Latest Serious Citations
Stay informed about the most recent serious citations (J-L severity) issued to long-term care facilities nationwide.
Latest high scope & severity citations
Every Immediate Jeopardy finding (J–L severity) issued nationwide in the last six months, summarized from the inspection reports.
Failure to supervise a resident at risk for elopement led to repeated exit-seeking and wandering events, including being found off the unit and near exterior areas. The resident had dementia with cognitive impairment, hemiplegia, and diabetes, and staff notes described missing documentation of several wandering episodes, an incomplete care plan intervention, and incidents involving a broken alarmed door, a Wanderguard, and an unknown visitor letting the resident off the unit.
A facility failed to keep the resident environment free of fire hazards after a dining room fire and a later smoke incident in the same area. A resident with asthma, COPD, and anxiety reported being in the dining room with two other residents when smoke appeared, leaving with breathing difficulty afterward, and not being assessed. The Administrator and Maintenance Supervisor described a ceiling light fire linked to incorrect bulb wattage, but the dining room lights were not checked afterward, the later smoke event was not investigated or reported to the fire department, and staff interviews showed confusion about code red response, extinguisher use, and resident evacuation.
An agency CNA found a full code resident unresponsive, but an agency RN did not check for a pulse or vital signs and did not start CPR before leaving to call EMS and look for help. Staff present were not CPR certified, and EMS arrived to find the resident pulseless and apneic with no CPR started by the facility. The resident later died at the hospital.
A resident with renal dialysis dependence, muscle weakness, and CVA history was being transported in a wheelchair when a driver started the van before fully securing the wheelchair securement system. While traveling uphill, the wheelchair fell backward, causing a T1 fracture and subdural hematoma. The DON initiated CPR, EMTs transported the resident to the ED, and the resident later died from anoxic brain injury after cardiac arrest.
A resident with multiple serious diagnoses, including COPD, CHF, CKD on dialysis, and an implanted cardiac defibrillator, had a signed Florida DNR and physician DNR order in the chart. After returning from HD, the resident became unresponsive in bed, staff called a code blue, and CPR was started based on an initial report that the resident was full code. Staff later found the DNR paperwork and told others the resident was DNR, but compressions continued until EMS arrived.
The facility failed to maintain adequate safety checks and supervision for two residents with serious psychiatric histories and suicidal ideation. One resident had repeated plans to starve, ingest eye drops, jump off a bridge, and poison self, yet room checks and other protections were not consistently documented or maintained, and monitoring was later reduced before the resident ingested Visine and Tylenol in suicide attempts. A second resident, who had been care planned for community supervision due to suicidal ideation, eloped multiple times and was not adequately supervised.
Failure to Supervise Resident at Risk for Elopement
Penalty
Summary
The facility failed to provide adequate supervision to prevent resident elopement for a resident who was identified as at risk for elopement and did not reside on a secured unit. The resident had diagnoses including hemiplegia, diabetes, and dementia, and the MDS indicated cognitive impairment. The record showed multiple elopement evaluations with changing results, including several assessments that identified the resident as at risk for elopement in July 2026, while earlier assessments had indicated not at risk or were incomplete. The care plan identified the resident as an elopement risk/wanderer related to impaired safety awareness, but the record contained only one incomplete intervention related to wandering, and no resident preferences were included. Behavior monitoring documented exit-seeking and wandering behaviors on multiple occasions in May, June, and July 2026, but progress notes did not document the behaviors noted on 5/21/26, 6/21/26, and 7/14/26. A physician order for a Wanderguard was created after the resident was found wandering outside on the curb, and staff notes described discussions with family and assessments after the resident was returned to the unit. The resident was later involved in additional elopement-related events. Staff statements and progress notes described the resident being found near a door, in the front hall, in the assisted living area, and off the unit near common areas, with staff searching for her after she was reported missing. One note stated the resident could escape through a security door because the alarm was broken and had not been fixed yet. Another investigation note stated the resident was found off the unit in a common area adjacent to the unit after being let off by an unknown visitor. The facility determined that the resident was cognitively unable to recognize the door requiring a code and would be physically unable to open it without assistance. The report states the facility was out of compliance with resident safety and supervision since 4/12/26.
Failure to Prevent Repeat Dining Room Fire Hazard
Penalty
Summary
The facility failed to keep the resident environment as free of accident hazards as possible and failed to provide adequate supervision and assistance devices to prevent fire affecting all 44 residents. The deficiency centered on two fire-related incidents in the dining room and the facility’s response to them. The report states that after a fire in the dining room, the facility did not implement effective interventions to prevent a second fire in the same area. An Immediate Jeopardy was identified, and the facility remained out of compliance after the IJ was removed because the effectiveness of the corrective systems still needed evaluation. Resident #1 was a female resident with diagnoses including mild persistent asthma, COPD, allergic rhinitis, and anxiety disorder. Her MDS reflected a BIMS score of 10, indicating moderately impaired cognition. Her care plan identified an increased risk of impaired respiratory status related to asthma, and she had an order for ipratropium-albuterol nebulizer treatment. During the second smoke incident, Resident #1 stated she was in the dining room playing dominoes with two other residents when smoke appeared and staff asked them to leave. She reported that the smoke bothered her, that she had some difficulty breathing afterward, and that she used her nebulizer in her room. She also stated no one assessed her after she had been around the smoke. The Administrator stated that during the first incident, a dietary aide saw smoke and flames coming from a ceiling light in the dining room, left the area, and reported it to the Business Office Manager. The Administrator and Business Office Manager went toward the dining room while yelling code red, and the fire was extinguished before the fire department entered the facility. The Maintenance Supervisor stated the wrong wattage bulbs were in the light fixture and that the dining room lights were not checked after the first fire. The report also documents a later smoke incident in the corridor near the kitchen in the same general area, which the Administrator said was not investigated and was not reported to the fire department, HHSC, electricians, or the sprinkler/fire alarm company because there were no flames. Interviews with staff showed inconsistent understanding of fire response procedures, including uncertainty about how to use a fire extinguisher, how to activate emergency communication, and where residents should be moved during a fire. The Fire Marshal stated he was concerned about future fire safety, noted that the facility did everything wrong during the dining room fire, and said the fire department was not notified of the second fire.
Failure to Start CPR for Full Code Resident
Penalty
Summary
The facility failed to assess a resident for a pulse or vital signs and failed to immediately start CPR for a resident who was a full code and was found unresponsive. Resident #60 had diagnoses including multiple fractured ribs on the left side, acute respiratory failure with hypoxia and hypercapnia, type 2 diabetes mellitus with diabetic peripheral angiopathy, CHF, PVD, osteoarthritis of the left knee, and atherosclerotic heart disease of the native coronary artery. The resident’s code status was documented as full code, and the care plan stated CPR should be started and EMS called if needed. According to the CCTV timeline and staff statements, an agency CNA found the resident unresponsive during rounds and summoned nursing staff. An agency RN arrived at the room, briefly entered, and then left without taking vital signs, checking for a pulse, or starting CPR. The RN then went to the nurses’ station and made calls while the resident remained without CPR. Other agency CNAs were present, but they were not CPR certified. EMS arrived several minutes later and found the resident unresponsive, pulseless, and apneic, with no evidence that facility staff had started CPR before EMS arrival. The 911 audio, CAD log, EMS report, police report, and witness statements all reflected that the resident was found unresponsive and that the facility did not initiate CPR. The police officer reported staff were standing in the room and did not know what to do, and EMS reported the facility staff did not start CPR and did not know the approximate down time. The hospital record stated the resident had been found unresponsive by nursing facility staff, no CPR had been performed by the facility for over ten minutes, and EMS initiated CPR and ACLS during transport. The resident was later pronounced dead at the hospital.
Wheelchair Transport Failure Resulted in Resident Injury and Death
Penalty
Summary
The facility failed to ensure that two front locking mechanisms were locked during wheelchair transport for one resident who was being taken to dialysis. The resident had diagnoses including dependence on renal dialysis, muscle weakness, and cerebrovascular disease, was cognitively intact with a BIMS score of 15, and was dependent on staff for all activities of daily living, using a manual wheelchair for mobility. The resident was also on antiplatelet medication and had a care plan noting dialysis three times weekly. On the day of the incident, the driver loaded the resident and another resident into the van and applied the wheelchair brakes and front wheelchair securement straps. The driver then started the van to run the air conditioner before completing the securing process. The driver later stated that the normal process was interrupted because they were in a hurry, and that they thought the front straps were tight enough but they were not. During transport back from the dialysis center, while traveling uphill, the resident's wheelchair fell backward and the driver stopped the van and called the DON. The DON arrived within minutes and found the resident unresponsive with no pulse, began CPR, and EMTs transported the resident to the ED. ED records showed a T1 vertebral fracture and a 3-millimeter subdural hematoma. The resident was later transferred to a tertiary care center and died from an anoxic brain injury resulting from cardiac arrest. Interviews with the other resident, the driver, the DON, and the maintenance director confirmed the sequence of events and that the front securement straps had not remained secured during transport.
Failure to Honor Resident DNR During Code Event
Penalty
Summary
The facility failed to act in accordance with a resident’s advance directive and did not honor the resident’s Do Not Resuscitate (DNR) status when the resident was found unresponsive and absent of life. Resident #6 had multiple diagnoses including COPD, type 2 diabetes mellitus, morbid obesity, hemiplegia and hemiparesis following cerebral infarction, generalized muscle weakness, dyspnea, atrial fibrillation, congestive heart failure, chronic kidney disease with dependence on renal dialysis, and an implantable cardiac defibrillator. The resident had a Florida DNR order signed by the resident and an APRN, and the physician order set also listed the resident as DNR. On the day of the incident, the resident returned from hemodialysis and was described as awake, alert, and conversing with staff during transport back to the room. Multiple staff statements described that after the resident was lowered into bed, the resident became unresponsive. Staff then assessed the resident and asked about code status. One nurse stated the resident was full code, and a code blue was called. CPR was started, the AED was applied, and EMS was called. Several staff later stated that the resident’s DNR paperwork was in the chart or red book and that they informed others that the resident was DNR after CPR had already begun. Witness statements and interviews showed conflicting accounts about when the DNR was discovered and whether CPR should have been stopped. Some staff stated they were told to continue compressions until EMS arrived even after the DNR was identified. Other staff stated they checked the record, confirmed the resident was DNR, and communicated that information to the team. The DON later stated that once the DNR was discovered, staff should have stopped CPR, and the Medical Director stated there was a process for checking code status using the code book and computer. The facility policy stated that CPR would be provided unless the resident had a fully executed Florida DNR order, and that two licensed nurses were to verify the resident identification and DNR order in the medical record.
Failure to Maintain Safety Checks and Supervision for Residents With Suicidal Ideation
Penalty
Summary
The facility failed to ensure an area was free from accident hazards and failed to provide adequate supervision to prevent accidents for two residents with significant psychiatric and self-harm histories. One resident had diagnoses including major depressive disorder, schizophrenia, PTSD, borderline personality disorder, OCD, ADHD, and autism, along with chronic passive suicidal ideation, prior suicide attempts, hallucinations, and repeated episodes of active suicidal planning. The resident’s treatment plan and vulnerability assessments identified the need for safety checks, removal of items that could be used for self-harm, and monitoring when suicidal ideation increased or a plan was expressed. For this resident, the record showed repeated suicidal statements and hospitalizations involving plans to starve, ingest eye drops, jump off a bridge, and poison self. After disclosing a specific plan to ingest eye drops, the record did not show that staff completed a room safety check, removed potentially harmful items, or evaluated whether the existing safety plan remained effective. The resident later returned from psychiatric hospitalization after expressing plans to ingest eye drops and jump from a bridge, but the facility documentation did not identify whether the hospital’s safety strategies were implemented on return. The resident was later found to have left the facility without staff knowledge, police were notified, and the resident was located after calling the facility and reporting they had run away. The resident’s monitoring was progressively reduced despite the ongoing pattern of suicidal ideation, multiple psychiatric crises, and repeated hospital transfers. The record showed shift checks, location checks, and room checks were used at various times, but the facility reduced location checks from one hour to two hours, then four hours, and later discontinued them, along with discontinuing shift checks. After these reductions, the resident ingested four bottles of Visine eye drops in an apparent suicide attempt, later reported hiding a bottle of Tylenol in a snack bag and ingesting it, and was hospitalized again. The report also describes a second resident who had suicidal ideation to jump off a bridge, eloped multiple times, and was unable to be found for extended periods, with the facility failing to provide the necessary supervision after the resident had been care planned to require supervision in the community.
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