Brentwood Health Center
Inspection Findings
F-Tag F0695
F 0695
Provide safe and appropriate respiratory care for a resident when needed.
Level of Harm - Minimal harm or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
record review and staff interview, it has been determined that the facility failed to ensure that each resident receives necessary respiratory care and services in accordance with professional standards of practice relative to a Bilevel Positive Airway Pressure device (BiPAP-a type of ventilator that assists with breathing and delivers two levels of air pressure, a higher pressure for inhalation and lower pressure for exhalation) for 1 of 1 resident reviewed, Resident ID #1.Findings are as follows:According to Mosby's 4th Edition, Fundamentals of Nursing, page 314 states in part, .The physician is responsible for directing medical treatment. Nurses are obligated to follow physician's orders unless they believe the orders are in error or would harm the clients .Record review revealed Resident ID #1 was readmitted to the facility on [DATE REDACTED] with
a diagnosis including, but not limited to, chronic respiratory failure with hypoxia (a serious condition characterized by the inability to effectively exchange carbon dioxide and oxygen).Record review of the resident's hospital discharge documents revealed a physician discharge instruction dated 11/3/2025 that states in part, .will require BiPAP during naps and nightly .Record review revealed a physician's order dated 11/3/2025 to administer BiPAP nightly.Record review of the November 2025 Treatment Administration
Record failed to reveal evidence that the resident received his/her BIPAP on 11/3, 11/4, 11/5 and 11/6/2025. Record review revealed a progress note dated 11/6/2025 authored by Nurse Practitioner, Staff A, indicated the resident experienced a recent hospitalization due to respiratory distress and was discharged back to the nursing home with instructions to use a BiPAP. Since readmission to the facility, they have been waiting for the BiPAP machine to be adjusted. The nursing staff reported that patient continued with a worsening condition, including shortness of breath, acute on chronic respiratory failure, and cough related to the fact that the patient still hasn't been able to use the BiPAP, as ordered.Additional record
review of a progress note dated 11/7/2025 authored by Nurse Practitioner, Staff B, indicated there was a concern that the resident's BiPAP machine is still pending arrival. During a surveyor interview on 11/19/2025 at 2:13 PM with Nurse Practitioner, Staff B, she revealed it would be her expectation that the resident would have received his/her BiPAP, as ordered.During a surveyor interview on 11/19/2025 at approximately 3:00 PM with the Director of Nursing Services, she revealed it would be her expectation that
the BiPAP would be obtained by the facility to administer to the resident within one day of readmission.
Additionally, she was unable to provide evidence that the BiPAP was administered as ordered until 11/7/2025, indicating the facility failed to provide this treatment for three days.
Residents Affected - Few
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99) Previous Versions Obsolete
Facility ID:
If continuation sheet
Event ID:
Brentwood Health Center in Warwick, RI inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in Warwick, RI, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Brentwood Health Center or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.