Based on interview and record review, facility staff failed to provide basic life support to a resident in accordance with physician orders and an advance directive for 1 resident (R) (R2) of 6 sampled residents.R2 was enrolled in Hospice services and was discovered pulseless and nonbreathing on [DATE]. At the time of the incident, R2 was a full code. Staff failed to check R2's code status, provide cardiopulmonary resuscitation (CPR) and basic life support, or call 911. The facility's failure to provide CPR/basic life support and call 911 for a full code status resident created a finding of immediate jeopardy that began on [DATE]. Nursing Home Administrator (NHA)-A was notified of the immediate jeopardy on [DATE] at 10:30 AM. …
F678 citations in Wisconsin
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
Wisconsin cites F678 more often than its own record predicts
1.40 times the share F678 takes of citations nationally.
Of every deficiency written in Wisconsin 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 Wisconsin surveyors wrote
F678 findings written in Wisconsin, 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 interviews, record review, and policy review, the facility licensed staff failed to ensure that cardiopulmonary resuscitation (CPR) was provided when resident was found unresponsive for one of three residents (Resident (R)1) reviewed for deaths out of a total sample of 11 residents. This failure had the potential to decrease the chance of survival for residents who required CPR. Findings include:Review of R1's admission Record located under the Profile tab in the electronic medical record (EMR) revealed R1 was admitted to the facility on [DATE]. R1 was discharged from the facility on [DATE] to a funeral home. R1 had diagnoses of gram-positive bacteremia (bacteria in the bloodstream), Parkinson's disease, seizure disorder or epilepsy, and difficulty in walking. …
The short window
Recent years
| Year | Share of Wisconsin citations | vs expected |
|---|---|---|
| 2023 | 0.39% | 2.08× |
| 2024 | 0.42% | 2.00× |
| 2025 | 0.26% | 1.40× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Wisconsin surveyors cite →
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