The incident occurred at Aviata at Central Park when Staff H, a certified nursing assistant, admitted to performing chest compressions on Resident #1 despite lacking CPR certification. The facility's administrator confirmed during an October interview that Staff H should not have performed the procedure.
"CPR is not in the CNA's job description and Staff H, CNA should not have performed chest compressions on Resident #1," the nursing home administrator told inspectors.
The emergency began when Staff B yelled for help to Resident #1's room. Staff A, a licensed practical nurse, immediately responded and found the resident unresponsive. She ran to get a blood pressure machine, called a rapid response, and verified the resident's code status.
Multiple staff members rushed to the scene. Staff C, an LPN, began directing the response while Staff F, a CNA, initially started compressions. But the response became chaotic as staff members switched roles.
"I requested to switch," Staff F later told inspectors. Staff C checked for a pulse, then Staff H began compressions. Another female staff member was prepared to take over from Staff H "but just froze up," according to Staff F's account.
Staff F jumped back in to continue compressions until EMS arrived and took over care.
The facility's own policy requires that "two licensed nurses" verify resident identification and any do-not-resuscitate orders before beginning CPR. The policy states that cardiopulmonary resuscitation will be provided to residents in cardiac arrest unless they have a fully executed Florida DNR order.
Staff D, another LPN, described arriving at the scene after Staff A announced the emergency at the nurse station. "Staff C, LPN was already performing compressions on Resident #1 when we arrived at the room. Staff F, CNA and Staff H, CNA were standing next to the bed," Staff D recalled.
Staff E, a registered nurse, provided a different timeline of events. She said when she arrived after calling code blue over the speakers, "the staff were not yet performing CPR; they determined Resident #1 was too heavy to move to the floor."
Staff C asked for the crash cart and backboard. "Upon returning with the backboard and cart, Staff C, LPN was performing chest compressions," Staff E said.
The confusion extended beyond the response itself. Staff E left the room once other licensed nurses were present, following what she understood to be proper protocol.
Inspectors made multiple attempts to reach Staff H by phone but received no response. A review of the facility's employee records showed no CPR certification on file for the nursing assistant.
The administrator acknowledged during the facility's internal review that Staff H had admitted to performing chest compressions without certification. The policy clearly designates "licensed nurses certified in CPR" as the expected staff members to perform the procedure.
Federal regulations require nursing homes to ensure staff are properly trained and certified for the duties they perform, particularly during medical emergencies. The violation was classified as causing minimal harm or potential for actual harm to few residents.
The incident highlights gaps in emergency response protocols at the 120-bed facility. While multiple staff members held current CPR certifications, the response devolved into an uncoordinated effort with an uncertified assistant performing a critical medical procedure.
Staff F confirmed being certified in CPR, as did Staff A, Staff D, and Staff E. The presence of multiple certified personnel makes Staff H's involvement in chest compressions particularly concerning to regulators.
The facility's policy requires immediate notification of physicians and resident representatives following cardiac events, along with proper documentation in medical records. The policy also mandates that CPR continue until emergency medical technicians assume responsibility or the resident responds.
EMS ultimately took over care of Resident #1, but the inspection report does not detail the resident's outcome following the emergency response.
The administrator's admission that the facility's internal review identified the certification violation suggests the facility was aware of the policy breach before federal inspectors arrived. The inspection was conducted in response to a complaint filed with state regulators.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Aviata At Central Park from 2025-10-08 including all violations, facility responses, and corrective action plans.