Based on interview, and record review, the facility's staff failed to immediately initiate Cardiopulmonary Resuscitation ([CPR] an emergency procedure to restart a person's heart and breathing after one or both suddenly stop) to one of five sampled residents (Resident 1), when Certified Nurse Assistant (CNA) 1 and CNA 2, who were CPR certified (successfully completed a training course and received a credential that qualifies a person to perform CPR), failed to check Residents 1's pulse, breathing and obtain immediate assistance to initiate CPR, activate a code blue (a specific code used to signal a patient who is having a life threatening medical emergency, typically a patient experiencing sudden cardiac arrest [when the heart stops] and/or respiratory arrest [when a person stops… …
F678 citations in California
Quality of Life and Care Deficiencies
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
California cites F678 less often than its own record predicts
0.73 times the national share — cited less often here than elsewhere.
Of every deficiency written in California in 2025, this is the portion that was F678.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What California surveyors wrote
F678 findings written in California, 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 interview and record review, the facility failed to provide care and treatment in accordance with professional standards of practice and resident's needs for Resident 1 by failing to administer oxygen (a life sustaining gas that travels from lungs to the blood and helps convert food into energy), when Resident 1 was found with critically low oxygen levels in the blood (a dangerous, life-threatening condition when the oxygen not reaching body tissues often causing confusion, rapid breathing, and altered level of consciousness-a change in arousal and responsiveness that ranges from mild to severe e.g. lethargy to coma state). …
Based on interview and record review, the facility failed to confirm one of 26 sampled residents (Resident 96's) code status in an emergency, when Licensed Nurse (LN) 3 did not follow Resident 96's physician's order to do not attempt resuscitation (DNR). This failure resulted in delivering unwanted life-sustaining treatment that was inconsistent with Resident 96's wishes. Findings: A review of an admission record indicated Resident 96 was readmitted to the facility on [DATE] with a diagnosis of congestive heart failure (a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling).A review of Resident 96's Progress Notes, dated [DATE], indicated Resident 96 was found unresponsive on [DATE] and cardiopulmonary resuscitation (CPR; a… …
The short window
Recent years
| Year | Share of California citations | vs expected |
|---|---|---|
| 2023 | 0.16% | 0.86× |
| 2024 | 0.18% | 0.87× |
| 2025 | 0.13% | 0.73× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else California surveyors cite →
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