North Florida Rehabilitation Hospital

“CHIEF EXECUTIVE OFFICER CFR(s): 482.12(b) The governing body must appoint a chief executive officer who is responsible for managing the hospital. This Standard is not met as evidenced by: 42310 Based on facility policy, staff interviews, and governing body documents, the facility failed to appoint a Chief Executive Officer (CEO)who is responsible for managing the hospital for one CEO of one CEO reviewed. The findings include: 1. Review of the facility ’ s Governing Board Minutes (Draft Pending Approval) noted that a Chief Executive Officer had been newly hired into the position. However, there was no documentation indicating that the CEO appointment had been formally approved and signed by the governing body as required. The facility presented a letter intended for the CEO to sign acknowledging acceptance of the role; however, the letter lacked signatures from the designated approving authorities and therefore did not constitute valid documentation of appointment. 2. Review of the facility ’ s leadership team appointments—including the Antimicrobial Stewardship Program Leader, Patient Safety Leader, Chief Nursing Officer, Compliance Officer, Lead of Healthcare Disparities Reduction Efforts, and the Facility Risk Manager—revealed no formal appointment documentation with required signatures indicating that these positions had been officially designated or approved. On 03/11/2026 at 2:30 PM, during an interview with the Director of Quality, the Director confirmed that the leadership appointments did not have completed appointment letters with the required signatures. The Director stated that this was an oversight and would be corrected. This deficient practice had the potential to adversely affect the overall management, oversight, and safe operation of the hospital. Without formal written designation and approval of the Chief Executive Officer—and without complete, signed appointment documents for other key leadership roles—the facility lacked clear lines of authority, accountability, and decision-making responsibility. This created the risk of inconsistent leadership direction, ineffective governance, and failure to ensure compliance with regulatory requirements and facility policies necessary to safeguard patient care and hospital operations.”

“PATIENT RIGHTS: INFORMED DECISION CFR(s): 482.13(b)(3) The patient has the right to formulate advance directives and to have hospital staff and practitioners who provide care in the hospital comply with these directives, in accordance with §489.100 of this part (Definition), §489.102 of this part (Requirements for providers), and §489.104 of this part (Effective dates). This Standard is not met as evidenced by: 42310 Based on medical record review, policy review, and staff interviews, the facility failed to ensure patients had the right to formulate advance directives and to have hospital staff and practitioners who provide care in the hospital comply with these directives for 3 (Patient #6, Patient #7, and Patient #8) of 8 patients sampled. The findings include: 1. Patient #6 arrived at the facility on 02/09/2026 for rehabilitation services following a decline in functional mobility caused by an acute onset of left sided hemiparesis related to a cerebrovascular accident (CVA). A Do Not Resuscitate (DNR) order was documented in the medical record at the time of arrival but there was no documented indication that the DNR form was filled out as required. 2. Record review for Patient #7, a female born on 12/30/1945, indicated she was admitted to the facility on 03/03/2026 at 4:39 PM. A DNR order for this patient was entered on 03/04/2026 at 4:40 PM. Review of the DNR form revealed incomplete due to no patient signature to indicate they wanted to be a DNR. As a result, the DNR form was not valid. 3. Record review for Patient #8, a male born on 09/19/1932, was admitted on 02/27/2026 at 8:13 PM with a DNR order documented at the same time. There was no documented DNR form, as required, in the patient’s medical record at the time of the survey. On 03/11/2026 at 3:56 PM, an interview was conducted with Registered Nurse, Employee E, who was assigned to Patient #7 at the time of the interview. Employee E confirmed that there was no valid DNR form for Patient #7 in the medical record; however, a physician’s DNR order was documented in the electronic medical record (EMR). When asked what actions would be taken if Patient #7 experienced a cardiopulmonary arrest, Employee E stated that CPR would not be initiated because the physician’s order in the EMR indicated that the patient was a DNR. Employee E confirmed they were not familiar with the facility DNR policy. On 03/11/2026 at 3:45 PM, an interview was conducted with Registered Nurse (RN) Employee F, who stated that they had been employed at the facility for approximately three weeks. When asked to locate Patient #8’s code status in the EHR, the RN was unable to do so. When asked to locate the Do Not Resuscitate (DNR) order, the RN was unable to do so. When asked to locate the DNR consent form, the RN stated that they did not know how to find the document in the medical record. When asked what actions would be taken if Patient #8 experienced a cardiopulmonary arrest and the RN could see a DNR order in the system but could not locate the corresponding DNR consent form, the RN stated that they would follow the provider’s order for “Do Not Resuscitate.” When asked whether they had received education on the facility’s DNR policy, the RN stated that they were not sure about the policy. On 03/11/2026 at 3:48 PM an interview was conducted with the Interim Chief Nursing Officer. She confirmed that the required DNR form was not present for Patient #6, Patient #7, and Patient #8. When asked how staff should proceed when a DNR order is present without a corresponding DNR form, the Interim CNO stated that staff would follow the DNR order. Facility policy requires that patients be treated as Full Code when a valid, completed DNR form is not available in the record. Review of the facility policy titled “Do Not Resuscitate,” effective 11/12/2024, revealed: Page 1: o “The physician order for ‘Do Not Resuscitate’ is documented on the physician orders and the consent form is signed by the patient, physician, and a witness.” Page 2: o Documentation of the DNR discussion with the patient and/or family is reflected in the medical record. o Documentation should appear in: - The physician progress note, and - The Do Not Resuscitate Signature Form in the Advanced Directives section. o “The DO NOT RESUSCITATE form is signed by the patient, the physician, and a witness.” Page 3: o “If a physician does not indicate a DNR status, a full code is performed.” o DNR status is communicated to staff through: - Purple armband - Plan of care notation - Chart label - Highlighted patient name on chart back/clipboard for transport. This deficient practice had the potential to cause serious harm by creating unclear or invalid resuscitation directives, increasing the risk that patients’ end of life wishes would not be honored or that staff would initiate inappropriate life saving interventions in the absence of a valid DNR form. Failure to maintain complete and valid DNR documentation created the risk of inconsistent communication among care team members and compromised adherence to facility policy and patient rights.”

“SUPERVISION OF CONTRACT STAFF CFR(s): 482.23(b)(6) All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer). This Standard is not met as evidenced by: 42310 Based on personnel files review and staff interview, the facility failed to ensure that nursing evaluations were completed as required by the facility for 2 (Registered Nurse B and Registered Nurse C) out of 2 staff members sampled. The findings include: 1. Review of personnel files revealed that Registered Nurse (RN) B began employment on 11/05/2025 and had been employed for 125 days as of the survey date, 03/09/2026. The personnel file contained no documentation of a completed 90 day probationary evaluation. 2. Registered Nurse (RN) C began employment on 05/06/2024 and had been employed for 673 days as of the survey date, 03/09/2026. Review of the personnel file revealed no documentation that a 90 day probationary evaluation had been completed. This deficient practice had the potential to affect the quality and safety of resident care by limiting the facility’s ability to identify performance concerns, validate staff competency, and ensure that nursing personnel were meeting expected practice standards during the initial period of employment. On 03/11/2026 at 2:37 PM, an interview was conducted with the Quality and Risk Manager. She explained that after their initial 90 days of working at the facility, staff would receive a probationary evaluation. She also confirmed that RN B and RN C had not received their 90-day probationary evaluations as required by the facility. This deficient practice had the potential to negatively affect the quality and safety of patient care by preventing the facility from identifying performance concerns, confirming staff competency, and ensuring that nursing personnel were meeting expected practice standards during the initial period of employment.”