Based on review of the clinical record, facility documentation, facility policy and interviews for one (1) of three (3) sampled residents (Resident #2) reviewed for supplemental oxygen, the facility failed to assess the resident and notify the provider when Resident #2 experienced Shortness of Breath (SOB) related to the facility's lack of oxygen concentrators and emergency tank supplies. The facility failed to ensure continuous, functioning supplemental oxygen and failed to provide timely, appropriate intervention for Resident #2's acute respiratory distress, resulting in Resident #2's condition deteriorating to acute respiratory arrest, ultimately leading to death. The failures resulted in the finding of Immediate Jeopardy. …
F695 citations in Connecticut
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
Connecticut cites F695 less often than its own record predicts
0.79 times the national share — cited less often here than elsewhere.
Of every deficiency written in Connecticut 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 Connecticut surveyors wrote
F695 findings written in Connecticut, 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 clinical record review, observations, facility documentation review, facility policy review, and interviews for one of one resident (Resident #2) reviewed for respiratory assessments the facility failed to ensure a resident with the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The findings include: Resident #2's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The annual Minimum Data Set (MDS) assessment dated [DATE] identified that Resident #2 had a Brief Interview for Mental Status (BIMS) score of fourteen out of fifteen, indicative of no cognitive impairment and required limited assistance with transfers, dressing, toileting and personal hygiene and was occasionally incontinent of bladder and always continent of bowels. …
Based on observations, review of clinical records, facility documentation, facility policy, and interviews, for 2 of 2 residents (Resident #5 and Resident #88) reviewed for respiratory care, the facility failed to ensure Continuous Positive Airway Pressure (CPAP) equipment was cleaned and the tubing, filter, and mask were changed in accordance with the manufacturer's recommendations. The findings include:1.Resident #5's diagnoses included pneumonia, acute and chronic respiratory failure, and obstructive sleep apnea.The physician's order dated 10/1/25 directed to administer CPAP at 4-25 cmH O (centimeters of water) with oxygen at 3 liters per minute using a face mask at bedtime every shift and to provide CPAP basic setup with replacement supplies including humidified heated tubing and… …
The short window
Recent years
| Year | Share of Connecticut citations | vs expected |
|---|---|---|
| 2023 | 2.43% | 1.04× |
| 2024 | 2.09% | 0.95× |
| 2025 | 1.74% | 0.79× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Connecticut surveyors cite →
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