Based on interview and record review, the facility failed to ensure care staff, including licensed nurses, were proficient in the care of a tracheotomy (a tube placed through an opening in the windpipe for respiration), prior to accepting one resident with a tracheotomy, (Resident #1) of four sampled residents. The facility failed to ensure the resident's baseline care plan addressed his/her tracheotomy, failed to ensure orders were in place regarding care of the tracheotomy, and failed to ensure staff were trained to appropriately place an ambu bag (a hand-held device commonly used to provide positive pressure ventilation to residents who are not breathing or not breathing adequately) to provide respirations for a resident with a tracheotomy during cardiopulmonary resuscitation (CPR). …
F695 citations in Missouri
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
Missouri cites F695 less often than its own record predicts
0.89 times the national share — cited less often here than elsewhere.
Of every deficiency written in Missouri 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 Missouri surveyors wrote
F695 findings written in Missouri, 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 interview and record review, the facility failed to provide respiratory care consistent with standards of practice when staff failed to administer oxygen as ordered, failed to notify the physician of respiratory changes, and failed to create a timely comprehensive care plan that addressed oxygen usage for one residents (Resident #1). The resident went into respiratory distress and was sent to the emergency department. The facility census was 46. Review showed the facility did not provide a policy regarding change of condition procedures. Review showed the facility did not provide a policy regarding physician notification. 1. …
Based on observation, interview, and record review, the facility failed to ensure residents who needs tracheostomy (an opening surgically created through the neck into the trachea to allow an airway and to remove secretions from the lungs) care received the care consistent with professional standards of practice when the facility failed to accurately assess the resident's tracheostomy type, failed to document and implement physician orders related to tracheostomy disposable inner cannulas (a removable inner insert used inside a tracheostomy tube to clear mucus, prevent airway blockage, and simplify care), and failed to ensure the facility was able to obtain necessary supplies for tracheostomy treatment for one resident (Resident #1). …
The short window
Recent years
| Year | Share of Missouri citations | vs expected |
|---|---|---|
| 2023 | 1.68% | 0.72× |
| 2024 | 1.65% | 0.75× |
| 2025 | 1.96% | 0.89× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Missouri 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