Based on record review and interviews the facility failed to ensure basic life support was provided to one of three residents immediately according to the resident's requested code status signed in the POLST. Findings: Record review reflected documentation that the resident was found unresponsive, not breathing and appeared pale in the living room in a high back chair on (MONTH) 29, (YEAR). Time this occurred was not reflected in the medical record with the writer stating they last sighted the resident at approximately 10:30 AM, whom at the time requested to change the blanket. The Resident Care Manager (RCM) and the Director of Nursing (DON) were immediately notified. A nursing note in the progress notes dated [DATE] written at 04:01 PM stated Resident in DNR status. …
F678 citations in Hawaii
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
Hawaii cites F678 more often than its own record predicts
1.86 times the share F678 takes of citations nationally.
Of every deficiency written in Hawaii 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 Hawaii surveyors wrote
F678 findings written in Hawaii, 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 records and staff interviews, three of ten staff sampled for cardiopulmonary resuscitation (CPR) competency were not properly trained to provide basic life support subject to accepted professional guidelines. This deficient practice could result in the facility not providing the necessary care, placing residents at risk for decline in health status and/or death. Findings Include: A review of Cardiopulmonary Resuscitation (CPR) documentation for three staff was done on [DATE] at 11:15 AM. Documentation for Registered Nurse (RN) 11, Certified Nurse Aide (CNA) 12 and CNA13 reflects training from an online training course that does not provide hands-on practice and in-person skills assessment. …
What else Hawaii surveyors cite →
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