Based on interview, record review and review of the facility's policy, the facility failed to ensure Cardiopulmonary Resuscitation (CPR) was initiated for one (Resident (R) 1) of 19 sampled residents reviewed for Advance Directives. Staff found R1 unresponsive on 11/09/2025 without pulse or respiration. R1 was a Full Code status (indicating that CPR should be performed if the resident was found without vital signs); however, no lifesaving measures were attempted. On 03/04/2026 at 3:10 PM, the Administrator was provided a copy of the CMS Immediate Jeopardy (IJ) Template and was notified the failure to ensure residents were provided CPR was likely to cause serious injury, impairment, or death. …
F678 citations in Kentucky
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
Kentucky cites F678 less often than its own record predicts
0.77 times the national share — cited less often here than elsewhere.
Of every deficiency written in Kentucky 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 Kentucky surveyors wrote
F678 findings written in Kentucky, 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, record review, and review of facility policy, the facility failed to ensure that the electronic medical record reflected the resident's choice of code status for one of 19 sampled residents (Resident (R) 3) reviewed for advance directives. Record review revealed R3 initially expressed a desire to initiate a code status of Do Not Resuscitate (DNR). However, the code status reflected in the physician order was to be Full Code with no documented evidence that this was the resident and/or their health surrogate's current choice. …
The short window
Recent years
| Year | Share of Kentucky citations | vs expected |
|---|---|---|
| 2024 | 0.60% | 2.85× |
| 2025 | 0.14% | 0.77× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Kentucky surveyors cite →
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