Based on surveyor observation, clinical record review, and staff interview, the facility failed to provide necessary respiratory care and services in accordance with professional standards of practice for a resident who requires mechanical ventilation (a life-support therapy that assists or replaces natural breathing by delivering oxygen and removing carbon dioxide through a ventilator) who experienced chest pain and was sent via rescue to an acute care hospital for evaluation, Resident ID #1, who ultimately expired in transit to the hospital. …
F695 citations in Rhode Island
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
Rhode Island cites F695 less often than its own record predicts
0.71 times the national share — cited less often here than elsewhere.
Of every deficiency written in Rhode Island 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 Rhode Island surveyors wrote
F695 findings written in Rhode Island, 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 surveyor observation, record review, and staff interview, it has been determined that the facility failed to provide respiratory care consistent with professional standards of practice for 1 of 4 residents reviewed for oxygen therapy, Resident ID #105.Findings are as follows:Review of the policy titled, OXYGEN - CYLINDERS dated 1/2023, states in part, .Oxygen is administered by Licensed Nurses with a Physician's Order in order to provide a resident with sufficient oxygen to their blood and tissues.PROCEDURE: .Look at the pressure gauge to determine how much oxygen is in the cylinder. …
Based on surveyor observation, clinical record review, and staff interview, the facility failed to provide respiratory care consistent with professional standards of practice for 1 of 3 residents reviewed for oxygen therapy, Resident ID #33.Findings are as follows:Record review revealed the resident was readmitted to the facility in January of 2026 with a diagnosis including, but not limited to, atrial fibrillation (an irregular heart rhythm which can cause symptoms such as heart palpitations, and shortness of breath).Record review revealed a physician's order dated 12/18/2025 for oxygen at 2-4 liters per minute (LPM) via nasal cannula for shortness of breath every shift, as needed.During surveyor observations the resident was noted to be receiving oxygen outside of the ordered LPM, on the… …
The short window
Recent years
| Year | Share of Rhode Island citations | vs expected |
|---|---|---|
| 2023 | 1.52% | 0.65× |
| 2024 | 2.07% | 0.94× |
| 2025 | 1.56% | 0.71× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Rhode Island 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