Based on interview and record review, it was determined that the facility failed to provide respiratory care and tracheostomy care to residents who required these services. Specifically, for 3 out of 9 sampled residents, staff did not follow physician orders for changing tracheostomies; staff were not obtaining needed consultations with outside providers; staff were not accurately documenting the resident condition prior to the tracheostomy change; staff did not initiate a hospital transfer for a resident with concerns about the integrity of the tracheostomy. Additionally, staff interviews revealed knowledge of faulty equipment with a resident experiencing a broken flange which caused a dislodged tracheostomy, and subsequently going into cardiac arrest and dying. …
F695 citations in Utah
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
Utah 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 Utah 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 Utah surveyors wrote
F695 findings written in Utah, 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 observation, interview, and record review, the facility did not ensure that a resident who needed respiratory care, was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. Specifically, for 1 out of 29 sampled residents, a resident with a bilevel positive airway pressure (BiPAP) machine was unable to use the machine due to missing parts. Resident identifier: 5.Findings included: Resident 5 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, chronic obstructive pulmonary disease, asthma, and obstructive sleep apnea.On 3/1/26 at 9:22 AM, an interview was conducted with resident 5. Resident 5 was observed with an oxygen concentrator. …
The short window
Recent years
| Year | Share of Utah citations | vs expected |
|---|---|---|
| 2023 | 1.39% | 0.59× |
| 2024 | 1.90% | 0.86× |
| 2025 | 1.56% | 0.71× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Utah surveyors cite →
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