Based on observation, staff interviews, and record review, the facility failed to initiate Cardiopulmonary Resuscitation (CPR) in a timely manner to an unresponsive resident who had full code status. This was evident in one (Resident #3) of three residents sampled for cardiopulmonary resuscitation. Specifically, on [DATE] at approximately 6:40 PM, staff entered Resident #3's room without emergency medical equipment after being alerted by a family member that the resident was unresponsive. Registered Nurses #11 and #12 failed to initiate any emergency response and action. As a result, approximately 15 minutes had passed before cardiopulmonary resuscitation was initiated, and ultimately, Resident #3 expired at 7:22 PM. …
F678 citations in New York
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
New York cites F678 more often than its own record predicts
1.41 times the share F678 takes of citations nationally.
Of every deficiency written in New York 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 New York surveyors wrote
F678 findings written in New York, 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 observations, record review, and interviews during the abbreviated (IQIES 2600078) survey, the facility did not ensure provision of emergency basic life support immediately when needed, for one (1) of three (3) residents (Resident #1) reviewed. Specifically, Resident #1 was found in the dining room unresponsive and without a pulse and staff did not initiate cardiopulmonary resuscitation (chest compressions and rescue breathing) immediately and moved the resident to their room to start cardiopulmonary resuscitation.Findings include: The facility policy Cardiopulmonary Resuscitation. …
Based on interviews and record review conducted during a survey, the facility failed to check the code status to an unresponsive resident who had a Do Not Resuscitate (DNR) Order with Advance Directives in place for one (1) (Resident #1) of three (3) residents reviewed. Specifically, Resident #1 was found unresponsive on [DATE] at 2:09 PM, without a pulse, respirations, or blood pressure by Licensed Practical Nurse #1. Licensed Practical Nurse #1 failed to check code status of Resident #1 and initiated Cardiopulmonary Resuscitation (CPR). Based on interviews and record review it was determined the facility corrected the non-compliance as of [DATE] and was cited at Past Noncompliance. …
The short window
Recent years
| Year | Share of New York citations | vs expected |
|---|---|---|
| 2023 | 0.10% | 0.56× |
| 2024 | 0.18% | 0.83× |
| 2025 | 0.26% | 1.41× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else New York surveyors cite →
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