Based on interview, and record review, the facility failed to ensure: 1. A ventilator assisted individual ([[NAME]] a person who relies on a medical device to completely or partially assist with their breathing) received appropriate airway management by ensuring the ventilator (a medical machine that helps or fully takes over the breathing process for a patient) was turned on after one of five sampled residents (Resident 1) was transported to her room following a shower. 2. A Respiratory Therapist ([RT] a specialized health professional who diagnoses, treats, and manages patients with breathing and cardiopulmonary disorders) was available to monitor and manage Resident 1's airway. …
F695 citations in California
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
California cites F695 less often than its own record predicts
0.86 times the national share — cited less often here than elsewhere.
Of every deficiency written in California 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 California surveyors wrote
F695 findings written in California, 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, interview, and record review, the facility failed to provide respiratory treatment and care for one of 16 sampled residents (Resident 13), who had chronic obstructive pulmonary disease (COPD, group of diseases that cause airflow blockage and breathing-related problems) and history of pneumonia (a serious infection of one or both lungs in which the air sacs fill with pus and other liquid). The facility failed to: 1. Closely monitor Resident 13's respiratory condition, including response to treatment after being identified to have a change of condition (COC, a sudden clinically important deviation from a patient's baseline) when Resident 13 develop a cough on 3/20/2024. 2. …
Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 73) receiving oxygen therapy was provided respiratory care and resident safety in accordance with the facility's Policy and Procedure (P&P) titled Oxygen Administration and professional standards of practice. This deficient practice had the potential to increase the risk for shortness of breath and/or hypoxia (low levels of oxygen in the body tissues) for Resident 73, which could result in serious respiratory complications. …
The short window
Recent years
| Year | Share of California citations | vs expected |
|---|---|---|
| 2023 | 1.60% | 0.68× |
| 2024 | 1.97% | 0.90× |
| 2025 | 1.89% | 0.86× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else California 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