Based on interview and record review the facility failed to initiate Cardio-Pulmonary Resuscitation (CPR) timely for 1 (R1) of 4 residents reviewed for death in a sample of 15. This failure resulted in a delay in providing immediate emergency basic life support including CPR after finding R1 in his wheelchair with no pulse and no respirations. After CPR was initiated, R1 was transferred via ambulance to the local hospital and pronounced dead. The Immediate Jeopardy began on [DATE] at approximately 5:30 PM when R1 was found unresponsive in his room. V45 (Administrator), V42 (Regional Director of Operations), V18 (Regional Clinical Director), and V46 (Regional [NAME] President of Operations) were notified of the Immediate Jeopardy on [DATE] at 2:53 PM. …
F678 citations in Illinois
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
Illinois cites F678 less often than its own record predicts
0.99 times the national share — cited less often here than elsewhere.
Of every deficiency written in Illinois 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 Illinois surveyors wrote
F678 findings written in Illinois, 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 follow their Code Blue policy and practice by not announcing a code blue, not immediately starting Cardiopulmonary Resuscitation (CPR) and by stopping CPR before emergency team implemented efforts when a resident was observed unresponsive, irregular breathing, breathless and pulseless. This affects 1 of 3 residents (R9) reviewed for CPR. This failure resulted in a delay in emergency medical attention, Resident was found outside at 4:50am, 911 was called at 5:31am. The EMS team arrived to the resident at 5:39am and found R9 was pulseless, not breathing, rigor to jaw, with obvious signs of death, and no staff performing CPR, R9 was pronounced deceased at 5:49am. …
Based on interviews and record review, the facility failed to ensure that a nurse and CNA (Certified Nursing Assistant, CNA) maintained a current CPR (Cardiopulmonary Resuscitation) certification card while working in the facility.Findings include: On [DATE] at 9:45AM, a telephone interview was conducted with V4 (Former Employee), and V4 states that some staff are not CPR certified. On [DATE] at 11:31AM, V5 (Certified Nurse Assistant/CNA) states a valid, active CPR certification card is required to work as a CNA in this facility.On [DATE] at 11:51AM, V12 (CNA) states CPR certifications are required for all CNAs.On [DATE] at 12:35PM, surveyor first request was made via email for V15's (CNA) CPR certification card with request sent to V1 (Administrator), V2 (Assistant Administrator) and V3… …
The short window
Recent years
| Year | Share of Illinois citations | vs expected |
|---|---|---|
| 2023 | 0.13% | 0.69× |
| 2024 | 0.17% | 0.83× |
| 2025 | 0.18% | 0.99× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Illinois surveyors cite →
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