of F695 citations were written at actual harm or above. The mark is the share across all tags, 5.4%.
Citations in 20252,389
Every F695 citation surveyors wrote nationally that year.
Facilities cited2,287
Distinct nursing homes with at least one F695 finding.
The harm level
How severely F695 is cited
1.7% of citations found actual harm or worse (level G and above).
Citations by CMS scope and severity. Rows are harm level, columns are how widespread the finding was.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
J810.8%
K290.3%
L30.0%
Actual harm
G570.6%
H20.0%
I—
No harm, potential for more than minimal
D8,12181.5%
E1,64816.5%
F50.1%
No harm, potential for minimal
A—
B200.2%
C10.0%
Every recorded F695 citation, by the harm level and scope the surveyor assigned.
In the surveyor’s words
What an F695 citation says
One finding from each severity level, most serious first.
Severity is as the surveyor wrote it. Some findings had already been corrected before the survey.
J · Immediate jeopardy, isolatedAugust 7, 2026
Based on review of facility policy, facility documentation, clinical records, observations, and staff interviews it was determined the facility failed to ensure emergency equipment readily available for accidental extubation for a resident with a tracheostomy (An extubation creates an emergency situation that requires that an obturator be readily available that can be used by competent staff for reinsertion) for one of two residents reviewed (Resident R130). Facility staff were unaware of the location of emergency equipment or how to use it in case of accidental extubation, resulting in an Immediate Jeopardy situation (Resident R130). …
Based on clinical record review, facility document review, resident interview, staff interviews, safety data sheets, and policy review, the facility failed to ensure a continuous positive airway pressure (CPAP) machine (device used to keep airway open during sleep) was filled with the correct solution for 1 of 2 residents reviewed (Resident #14) for CPAP use. Staff filled Resident #14's CPAP machine with distilled vinegar (acedic acid) instead of distilled water resulting in the resident complaining of a headache, burning eyes and altered taste. The facility reported a census of 36. Findings include: The Minimum Data Set (MDS) Assessment completed on 7/18/26 revealed Resident #14 admitted to the facility on [DATE]. …
D · No harm, potential for more than minimal, isolatedSeptember 11, 2026
Based on interview, and document review, the facility failed to ensure a system was in place to monitor for resident BiPAP (bilevel positive airway pressure, used to assist in delivering oxygen to the body and ridding it of excess carbon dioxide) machine tolerance and intervention effectiveness to reduce the risk of possible complication for 1 of 1 resident (R46) reviewed for BiPAP machine use.Findings include:R46's admission Minimum Data Set (MDS) dated [DATE], indicated R46 had intact cognition and no rejection of care behaviors. The MDS did not include non-invasive ventilation use. …
B · No harm, potential for minimal, patternJune 25, 2026
Based on observation, interview, medical record and facility P&P review, the facility failed to ensure the appropriate respiratory care and services were provided for three of six residents (Residents 3, 7, and 80) reviewed for respiratory care. * The facility failed to ensure Resident 3 and 7's oxygen concentrators were free of dust like particles. * The facility failed to ensure Resident 80's nebulizer machine was maintained in a sanitary condition. These failures had the potential to negatively impact the residents' health outcomes.Findings: Review of the facility's P&P titled Maintenance, Cleaning and Repair of Resident Equipment dated 1/20/19, showed the residents equipment shall be cleaned and disinfected according to manufacturer guidelines and facility infection control policies. …
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Cited in the same inspection, not caused by one another.
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