Aviata at Tallahassee: CPR Withheld From Full Code Resident - FL
Nearly two hours passed.
Federal inspectors cited Aviata at Tallahassee for actual harm following an August 2025 complaint inspection, finding that the facility neglected to provide basic life support to a resident whose own care plan, advance directives, physician orders, and hospice nursing notes all said the same thing: full code.
The sequence of events, reconstructed from the inspection report, is precise and difficult to read.
At 1:05 PM, Staff A, a registered nurse, observed that the resident, identified in the report only as Resident 1, was not breathing. She checked vital signs. Respirations: zero. Blood pressure: zero. Oxygen saturation: zero percent. Rather than initiating CPR, she picked up the phone. At 1:09 PM, four minutes after finding the resident unresponsive, she called the hospice nurse to report the death.
Nobody started CPR. Nobody called 911. Nobody checked the advance directives book sitting at the nurses station or pulled up the electronic medical record where the code status was documented.
At 3:00 PM, nearly two hours later, another nurse working in the facility noticed something. Resident 1 was a full code.
At 3:02 PM, 911 was called. CPR was started. At 3:06 PM, paramedics arrived and continued resuscitation efforts. At 3:25 PM, paramedics declared Resident 1 dead.
The inspection report does not identify Resident 1 by name, age, diagnosis, or length of stay at the facility. What it does document is a paper trail so consistent and redundant that its failure to reach the nurse who needed it most is the central fact of this case.
A physician order on file read: FULL CODE. The advance directive discussion document, completed by social services, said: FULL CODE. Hospice nursing notes from two separate dates said: FULL CODE. The care plan, revised and current, stated the resident had an advanced directive and that the directive was FULL CODE.
The code status was also accessible in two locations any nurse could reach without leaving the floor: the electronic medical record and the advance directives book kept at the nurses station.
The Director of Nursing, interviewed by inspectors on the day of the inspection at approximately 3:30 PM, said it is the expectation of any nurse to complete a CPR flowsheet and document a timeline of events in a nursing note any time CPR is performed. Inspectors reviewed the electronic medical record. There was no CPR flowsheet. There was no nursing note summarizing the event or its timeline. The documentation requirement was never triggered because, from the perspective of the nurse who found Resident 1 at 1:05 PM, there had been no code. There had only been a death.
Three other nurses were interviewed during the inspection, and each described the same straightforward process for determining a resident's code status. Staff B, a licensed practical nurse, said the code status is in the EMR and the advance directives book at the nurses station. Staff E, also an LPN, said that for an unresponsive resident you would always check for breathing and a pulse and verify the code status, found in the EMR and the advance directives book at the nurses station. Staff F, another LPN, said a yellow DNR form must be signed and completed in order to not perform CPR, and that if a resident requires CPR, the nurse would document the entire timeline of events from the condition of the resident prior to the code through the time the body leaves the facility.
Three nurses described the protocol correctly. The nurse who was actually in the room at 1:05 PM did not follow it.
The facility's own written policy, reviewed by inspectors, stated that CPR will be provided to all residents identified to be in cardiac arrest unless such resident has a fully executed Florida Do Not Resuscitate order. Resident 1 had no DNR. The policy required CPR. The nurse called hospice instead.
What the inspection report cannot answer, because it does not address it, is what Staff A understood about Resident 1's status, whether she had ever reviewed the advance directives for this resident, whether she believed the hospice involvement meant a DNR was in place, or whether she had any training gap that contributed to what happened. The report documents what she did. It does not explain why.
Hospice involvement in a nursing home does not automatically mean a resident has chosen to forgo resuscitation. Residents can be enrolled in hospice and remain full code, a combination that requires facilities to track and communicate code status with particular care. The inspection report notes that hospice nursing notes from two different dates both documented Resident 1 as full code, meaning the hospice team itself had recorded the correct status. That information was in the chart. The nurse who called hospice at 1:09 PM to report the death apparently had not checked it.
The two-hour gap between 1:05 PM and 3:00 PM is not explained in the report. The inspection does not describe what was happening in the facility during that period, who else may have entered Resident 1's room, or how a second nurse came to notice the code status discrepancy at 3:00 PM. What is documented is that by the time paramedics arrived at 3:06 PM and worked for nearly twenty minutes, they declared the resident dead at 3:25 PM.
CMS rated the level of harm in this deficiency as actual harm. The inspection covered three residents for this particular citation; the failure was found in one of them.
The inspection was triggered by a complaint, not a routine survey. Someone reported a concern to regulators. Inspectors came. They found what they found.
Aviata at Tallahassee is a skilled nursing facility in Florida's capital. The inspection report does not describe any corrective action taken by the facility between the time the second nurse noticed the code status at 3:00 PM and the time inspectors conducted their interviews. It does not describe whether Staff A received any immediate counseling, retraining, or disciplinary action. It does not say whether the family of Resident 1 was informed of the sequence of events or what they were told in the hours between 1:09 PM, when hospice was called, and 3:25 PM, when paramedics made their declaration.
Resident 1 had made a choice, recorded in the chart, witnessed by social services, tracked by the hospice team, written into the care plan, and entered as a physician order. The choice was to fight. CPR if the heart stops. That was the directive.
At 1:05 PM on a Tuesday afternoon, the heart stopped. Nobody fought.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Aviata At Tallahassee from 2025-08-13 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 22, 2026 · Our methodology
AVIATA AT TALLAHASSEE in TALLAHASSEE, FL was cited for violations during a health inspection on August 13, 2025.
The sequence of events, reconstructed from the inspection report, is precise and difficult to read.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.