Based on review of facility policy, facility documentation, clinical records, observations, and staff interviews it was determined the facility failed to ensure emergency equipment readily available for accidental extubation for a resident with a tracheostomy (An extubation creates an emergency situation that requires that an obturator be readily available that can be used by competent staff for reinsertion) for one of two residents reviewed (Resident R130). Facility staff were unaware of the location of emergency equipment or how to use it in case of accidental extubation, resulting in an Immediate Jeopardy situation (Resident R130). …
F695 citations in Pennsylvania
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
Pennsylvania cites F695 less often than its own record predicts
0.98 times the national share — cited less often here than elsewhere.
Of every deficiency written in Pennsylvania 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 Pennsylvania surveyors wrote
F695 findings written in Pennsylvania, 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 review of facility policy, clinical records, and staff interview it was determined that the facility failed to follow a physician order for a Bipap device (a positive airway pressure machine when breathing in and breathing out) and failed to act on a malfunctioning Bipap in a timely manner for one of three residents (Resident R2) which resulted in actual harm of dyspnea (difficulty breathing), hypoxemia (a low level of oxygen in the blood), hypercapnia (too much carbon dioxide in the blood stream), requiring an intensive care unit (ICU - specialized hospital department where critically ill patients receive intensive, round-the-clock care) admission for Bipap. …
Based on review of facility policy, clinical records, staff interview, and observations, it was determined that the facility failed to provide appropriate respiratory care for three of four residents (Resident R1, R2, and R3).Findings include: Review of facility policy Oxygen Administration dated 7/17/26, indicated clinicians with demonstrated competence will administer oxygen via the specified route ordered by a provider. Change tubing, mask, cannula weekly. Change prefilled humidifier bottle when empty. Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE]. …
The short window
Recent years
| Year | Share of Pennsylvania citations | vs expected |
|---|---|---|
| 2023 | 1.84% | 0.79× |
| 2024 | 2.16% | 0.98× |
| 2025 | 2.16% | 0.98× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Pennsylvania 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