Based on Named State Medicaid Long Term Care Program requirements, policy review, medical record review, and interview, the facility failed to provide the necessary mechanical ventilator audible alarm, redundant external alarm system, response processes, and monitoring processes of continuous pulse oximetry (a process to measure the oxygen level in the blood) and end tidal carbon [MEDICATION(S)] (ETCO2) (the level of carbon [MEDICATION(S)] that is released at the end of an exhaled breath) or ETCO2 monitoring for 1 of 4 sampled residents (Resident #7) on mechanical ventilation. The facility's failure resulted in Immediate Jeopardy when Resident #7 was found unresponsive and no mechanical ventilator or pulse oximetry alarms sounded. …
F695 citations in Tennessee
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
Tennessee cites F695 more often than its own record predicts
1.41 times the share F695 takes of citations nationally.
Of every deficiency written in Tennessee 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 Tennessee surveyors wrote
F695 findings written in Tennessee, 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 facility policy review, medical record review, observation, and interview, the facility failed to perform tracheostomy (trach) (a surgically created opening in the front of the neck leading to the windpipe/trachea for breathing) care to maintain infection control practices during trach care for 1 resident (Resident #11) of 1 resident reviewed for tracheostomies and the facility failed to ensure oxygen was administered according to Physician's Orders for 1 resident (Residents #25) of 10 residents reviewed for oxygen (O2) therapy. …
The short window
Recent years
| Year | Share of Tennessee citations | vs expected |
|---|---|---|
| 2023 | 1.49% | 0.64× |
| 2024 | 1.95% | 0.88× |
| 2025 | 3.11% | 1.41× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Tennessee 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