Based on observation, record review and staff and family interviews, for two (2) of two (2) sampled residents with laryngectomies, the facility's staff failed to: 1. ensure Resident #3's airway (stoma) was not occluded by a medical device Heat Moisture Exchanger (HME) subsequently, the resident to be transferred to the emergency room (ER) for dislodgment, 2. keep a supply of respiratory medical equipment in the facility that was necessary to care for and treat Resident #3's laryngectomy and stoma, resulting in the resident being transferred to the ER for a replacement 3. obtain/provide Resident #3 with HMEs, 4. change and clean respiratory equipment in accordance with the physician's orders for Resident #304, and 4. …
F695 citations in District of Columbia
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
District of Columbia cites F695 less often than its own record predicts
0.36 times the national share — cited less often here than elsewhere.
Of every deficiency written in District of Columbia 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 District of Columbia surveyors wrote
F695 findings written in District of Columbia, 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, record review and staff interviews, for one (1) of ten (10) sampled residents, facility staff failed to have an extra tracheostomy tube at Resident #6's bedside in the event of an accidental dislodgment or decannulation.The findings included: A facility policy titled, Unplanned Decannulation: Risk Assessment, Precautions and Interventions dated 12/09/25 documented in part: A replacement airway must be kept at the bedside for all airway patients. Resident #6 was admitted to the facility on [DATE] with multiple diagnoses that included: Acute and Chronic Respiratory Failure with Hypoxia, Chronic Kidney Disease and Hyperkalemia. …
The short window
Recent years
| Year | Share of District of Columbia citations | vs expected |
|---|---|---|
| 2023 | 1.36% | 0.58× |
| 2024 | 1.02% | 0.46× |
| 2025 | 0.80% | 0.36× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else District of Columbia surveyors cite →
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