Based on observation, record review, and interviews, the facility did not ensure that a resident (R) received tracheal/stoma (soft tissue opening in tracheal airway) suctioning of respiratory secretions to maintain adequate respiratory care in accordance with professional standards of practice for 1 of 1 resident (R17) with a tracheostomy/stoma. R17 has tracheostomy from a laryngectomy. R17 has a build-up of secretions and a history of mucous plugs in R17's airway, which have required emergency room (ER) visits on 7 occasions from 1/13/25 - 4/28/25. …
F695 citations in Wisconsin
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
Wisconsin cites F695 less often than its own record predicts
0.73 times the national share — cited less often here than elsewhere.
Of every deficiency written in Wisconsin 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 Wisconsin surveyors wrote
F695 findings written in Wisconsin, 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 staff interview and record review, the facility did not provide the necessary respiratory care and services 1 of 1 (R52) sampled residents.R52 had orders to use Bilevel Positive Airway Pressure (BIPAP), BIPAP settings were not transcribed, and the facility did not ensure staff had the right settings for usage, did not ensure it was being worn, and did not contact R52's physician after refusals to wear the BIPAP, no evidence of Risk. Vs benefits being provided regarding refusals resulting in R52 being sent to the hospital for exacerbation of acute respiratory failure with hypoxia (low oxygen levels in the body tissues) and hypercarbia (elevated levels of carbon dioxide in the blood).Evidenced by:R52 was admitted to the facility from the hospital on 9/10/25 and has diagnoses that… …
Based on interview, and record review, the facility did not provide the necessary respiratory care and services for 1 resident (R) (R12) of 1 sampled resident.R12 received supplemental oxygen. R12 did not have a care plan for oxygen use. In addition, staff did not document that R12 received oxygen.Findings include:The facility's Oxygen Administration policy indicates: Oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care planand the resident's goals and preferences .1. Oxygen is administered under the orders of a physician, except in the case of an emergency. In such case, oxygen is administered and orders for oxygen are obtained as soon as practicable when the situation is under control. 2. …
The short window
Recent years
| Year | Share of Wisconsin citations | vs expected |
|---|---|---|
| 2023 | 1.11% | 0.48× |
| 2024 | 1.19% | 0.54× |
| 2025 | 1.60% | 0.73× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Wisconsin 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