Based on interview and record review it was determined the facility failed to implement and maintain an effective tracheostomy training program for 1 of 1 sampled resident (#19) reviewed for respiratory care. This placed residents at risk for inappropriate tracheostomy care and the potential for a decline in respiratory status. Findings include: Resident 19 admitted to the facility in 4/2024, with diagnoses including acute respiratory failure and tracheostomy (a surgical opening through the front of the neck and into the windpipe, which a tube is placed into the hole to keep it open for breathing). A 5/5/25 Progress Note revealed Resident 19 was transferred to the hospital for vomiting. …
F940 citations in Oregon
Administration Deficiencies
Develop, implement, and/or maintain an effective training program for all new and existing staff members.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Oregon cites F940 more often than its own record predicts
1.07 times the share F940 takes of citations nationally.
Of every deficiency written in Oregon in 2025, this is the portion that was F940.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Oregon surveyors wrote
F940 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 | 0.16% | 1.94× |
| 2025 | 0.10% | 1.07× |
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