Based on observation, record review, and staff review, the facility failed to ensure Resident #111 received respiratory care to ensure Resident #111's airway remained intact and was able to be reestablished immediately if the tracheotomy tube would become dislodged. This was true for one (1) resident reviewed for the care area of Respiratory care during the long term care survey process. The facility failed to ensure they had the supplies at bedside to replace Resident #111's tracheotomy canula. The physician orders and Resident #111's care plan dictated the supplies were to be kept at bedside. When the staff was asked were the supplies were to replace the canula were located, it took greater than 15 minutes to find the needed supplies in the supply closet. …
F695 citations in West Virginia
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
West Virginia cites F695 less often than its own record predicts
0.29 times the national share — cited less often here than elsewhere.
Of every deficiency written in West Virginia 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 West Virginia surveyors wrote
F695 findings written in West 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.
Based on resident facility record review, medical record review, and staff interview, the facility failed to ensure that a resident's respiratory care was provided consistent with professional standards of practice. A resident's oxygen concentrator was set at a lower liter than ordered. This was a random opportunity for discover identified during a complaint survey. Resident identifier: #66. Facility census: 65. Findings included: a) Resident #66 On 05/20/24 at approximately 7:00 PM during a record review of the facility reported incident involving the allegation of neglect on 04/12/24 for Resident #66, it was identified that the daughter of Resident #66 found the resident lying flat in bed, lethargic and difficult to arouse. …
Based on observation, record review and staff interview, the facility failed to administer oxygen to Resident #29 and Resident #4 at the correct rate. This was true for two (2) of two (2) residents sampled for oxygen during the Long-Term Care Survey process. Resident Identifiers: #29, #4. Facility Census: 36.Findings included: a) Resident #29 Resident #29 was observed, at 1:07 PM on 08/03/26, with her oxygen set to four (4) liters per minute. At 1:10 PM, the Director of Nursing (DON) stated that Resident #29's oxygen was set to four (4) liters per minute and it is not supposed to be. The physician order for Resident #29 stated, Oxygen at two (2) liters per minute via nasal cannula continuously. …
The short window
Recent years
| Year | Share of West Virginia citations | vs expected |
|---|---|---|
| 2023 | 2.27% | 0.97× |
| 2024 | 0.89% | 0.41× |
| 2025 | 0.64% | 0.29× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else West Virginia surveyors cite →
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