Based on record review and interview, the facility failed to ensure its staff provided necessary respiratory care for one Resident (#89) with a tracheostoma (opening to make a direct airway through the trachea [windpipe]) and laryngectomy (removal of the larynx [voice box] resulting in the trachea [airway] being brought to the skin as a stoma [opening] in the front of the neck) tube, of one applicably sampled resident, out of a total sample of two discharged residents. Specifically, facility staff failed to provide necessary respiratory care when Resident #89 required assistance to manage his/her laryngectomy tube and experienced a decline in respiratory status on [DATE], and nursing staff administered oxygen and nebulizer (drug delivery device used to administer medication in the form of… …
F695 citations in Massachusetts
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
Massachusetts cites F695 less often than its own record predicts
0.91 times the national share — cited less often here than elsewhere.
Of every deficiency written in Massachusetts 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 Massachusetts surveyors wrote
F695 findings written in Massachusetts, 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 interview, the facility failed to ensure that respiratory care and services consistent with professional standards of practice, and in accordance with physician's orders were provided for two Residents (#44, and #109) out of a total sample of 27 residents. Specifically: 1. For Resident #44 the facility failed to, ensure oxygen tubing was changed and dated accurately and ensure the oxygen filter was wiped down. 2. For Resident #109, the facility failed to ensure that a significant change in respiratory status was monitored, assessed, medications ordered by the physician were utilized, and changes in condition were reported timely to the physician for Resident #109; resulting in oxygenation levels falling below parameters, and subsequent death. …
Based on observations, record review, and interviews, the facility failed to provide respiratory care services in accordance with professional standards of practice for three Residents (#9, #38, and #15) out of a total sample of 23 residents. Specifically, the facility failed to: 1.Ensure Resident #9's oxygen administration included humidification in accordance with the medical plan of care. 2a. Ensure Resident #38's nebulizer equipment was changed in a timely manner. 2b. Ensure Resident #15's nebulizer equipment was cleaned, bagged, and dated. Findings include: 1. For Resident #9, the facility failed to ensure the administration of oxygen included humidification in accordance with the medical plan of care. …
The short window
Recent years
| Year | Share of Massachusetts citations | vs expected |
|---|---|---|
| 2023 | 2.84% | 1.22× |
| 2024 | 2.72% | 1.23× |
| 2025 | 2.01% | 0.91× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Massachusetts surveyors cite →
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