Based on observation, record review and interview of the staff, physician, Respiratory Therapist, and resident, the facility failed to provide necessary respiratory care and services that met the need for Resident #46 to maintain a clear airway from tracheal secretions and frequent coughing which resulted in five trips in a two- and one-half week period of time to the Emergency Department (ED) to clear her airway and treat [CONDITION(S)]. The facility failed to seek medical attention for Resident #505 when he complained of shortness of breath earlier in the night which resulted in low oxygen of 50% (out of 100%) by early morning. Emergency medical services were required, and a non-rebreather oxygen mask (high level oxygen flow) was needed and treatment at the Emergency Department. …
F695 citations in North Carolina
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
North Carolina cites F695 more often than its own record predicts
1.46 times the share F695 takes of citations nationally.
Of every deficiency written in North Carolina 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 North Carolina surveyors wrote
F695 findings written in North Carolina, 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 Medical Director interview, the facility failed to provide tracheostomy (a hole surgeons make through the front of the neck and into the windpipe, also known as the trachea) care consistent with professional standards of practice for 1 of 1 resident observed for tracheostomy care (Resident #9). In addition, the facility administered supplemental oxygen for 5 days without a physician order for 1 of 3 residents investigated for oxygen therapy (Resident #126). The findings included: 1. …
Based on record review, observation and staff interviews, the facility failed to obtain an order for [REDACTED]. Findings included: Resident #63 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A nursing note dated 10/15/2019 at 11:00 PM noted that Resident #63 had a low oxygen saturation level of 85 % (normal 88-99%) and the nurse applied oxygen at 2 liters per minute by a nasal cannula. A review of the physician orders [REDACTED]. The most recent quarterly Minimum Data Set assessment dated [DATE] assessed Resident #63 to be severely cognitively impaired and she did not to use oxygen. Resident #63's treatment administration record and Medication Administration Record [REDACTED]. Resident #63 was observed on 12/16/2019 at 12:08 PM in bed. …
The short window
Recent years
| Year | Share of North Carolina citations | vs expected |
|---|---|---|
| 2023 | 1.59% | 0.68× |
| 2024 | 2.43% | 1.10× |
| 2025 | 3.23% | 1.46× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else North Carolina 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