Based on observations, interviews, and record review the facility failed to provide respiratory care and services for tracheostomy dependent residents according to professional standards of practice for four residents (#14, #15, #16, and #19) out of five residents with a tracheostomy. On [DATE] a grievance was filed by Resident #16's family related to tracheostomy care and suctioning. The grievance process was not followed through by the facility to a resolution for the resident. On [DATE] Resident #15 requested his tracheostomy to be suctioned. The certified nursing assistant (CNA) notified the nurse. By the time the nurse got to the room, Resident #15 was unresponsive. …
F695 citations in Florida
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
Florida cites F695 more often than its own record predicts
1.62 times the share F695 takes of citations nationally.
Of every deficiency written in Florida 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 Florida surveyors wrote
F695 findings written in Florida, 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 interviews and record review, the facility failed to ensure continuous oxygen therapy was provided in consistent with professional standards of practice, related to failure to ensure the resident's record included accurate and active physician orders and on-going assessment of the resident's respiratory status and response to oxygen therapy, for two (#18 and #12) of two residents reviewed, resulting in Resident #18 experiencing respiratory distress requiring emergency hospitalization . Findings included: 1. …
Based on observation, interview, and record review the facility failed to implement the proper storage of Aerosol drug delivery systems (nebulizer) used for respiratory treatments in 2 out of 3 Residents, Resident #94 and #130 reviewed for Respiratory Care.Findings Include: 1.) During an observation on 08/29/2026 at 10:22AM, Resident #94's nebulizer mouthpiece was not in a bag. The mouth piece was sitting on the nightstand. During interview with ADON, Infection Control Nurse on 09/03/2026 at 9:19 AM, she stated Nebulizer pipes are to be cleansed and put back into a bag after every use. …
The short window
Recent years
| Year | Share of Florida citations | vs expected |
|---|---|---|
| 2023 | 3.82% | 1.64× |
| 2024 | 3.55% | 1.61× |
| 2025 | 3.56% | 1.62× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Florida 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