F695 Respiratory Care: QA Review of Residents on Oxygen
Ensuring safe, consistent, and compliant oxygen therapy is a critical responsibility in skilled nursing facilities (SNFs). As of the 2025 survey year, F695 Respiratory Care remains one of the top ten most frequently cited deficiencies nationwide. In many cases, survey findings reveal preventable documentation gaps, missed equipment checks, and staff competency issues—making oxygen therapy a high-value area for continuous QAPI monitoring. A structured Quality Assurance (QA) review for residents on oxygen helps prevent negative outcomes, ensures adherence to SOM Appendix PP requirements, and protects the facility from avoidable citations.
Why Oxygen Therapy Requires Ongoing QAPI Oversight
Under §483.25(i), facilities must ensure that each resident who requires respiratory care—including oxygen therapy—receives treatment consistent with:
- Professional standards of practice
- Practitioner orders
- The individualized, person-centered care plan
- Facility policies and resources
- Resident goals and preferences
Because oxygen delivery touches multiple compliance domains—clinical care, infection control, safety, care planning, and nurse competency—even minor deviations can snowball into multi-tag citations.
A recurring QAPI review helps facilities:
- Identify care gaps before surveyors do
- Validate that staff competencies remain current
- Ensure accuracy between orders, MAR/TAR, and care plans
- Promote resident safety
- Reduce facility liability
Key Components of a QA Review for Oxygen Therapy
A comprehensive QA/monitoring tool should review the following elements for every resident receiving oxygen:
- Physician Orders Are Complete and Match Practice
Orders must clearly specify:
- Oxygen flow rate (LPM)
- Mode of administration (e.g., nasal cannula, mask)
- Frequency of SpO₂ monitoring
- Parameters for initiation/discontinuation (when applicable)
The care plan must reflect these orders and be updated when changes occur.
- Tubing, Filters, and Humidification Supplies Are Changed per Facility Policy
Surveyors frequently cite expired or unchanged respiratory equipment.
Confirm:
- Supplies are changed per policy and/or practitioner orders
- Humidification water is present when indicated
- No outdated or visibly soiled supplies remain in use
- Oxygen Tubing Is Dated
Undated tubing is one of the most common deficiencies.
During QA rounds, verify that:
- Tubing is dated at the time of replacement
- Dates are legible and current
- Staff can verbalize facility policy
- Ear Protectors Are Used
Residents using nasal cannulas continuously are at risk for skin breakdown.
QA should confirm:
- Ear protectors are in place
- Skin integrity is routinely assessed and documented
- Oxygen Is Delivered Exactly as Ordered
During observation:
- Ensure the flowmeter matches the order
- Confirm oxygen is on (when ordered as continuous)
- Identify whether “prn” or intermittent oxygen is being used appropriately
- Required Safety Signage Is Posted
This includes:
- “No Smoking—Oxygen in Use” signs on the resident’s room door or doorframe
- Additional signage in areas where portable tanks are stored
- Oxygen Tanks Are Secured
Portable tanks must always be:
- Secured in a rolling cart or
- Properly attached to the resident’s wheelchair
Loose or improperly stored tanks present major life safety risks.
Regulatory Standards: What Appendix PP Requires
SOM Appendix PP (F695) specifies that facilities must have:
✔ Sufficient qualified staff
Including individuals trained and competent in oxygen setup, troubleshooting, suctioning, equipment care, and emergency response.
✔ Comprehensive respiratory assessments
Records must reflect:
- Respiratory assessment findings
- Baseline SpO₂ values
- Resident response to oxygen therapy
- Clinical rationale for oxygen use
✔ Care plan interventions specific to the resident’s needs, such as:
- Delivery method and equipment
- Continuous vs. PRN usage
- Ordered flow rate
- Monitoring parameters
- Skin integrity monitoring for nasal cannula use
✔ Well-developed respiratory care policies
Created collaboratively by the DON, Medical Director, and respiratory therapist (when applicable), and implemented before admitting residents who require specialized respiratory services.
Importance of Staff Competency
Competency failures are a major driver of respiratory citations in 2025. Facilities must ensure staff can:
- Set up oxygen delivery equipment correctly
- Use, change, and date tubing
- Monitor and document SpO₂
- Recognize and report respiratory distress
- Understand ventilator/trach mask equipment when used in the facility
- Implement oxygen safety precautions
- Provide emergency response until help arrives
Gaps in staff knowledge have resulted in Immediate Jeopardy (IJ) findings this year—underscoring that competency validation is not optional.
2025 Examples of F695 Deficiencies
Below are real examples (de-identified) cited in the 2025 calendar year.
Immediate Jeopardy Examples
- Resident hospitalized due to obstructed tracheostomy inner cannula
The facility failed to ensure respiratory assessments and trach care were performed correctly, resulting in respiratory distress and hospitalization.
- Resident sent to MD appointment without adequate oxygen supply
Continuous oxygen user became unstable when the tank depleted; hospital transport was required.
- Staff lacked competencies in respiratory care on a ventilator unit
Examples included:
- Resident not placed on ventilator as ordered due to lack of RT staff
- Missing respiratory assessments on each shift
- Family member had to attach trach mask and perform suctioning because staff lacked the skill to do so
These represent classic IJ situations: failure of care, failure of competency, and immediate risk of serious harm.
Non-Jeopardy Citation Examples
- Undated and unchanged oxygen tubing
Resident reported tubing had not been changed; LPN was unaware of when it was last replaced; no current order existed.
- Oxygen administered without a practitioner’s order
Resident used oxygen PRN for shortness of breath, but no order was in place.
- Improper storage and infection control breaches
Nasal cannula attached to a portable tank was unbagged and hanging from the wheelchair, violating infection control standards.
These are preventable through routine QA audits and staff education.
Conclusion: Strengthen Your QA Process Now
Oxygen therapy is deceptively simple, but one of the most heavily scrutinized areas during SNF surveys. A facility’s QAPI program must include routine, structured, and ongoing audits to confirm:
- Orders match care and documentation
- Equipment is clean, dated, and safe
- Staff are competent in oxygen administration
- Safety precautions are consistently followed
By proactively reviewing all residents receiving oxygen, facilities can avoid the common pitfalls leading to F695 and related citations—while ensuring residents receive the safe, high-quality respiratory care they deserve.
Next steps: Schedule a 2026 mock survey with Proactive Nursing Home Consultants to drive quality and regulatory compliance in the New Year.
Written By:
Angie Hamer, RN, RAC-CT
Senior Consultant
Proactive LTC Consulting
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