Based on interview and record review, the facility failed to immediately initiate cardiopulmonary resuscitation (CPR) and activate the emergency response system (EMS) when 1 of 1 residents, with a full code status (when a resident's heart stops being (SP) the medical team uses all available lifesaving measures) was found unresponsive. This resulted in an Immediate Jeopardy (IJ) citation when licensed practical nurse, (LPN)-A, was notified by nursing assistant (NA)-A that R1 was unresponsive. LPN-A immediately checked on R1 finding R1 cool to the touch, without pulse and was not breathing. …
F678 citations in Minnesota
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
Minnesota cites F678 less often than its own record predicts
0.85 times the national share — cited less often here than elsewhere.
Of every deficiency written in Minnesota 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 Minnesota surveyors wrote
F678 findings written in Minnesota, 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 document review, facility staff failed to provide emergency care for 1 of 9 residents reviewed, (R1), who requested cardio [MEDICAL CONDITION] resuscitation (CPR) and did not receive CPR when R1's heart stopped and respirations ceased. R1 was a full code status. Harm occurred when R1 passed away. Findings include: R1's quarterly Minimum Data Set (MDS) dated (MONTH) 20, (YEAR), indicated R1 was diagnosed with [REDACTED]. R1's facility admission face sheet dated (MONTH) 15, (YEAR), indicated R1's advance directive was to do CPR. R1's Provider Orders for Life-Sustaining Treatment (POLST) indicated CPR should be performed in the event R1 had no pulse and was not breathing. …
Based on observation, interview, and document review, the facility failed to update code status for 1 of 16 resident (R40) who requested to have his code status changed.Findings include:Document review on [DATE] at 4:51 p.m., R40 was identified to be a full code (Cardiopulmonary Resuscitation (CPR)) noted on his electronic medical record dashboard. Review of R40's Provider Orders for Life-Sustaining Treatment (POLST) signed by the resident and the physician identified he had changed his code status on [DATE] from CPR to Do not resuscitate (DNR).Interview on [DATE], at 2:00 p.m., with licensed practical nurse (LPN)-A identified if a resident's heart stops, they look at the dashboard to check code status, she explained the dashboard is at the top of a resident's main page in Point Click Care… …
The short window
Recent years
| Year | Share of Minnesota citations | vs expected |
|---|---|---|
| 2023 | 0.13% | 0.69× |
| 2024 | 0.28% | 1.31× |
| 2025 | 0.16% | 0.85× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Minnesota surveyors cite →
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