Based on clinical record review, facility documentation review, facility policy review, and interviews for one of five residents (Resident #1) reviewed for advanced directives, the facility failed to ensure staff addressed Resident #1's Advanced Directive choices (full code vs. do not resuscitate) upon readmission in accordance with facility policy. This resulted in contradictory information in the medical record which cause confusion when R #1 was found without a pulse and respirations and staff did not initiate Cardiopulmonary Resuscitation (CPR) timely resulting in a finding of Immediate Jeopardy. The finding includes: Resident #1's diagnoses included diabetes, gangrene, major depressive disorder, anxiety, and acquired absence of left leg above knee. …
F578 citations in Connecticut
Advance directives · Resident Rights Deficiencies
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Connecticut cites F578 more often than its own record predicts
1.32 times the share F578 takes of citations nationally.
Of every deficiency written in Connecticut in 2025, this is the portion that was F578.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Connecticut surveyors wrote
F578 findings written in Connecticut, 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 review of the clinical record, facility documentation, facility policy, and interviews for 1 of 16 residents (Resident #6) reviewed for advance directives, the facility did not review the residents wish for code status with the resident representative for 10 months following admission to the facility. The findings include:Resident #6 was admitted to the facility on [DATE] with diagnoses that included dementia, history of falling, and muscle weakness. The care plan dated 10/24/25 identified Resident #6 needed staff assistance with ADLs. Interventions included advance directives per MD orders. The care plan also identified Resident #6 had impaired cognition and decision-making skills. …
Based on interviews, facility documentation review, and facility policy for 2 of 24 sampled residents (Resident #2 and Resident #18) reviewed for advance directives the facility failed to obtain and transcribe physician's orders to the electronic clinical record. The findings include:1. Resident #2's diagnoses included chronic obstructive pulmonary disease, chronic respiratory failure and obesity.Review of the Medical Interventions Consent form dated [DATE] located in Resident #2's chart identified signed advance directives for a full code (resuscitate if unresponsive).The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #2 had a Brief Interview of Mental Status of 15 indicating intact cognition, required set up with eating, and was dependent on all other… …
The short window
Recent years
| Year | Share of Connecticut citations | vs expected |
|---|---|---|
| 2023 | 2.09% | 1.96× |
| 2024 | 1.60% | 1.63× |
| 2025 | 1.25% | 1.32× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Connecticut surveyors cite →
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