Based on record review and interviews, review of the facility's tools Using SBAR Communication, the facility failed to ensure one resident (R) (R1) of four sampled residents received necessary respiratory care. Nursing staff did not assess resident during an acute change in condition, did not notify the physician, and attempted to cancel a 911 call which R1 initiated. In addition, facility's nursing staff did not document anything in R1's clinical record related to the change in condition. …
F695 citations in Georgia
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
Georgia cites F695 more often than its own record predicts
1.76 times the share F695 takes of citations nationally.
Of every deficiency written in Georgia 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 Georgia surveyors wrote
F695 findings written in Georgia, 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 observations, record review, staff interviews, and review of the facility's policy titled Trach Decannulation Emergency Procedures, the facility failed to ensure emergency supplies, specifically a resuscitation bag, were at bedside for one of two residents (Resident (R) 60) reviewed for tracheostomies of 21 sample residents. This failure had the potential to affect resuscitation efforts for R60. Findings include: Review of the facility's policy titled, Trach Decannulation Emergency Procedures, revised 01/25/22, revealed Equipment.Ambu bag and mask.Review of R60's Face Sheet, located under the Resident Face Sheet tab of the electronic medical record (EMR), revealed that the resident was admitted on [DATE] with diagnoses that included tracheostomy. …
The short window
Recent years
| Year | Share of Georgia citations | vs expected |
|---|---|---|
| 2023 | 5.11% | 2.19× |
| 2024 | 4.84% | 2.19× |
| 2025 | 3.89% | 1.76× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Georgia surveyors cite →
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