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F0695
D

Failure to Provide Continuous Respiratory Therapy Coverage

Colton, California Survey Completed on 11-18-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide continuous respiratory therapy coverage for 41 residents when no respiratory therapist (RT) was on duty for approximately seven hours during a night shift. Interviews with a resident and multiple staff members confirmed that the scheduled RTs called off, and no replacement was found. As a result, there was a gap in RT coverage from 10:10 PM until 4:55 AM the following morning. During this period, a resident reported that nurses were unable to operate their respiratory equipment, leading the resident to remain off the machine, although they had been suctioned before the RT left. Review of the respiratory therapist timesheets corroborated the absence of RT staff during the specified hours. The Director of Nursing acknowledged that the facility did not follow its own staffing policy, which requires sufficient numbers of staff with the necessary skills and competency to provide care in accordance with resident care plans and the facility assessment. The lack of RT coverage was confirmed by both the timesheets and staff interviews.

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