F0835

D

Failure of Leadership to Ensure CPR for a Full Code Resident

Exton, Pennsylvania Survey Completed on 02-18-2026

Penalty

Fine: $53,550

Summary

The deficiency involves the failure of facility leadership, specifically the Nursing Home Administrator (NHA) and the Director of Nursing (DON), to effectively manage and oversee care so that cardiopulmonary resuscitation (CPR) was provided in accordance with facility policy and procedures for a resident who was designated as FULL CODE. Review of the NHA job description showed that this role carries administrative authority, responsibility, and accountability for directing the activities and programs in the center, while the DON job description assigns responsibility for planning, developing, organizing, evaluating, and directing the nursing service department and its programs in accordance with current rules, regulations, and guidelines governing nursing care facilities.

Survey findings determined that, despite these defined responsibilities, the facility did not ensure that CPR was carried out as required for a FULL CODE resident, resulting in noncompliance with facility policy and procedures. As a result, the NHA and DON were found to have failed to fulfill their essential job duties to ensure that federal and state guidelines and regulations related to CPR and nursing services were followed, as cited under F678 and multiple sections of 28 Pa. Code regarding licensee responsibility, management, administrator’s responsibility, and nursing services.