Based on record review and interview, the facility failed to immediately perform cardiopulmonary resuscitation (CPR) according to professional standards of care for one Resident (#89), who was a full code, out of a total sample of 26 residents. Specifically, after Resident #89 was found with no pulse the nurse on duty, whose CPR certification had expired, left the Resident in a room with a Certified Nursing Aide (CNA), while he retrieved life saving materials and called 911, delaying life saving CPR measures for Resident #89. Findings include: Review of the current American Heart Association: CPR (cardiopulmonary resuscitation) and First Aide indicates that CPR - or Cardiopulmonary Resuscitation - is an emergency lifesaving procedure performed when the heart stops beating. …
F678 citations in Massachusetts
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
Massachusetts cites F678 less often than its own record predicts
0.42 times the national share — cited less often here than elsewhere.
Of every deficiency written in Massachusetts 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 Massachusetts surveyors wrote
F678 findings written in Massachusetts, 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 records reviewed and interviews for one of three sampled resident's (Resident #1), who was a Full Code (Facility to interceded if a patient's heart stops beating or if the patient stops breathing), the facility failed to ensure Resident #1 was provided Cardiopulmonary Resuscitation (CPR), and that Emergency Medical Services (EMS) (911) were promptly notified of the need for emergent services, when on [DATE], Resident #1 who was having a life threatening medical emergency and required transfer to the Hospital Emergency Department, died . Findings Include: Pursuant to Massachusetts General Law (M.G.L.), chapter 112, individuals are given the designation of Registered Nurse and Practical Nurse which includes the responsibility to provide nursing care. …
Based on records reviewed and interviews for one of three sampled residents (Resident #1), who was found unresponsive by nursing staff and whose Physician's orders indicated he/she was a full code (in the event of cardiac or respiratory arrest, attempts at resuscitation will be initiated), the Facility failed to ensure nursing staff provided appropriate and necessary basic life saving measures to him/her that were consistent with his/her Advanced Directives and Physician orders. …
The short window
Recent years
| Year | Share of Massachusetts citations | vs expected |
|---|---|---|
| 2023 | 0.11% | 0.61× |
| 2024 | 0.03% | 0.14× |
| 2025 | 0.08% | 0.42× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Massachusetts surveyors cite →
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