This citation has two deficient practices. Deficient Practice Statement 1 Based on observation, interview, and record review, the facility failed to ensure an emergency tracheostomy (an incision into the windpipe made to relieve an obstruction to breathing) was accessible, resulting in the likelihood of serious injury, serious harm, serious impairment, or death for one resident (R138) who required mechanical ventilation. In an observation on 4/16/24 at 9:55 a.m., R138 laid in bed and had a tracheostomy (trach). There was not an emergency trach visible in R138's room. In an observation and interview on 4/16/24 at 10:32 a.m., Licensed Practical Nurse (LPN) L was asked about R138's emergency backup trach and could not locate one in R138's room. …
F695 citations in Michigan
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
Michigan cites F695 less often than its own record predicts
0.84 times the national share — cited less often here than elsewhere.
Of every deficiency written in Michigan 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 Michigan surveyors wrote
F695 findings written in Michigan, 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.
This Citation pertains to Intake#: MI00135254 Based on interviews and record reviews the facility failed to implement the physician order and provide the CPAP (Continuous Positive Airway Pressure machine-keeps the airway open by gently providing air through a mask while sleeping) machine during their entire length of stay for one of one Resident (R908) reviewed for respiratory care resulting in inadequate ventilation and respiratory distress requiring hospitalization . Findings include: R908 was admitted to facility on 2/9/23 for short-term skilled nursing and rehabilitation management after hospitalization . R908 was living the community prior to this hospitalization . …
This citation pertains to Intake Number: 3096069 Based on observation, interview, and record review, the facility failed to ensure respiratory care was provided according to physician's orders and plan of care for one (R32) of three residents reviewed for respiratory care, resulting in the resident calling 911 due to not being able to breathe and experiencing temporary hypoxemia (desaturation of oxygen levels in the blood). Findings include: A review of a complaint submitted to the State Agency revealed on 7/16/26, Patient (R32) called 911 directly on his cell phone at 0500 hrs (5:00 AM) because he was having difficulty breathing. (Local Fire Department) responded via priority response. …
The short window
Recent years
| Year | Share of Michigan citations | vs expected |
|---|---|---|
| 2023 | 1.89% | 0.81× |
| 2024 | 1.71% | 0.78× |
| 2025 | 1.86% | 0.84× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Michigan surveyors cite →
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