two equal 12-month windows). The most recent 1 months are excluded because CMS is still publishing them.
Top tags by month · last 24 months
dashed = still reportingMonthly citation counts for the 5 most-cited tags. The dashed tail is the 1-month reporting lag.
Frequency movers
Biggest change in how often each tag is cited, as a rate per 100 inspections (so it isn't skewed by survey volume): Aug 2025 – Jul 2026 vs the prior period Aug 2024 – Jul 2025. Only tags with at least 20 citations in both periods are shown.
Severity movers
Tags whose average scope/severity shifted the most: Aug 2025 – Jul 2026 vs the prior period Aug 2024 – Jul 2025. The number is the average severity on the A–L scale (A=0…L=11); the letter is the band it falls in. A rise means the same tag is being cited at a more serious level — note the average can move enough to rank here while staying within the same letter. Same 20-citation minimum applies.
Care domain movers
Citations grouped into CFR care domains — F-tags by their §483 regulatory section (CMS State Operations Manual, Appendix PP) — measured as a rate per 100 inspections: Aug 2025 – Jul 2026 vs the prior period Aug 2024 – Jul 2025. Share is the domain's portion of citations this period; avg severity is the mean scope/severity letter and immediate jeopardy the percentage cited at J–L, both over the current period. Domains with at least 20 citations in both periods are shown; the sparkline tracks the last 12 months (left = oldest).
Immediate jeopardies · this period
Citations at the most serious scope/severity — J–L, immediate jeopardy, residents placed at risk of serious harm or death — over Aug 2025 – Jul 2026 vs the prior period Aug 2024 – Jul 2025. "Surveys with an IJ" counts distinct health inspections that had at least one.
Survey activity · by month
faded/dashed = still reportingCitations each month split into complaint-driven (unscheduled, triggered by grievances) vs standard surveys — bars, left axis — with the number of inspections as a line on the right axis. Rising inspections signal more scrutiny; a rising complaint share means more off-cycle surveys. The most recent 1 months are still being reported.
Deficiency-free survey rate
Share of health surveys that found zero deficiencies — the odds of a clean survey. Aug 2025 – Jul 2026 vs the prior period Aug 2024 – Jul 2025; the most recent 1 months are still being reported (dashed).
Penalties · by month
faded = still reportingTotal civil money penalty dollars imposed on the state's facilities each month — how hard the state is enforcing. The most recent 1 months are still being reported, and penalties often lag citations by several months.
Emerging tags
Tags that weren't established last period but surged — an early warning, distinct from movers (which track already-common tags). Criteria: fewer than 20 citations in the prior period, but at least 10 this period and 2.5× their prior volume. The sparkline shows monthly counts over the last 12 months (left = oldest).
Trusted data from CMS and state health departments
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