F695 in Virginia. Pick another state for the same tag.
Against expectation — 2025
Virginia cites F695 more often than its own record predicts
Versus expected share1.18×
1.18 times the share F695 takes of citations nationally.
Share of Virginia citations2.60%
Of every deficiency written in Virginia in 2025, this is the portion that was F695.
Virginia2.60%
National2.20%
Share of all citations that were F695.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Virginia surveyors wrote
F695 findings written in Virginia, 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.
J · Immediate jeopardy, isolatedDecember 20, 2022
Based on observations, interviews, document review, and in the course of a complaint investigation, the facility staff failed to provide respiratory therapy care and services to address the needs of four (4) of eight (8) sampled residents with ventilator orders (Resident #1, Resident #2, Resident #3, and Resident #4). For Resident #1, On [DATE] at 3:50 P.M., Immediate Jeopardy-Past Noncompliance was called, and lowered to a D. Resident #2, Resident #3, and Resident #4 were included in the Past non-compliance designation.
The findings include:
1. The facility staff failed to implement Resident #1's medical provider's ventilator orders to ensure the resident was provided the necessary ventilation and oxygen. …
Based on Resident interview, staff interview, facility documentation review, and clinical record review, the facility staff failed to provide respiratory care and services to maintain the highest practicable wellbeing for one resident, (Resident #1) in a survey sample of 2 residents resulting in harm for Resident #1.
The findings included:
For Resident #1, the facility staff failed to assess and monitor the Resident's respiratory status and intervene with appropriate measures prior to the death of the Resident who was suffering labored breathing & respiratory difficulty. No other tracheostomy Residents were residing in the facility at the time of survey so could not be added to the sample.
Resident #1 was a discharged Resident so a closed record review was conducted. …
D · No harm, potential for more than minimal, isolatedJuly 10, 2026
Based on Staff interview, clinical record review, hospital record review, and facility document review, the facility staff failed to obtain and provide appropriate oxygen orders during a change in condition event for one Resident (Resident #100) in a survey sample of 13 residents.The findings included;Resident #100 was admitted to the facility on [DATE] with diagnoses including; encephalopathy, heart attack, hypertension, diabetes, chronic kidney disease stage 3, dysphagia, sick sinus cardiac syndrome, transient Ischemic attack [TIA], bradycardia, atherosclerotic cardiovascular disease, heart failure, and cerebral atherosclerosis.The Resident's most recent Minimum Data Set [MDS] assessment was a five day assessment and coded the Resident with severe cognitive impairment, memory problems,… …
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