Based on observation, interview, record review and review of other documentation as indicated, it was determined for one (R1) out of three residents reviewed for change of condition, the facility failed to initiate CPR for R1, who was choking and became hypoxic and unresponsive. The RN supervisor did not assess R1's airway or respiratory status after choking and only delegated applying a non-rebreather mask and preparing for transfer without initiating CPR or further emergency intervention. The facility's failure resulted in R1 death. Due to this failure an Immediate Jeopardy (IJ) was called at 1:58 PM on 7/3/25. Findings include: Cross Refer F726A facility policy last reviewed 1/3/25 for Code Status Policy documented. …
F678 citations in Delaware
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
Delaware cites F678 more often than its own record predicts
1.17 times the share F678 takes of citations nationally.
Of every deficiency written in Delaware 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 Delaware surveyors wrote
F678 findings written in Delaware, 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 record review, interview, and review of other documentation as indicated, it was determined that the facility failed to provide CPR, consistent with current guidelines which includes staff competency for implementation of emergency interventions for cardiac/respiratory complications, and failed to include the provision of appropriate equipment with immediate access for one (R1) out of 5 sampled residents. R1 on the morning of [DATE] developed signs and symptoms of respiratory distress and the need for emergent care including CPR. Following R1's signs and symptoms of respiratory distress, the facility failed to administer CPR in accordance with current acceptable guidelines. …
What else Delaware surveyors cite →
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