46841 Based on interview and record review it was determined the facility failed to recognize and respond to Resident 2's respiratory status change of condition for 1 of 3 sampled residents (#2) reviewed for change in condition. This failure was determined to be an immediate jeopardy situation because the facility failed to recognize, treat, and notify the provider of Resident 2's respiratory decline which resulted in hospitalization for pneumonia and death. Findings include: Resident 2 was admitted to the facility on [DATE] with diagnoses including acute and chronic respiratory failure and COPD (Chronic Obstructive Respiratory Disease). The 8/22/23 Physician Order revealed an order for oxygen 0-4 LPM (liters per minute) to maintain oxygen saturations between 88-92% via nasal cannula. …
F695 citations in Oregon
Respiratory care · Quality of Life and Care Deficiencies
Provide safe and appropriate respiratory care for a resident when needed.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Oregon cites F695 less often than its own record predicts
0.48 times the national share — cited less often here than elsewhere.
Of every deficiency written in Oregon in 2025, this is the portion that was F695.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Oregon surveyors wrote
F695 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, interviews, and record review, it was determined the facility failed to provide adequate respiratory care and services for 2 of 2 sampled residents (#s 3 and 4) reviewed for respiratory services. The facility failed to obtain and follow physician orders for tracheostomy care in a timely and consistent manner, which resulted in multiple hospitalizations This placed residents at risk for respiratory complications. Findings include:The 8/1/24 Tracheostomy Care Policy and Procedure Revealed staff were to verify physician orders and identify the resident. The 2025 facility assessment revealed: staff training/competencies and skill sets are required. Clients are reviewed prior to admission to determine if additional training is needed and is provided. 1. …
Based on observation, interview and record review it was determined the facility failed to maintain oxygen equipment for 1 of 1 sampled resident (#34) reviewed for respiratory. This placed residents at risk for respiratory infection. Findings include:Resident 34 admitted to the facility in 2026 with diagnoses including oxygen dependence.The 7/22/26 care plan indicated Resident 34 used oxygen therapy related to COPD (Chronic Obstructive Pulmonary Disease), asthma and sleep apnea. Interventions included use of oxygen at two liters per minute. On 8/3/26 at 11:00 AM Resident 34 was observed to have oxygen in use. An observation of the oxygen concentrator revealed on the top a layer of dust. …
The short window
Recent years
| Year | Share of Oregon citations | vs expected |
|---|---|---|
| 2023 | 2.33% | 1.00× |
| 2024 | 2.19% | 0.99× |
| 2025 | 1.05% | 0.48× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Oregon surveyors cite →
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