Based on medical record review, staff and physician interview, and policy review, the facility failed to provide CPR in accordance with a resident's advance directive for 1 of 1 sample resident (#36) who expired. The emergency happened shortly after admission. The facility had not identified the issue, which left all new admits at risk and a determination of immediate jeopardy. The census was 35 and there were two new admits in the last 30 days. The findings were: 1. Medical record review for resident #36 showed an admission and discharge date of [DATE]. Further review showed the resident signed the admission paperwork, including a POLST [physician orders for life-sustaining treatment] dated [DATE] that indicated the resident chose to be a full code. …
F678 citations in Wyoming
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 — 2024
Wyoming cites F678 more often than its own record predicts
4.23 times the share F678 takes of citations nationally.
Of every deficiency written in Wyoming in 2024, 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 Wyoming surveyors wrote
F678 findings written in Wyoming, 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 medical record review, staff interview, review of the facility policy and procedure, review of a facility performance improvement plan, and review of professional standards, the facility failed to ensure basic life support was administered to 1 of 1 sample resident (#10) who required and elected cardio-pulmonary resuscitation. This failure resulted in actual harm to resident #10, who went into [CONDITION(S)] and did not receive CPR. The findings were: 1. Review of undated WyoPOLST which was signed by resident #10 and located in the resident's medical record on [DATE] showed the resident elected to have CPR/attempt resuscitation if s/he was found to have no pulse and was not breathing. 2. …
Based on medical record review, staff interview, incident log review, and incident investigation review the facility failed to ensure basic life support and advance directives were followed in 1 of 5 sample residents (#1) reviewed for advance directives. Corrective measures were implemented by the facility prior to the survey and compliance was determined to be met on [DATE]. The findings were: 1. Review the admission minimum data set (MDS) assessment dated [DATE] showed resident #1 had a brief interview for mental status (BIMS) score of 12 out of 15, which indicated moderate cognitive impairment, and diagnoses which included medically complex conditions, atrial fibrillation or other dysrhythmias, pneumonia, depression, respiratory failure, and anxiety disorder. …
What else Wyoming surveyors cite →
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