Citations in Florida
Statistics, citations and compliance trends for long-term care facilities in Florida.
Statistics for Florida (Last 12 Months)
Financial Impact (Last 12 Months)
Latest citations in Florida
Failure to Obtain Informed Consent for Psychotropic Medications: Two residents receiving psychotropic medications, including antidepressants, antipsychotics, and mood stabilizers, did not have documented informed consent in their records before the medications were administered. One resident had diagnoses including depression, bipolar disorder, and schizophrenia, and the other had traumatic brain injury, schizoaffective disorder-bipolar type, major depressive disorder, and paraplegia. The DON could not provide consent documentation for one resident, and the other resident's record lacked consent explaining the risks and benefits of the medications. The NP stated the facility is responsible for obtaining medication consents when residents are admitted on psychotropics or when doses or medications change.
PASARR screening was inaccurate for two residents. One resident had bipolar disorder and a Level I PASARR showing a need for Level II review, but the required Level II evaluation was not obtained before or after admission. Another resident was admitted with major depressive disorder, personality disorder, substance abuse, and PTSD, and the Level I PASARR also indicated a Level II evaluation was required prior to admission; the DON later confirmed the PASARR was incorrect and should have been caught on admission and during audit review.
Missing behavior and side effect monitoring for psychotropic medications: A resident with dementia, psychotic disorder, anxiety, and depression, another resident with traumatic brain injury and schizoaffective disorder, and a third resident receiving multiple psychotropics had no documented behavior monitoring or side effect assessments to support ongoing use of the medications. Staff confirmed missing monitoring orders and records, and the DON could not provide documentation showing routine monitoring of behaviors, symptoms, or AIMS follow-up after dose increases.
Smoking safety interventions were not consistently implemented for four residents who smoked. Two residents were observed smoking with staff supervision but without the smoking aprons listed in their assessments and care plans, and two other residents were also observed smoking in wheelchairs without aprons despite care plan interventions requiring them. The DON confirmed the apron requirement for two of the residents, while the ADON stated residents sometimes complained about the aprons and that he did not know when smoking assessments were completed.
An LPN contributed to a medication error rate of 10.71% after 3 errors were found in 28 observed medication opportunities. The LPN administered eye drops and ear drops to one resident without preventing the resident from wiping the medication away, and left another resident unsupervised during a nebulizer treatment without monitoring the response or cleaning the equipment afterward. Record review showed the resident receiving the nebulizer had no documentation supporting self-administration, and the facility's procedures required assessment and direct administration for these treatments.
Unsecured Medication and Treatment Carts: An LPN left a medication cart unlocked in the hallway with the computer screen visible and a medication cup left on top while away from the cart for about 10-15 minutes. A treatment cart with prescribed ointments and creams was also observed unattended at the nurses’ station with residents nearby, and later the 300 unit medication cart was found partially unlocked with no nurse on the unit. The DON confirmed carts should be locked when unattended, and facility policy stated medication carts are always locked when out of sight or unattended.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to ensure informed consent was obtained before psychotropic medications were administered to Resident #4. A record review on 8/12/26 showed physician orders for Paroxetine 40 mg daily for depression, Trazodone 100 mg daily for depression, Divalproex 500 mg twice daily for bipolar disorder, and Risperidone 2 mg three times daily for schizophrenia. Resident #4 was admitted with diagnoses including major depressive disorder, depression, bipolar disorder with manic severe psychotic features, and paranoid schizophrenia. When the DON was asked to provide documentation of informed consent for these psychotropic medications, she was unable to provide evidence that the resident or resident representative had been informed of and consented to their use prior to administration. The same issue was identified for Resident #11, who was admitted with diagnoses including traumatic brain injury, schizoaffective disorder-bipolar type, major depressive disorder, and paraplegia. The resident was receiving Haldol 10 mg three times daily, Olanzapine 10 mg at bedtime, and Divalproex sodium 500 mg every 12 hours for schizoaffective disorder and bipolar disorder, but the record did not contain consent for psychotropic medication use explaining the risks and benefits prior to administration. During interview, the DON stated the NP obtains medication and treatment consents when she visits residents, while the NP stated it is the facility's responsibility to obtain medication consents when a resident is admitted on psychotropic medications and when there is a dosage increase, decrease, or medication change. The facility policy stated residents receiving psychotropic medication are to have the risks and benefits reviewed and consent completed prior to initiation of the medication.
Inaccurate PASARR Screening and Missing Level II Evaluation
Penalty
Summary
PASARR screening for mental disorders or intellectual disabilities was inaccurate for 2 of 2 residents reviewed. One resident was admitted with a Level I PASARR dated 10/27/23 that identified bipolar disorder, receipt of mental illness services, and a need for a Level II PASARR evaluation for serious mental illness, but there was no evidence the required Level II evaluation and determination were obtained before admission or afterward. The facility did not initiate action to obtain the Level II PASARR until the survey process on 8/12/26, and the DON stated the admissions team and social services were responsible for review while audits were in place. A second resident was admitted with diagnoses including major depressive disorder, personality disorder, psychoactive substance abuse, and PTSD, and had care plan concerns for communication difficulty, altered mood and behaviors, physical and verbal aggression, and gender identity-related behaviors. The resident's Level I PASARR completed on 07/09/2026 indicated previous services for mental illness issues and stated that a Level II PASARR evaluation had to be completed prior to admission. During interview, the DON stated she completes and reviews PASARRs on admission, and after reviewing this resident's Level I PASARR, confirmed it was incorrect and should have been identified on admission and during audit review, with a Level II PASARR evaluation needing to be initiated.
Missing behavior and side effect monitoring for psychotropic medications
Penalty
Summary
The facility failed to ensure adequate monitoring for behaviors and side effects was documented for 3 of 6 residents reviewed. Resident #1 was admitted with diagnoses including dementia, seizure disorder, psychotic disorder, anxiety disorder, and depression, and had physician orders for multiple psychotropic medications, including olanzapine, haloperidol, and Ativan. No orders were found directing staff to monitor the resident for behaviors or side effects related to these medications. During review, staff confirmed that no such monitoring orders were present in the MAR or TAR, and the DON stated that behavioral and side effect monitoring orders had not been restarted after the resident returned from the hospital. Resident #11 was admitted with diagnoses including traumatic brain injury, schizoaffective disorder-bipolar type, major depressive disorder, and paraplegia, and had orders for Haldol, olanzapine, and divalproex sodium. The record did not contain an order for behavior monitoring or assessment of antipsychotic side effects, and there was no behavior monitoring flow record in the EMR. Although an AIMS assessment had been completed on 3/29/26 showing no abnormal movements, Haldol and divalproex doses were increased in May 2026 without a follow-up AIMS assessment for the dose changes or the scheduled quarterly assessment in June 2026. Resident #4 had orders for paroxetine, trazodone, divalproex, and risperidone, but the clinical record, including nursing documentation and behavior monitoring records, contained no documented behaviors, symptoms, frequency, severity, or other clinical indicators showing the continued need for the psychotropic medications. The DON was unable to provide documentation showing the resident's behaviors or symptoms were routinely monitored to evaluate effectiveness and continued clinical need, despite facility policy requiring behavior and side effect monitoring every shift using the electronic Behavior Monitoring Flow Record.
Smoking Safety Interventions Not Followed
Penalty
Summary
The facility failed to ensure adequate assessment and implementation of smoking safety interventions for four sampled residents who smoked. Residents #12 and #85 were observed smoking in the designated smoking area with staff supervision on multiple occasions, but neither was observed wearing a smoking apron even though the smoking binder and care plan indicated they needed one. During an interview, the ADON confirmed both residents were listed as needing aprons and stated the residents sometimes complained about the apron, but they should not smoke unless they put it on. The ADON also stated he does not go out with smokers often and does not know when assessments are completed. Resident #12 had diagnoses including COPD, muscle weakness, and epilepsy, and smoking evaluations noted tobacco use and balance problems while sitting or standing; smoking was added to the care plan with a clothing protector intervention. Resident #85 had diagnoses including hemiplegia and right-hand contracture, and although initial smoking evaluations indicated tobacco use with no impairments, smoking was later added to the care plan with a clothing protection requirement. Resident #52, who had CVA with right-sided weakness and paralysis, diabetes, mood disorder, major depressive disorder, and right hand and upper arm contracture, was observed smoking in a wheelchair without a smoking apron despite a care plan intervention requiring one. Resident #11, who had TBI, schizoaffective disorder, major depressive disorder, paraplegia, and upper extremity contractures, was also observed in the smoking area in a wheelchair without a smoking apron, and no attempt was made by the smoking monitor to get the apron on. The DON confirmed that Residents #52 and #11 were supposed to wear smoking aprons when smoking, and the facility smoking policy required residents to be educated and evaluated for smoking upon admission, re-admission, and quarterly.
Medication Error Rate Exceeded Threshold During Eye, Ear, and Nebulizer Administration
Penalty
Summary
A medication error rate of 10.71 percent was identified after 28 medication opportunities were observed and 3 errors were found, exceeding the 5 percent threshold. During one observation, an LPN administered prescribed eye drops to a resident with blepharitis and instilled 2 drops in each eye, but did not offer tissue or instruct the resident not to rub his eyes afterward; the resident immediately rubbed both eyes with his t-shirt and removed the drops. The same LPN then administered ear drops by placing the dropper tip inside the ear canal and instilling drops into both ears, after which the resident again wiped the drops away with his t-shirt. During another observation, the LPN prepared and started a nebulizer treatment for a resident who had an order for ipratropium-albuterol inhalation solution three times daily. The LPN handed the mask to the resident, instructed him to place it on himself, washed her hands, and left the room, leaving the resident unsupervised during the treatment and without monitoring the response or cleaning and disassembling the nebulizer equipment afterward. The LPN confirmed that the nebulizer treatment should not have been left unattended and that she did not perform an assessment before or after medication administration. Record review showed the resident had no documentation indicating self-administration of medications, and the facility's procedures required assessment, direct administration, and post-treatment evaluation for nebulizer use, as well as specific techniques for eye and ear drop administration.
Unsecured Medication and Treatment Carts
Penalty
Summary
The facility failed to ensure medications were stored in a locked secure manner. On 08/10/2026 at 2:38 PM, while observations were being made on the 300 unit, a medication cart was seen in the hallway outside room [ROOM NUMBER] with the cart unlocked, the computer screen visible with resident information displayed, and a small clear medication cup containing a small greenish-white tablet sitting on top of the cart. Staff B, an LPN, walked away from the cart to the nurses’ station and was out of view of the cart for approximately 10-15 minutes while residents passed by in the hallway. When interviewed, Staff B confirmed the cart should have been locked, the computer screen closed, and medication should not have been left unattended. On 08/12/2026 at 09:00 AM, a treatment cart was observed at the nurses’ station with prescribed ointments and creams for topical use sitting on top of the cart unattended while approximately 6-7 residents were seated at the nurses’ station and 2 residents walked by the cart. Later that morning, the 300 unit medication cart was observed with the lock halfway pushed in, leaving the cart unlocked, and no nurse was observed on the unit. The DON later confirmed that medication carts should always be locked when unattended and that medications should never be left on top of medication or treatment carts. The facility policy stated that medication carts are always locked when out of sight or unattended.
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Compliance trends in Florida
Data through Jun 2026Comparisons below measure the most recent period Jul 2025 – Jun 2026 against the prior period Jul 2024 – Jun 2025 (two equal 12-month windows). The most recent 2 months are excluded because CMS is still publishing them.
Top tags by month · last 24 months
dashed = still reportingMonthly citation counts for the 5 most-cited tags. The dashed tail is the 2-month reporting lag.
Frequency movers
Biggest change in how often each tag is cited, as a rate per 100 inspections (so it isn't skewed by survey volume): Jul 2025 – Jun 2026 vs the prior period Jul 2024 – Jun 2025. Only tags with at least 20 citations in both periods are shown.
Severity movers
Tags whose average scope/severity shifted the most: Jul 2025 – Jun 2026 vs the prior period Jul 2024 – Jun 2025. The number is the average severity on the A–L scale (A=0…L=11); the letter is the band it falls in. A rise means the same tag is being cited at a more serious level — note the average can move enough to rank here while staying within the same letter. Same 20-citation minimum applies.
Care domain movers
Citations grouped into CFR care domains — F-tags by their §483 regulatory section (CMS State Operations Manual, Appendix PP) — measured as a rate per 100 inspections: Jul 2025 – Jun 2026 vs the prior period Jul 2024 – Jun 2025. Share is the domain's portion of citations this period; avg severity is the mean scope/severity letter and immediate jeopardy the percentage cited at J–L, both over the current period. Domains with at least 20 citations in both periods are shown; the sparkline tracks the last 12 months (left = oldest).
Immediate jeopardies · this period
Citations at the most serious scope/severity — J–L, immediate jeopardy, residents placed at risk of serious harm or death — over Jul 2025 – Jun 2026 vs the prior period Jul 2024 – Jun 2025. "Surveys with an IJ" counts distinct health inspections that had at least one.
Survey activity · by month
faded/dashed = still reportingCitations each month split into complaint-driven (unscheduled, triggered by grievances) vs standard surveys — bars, left axis — with the number of inspections as a line on the right axis. Rising inspections signal more scrutiny; a rising complaint share means more off-cycle surveys. The most recent 2 months are still being reported.
Deficiency-free survey rate
Share of health surveys that found zero deficiencies — the odds of a clean survey. Jul 2025 – Jun 2026 vs the prior period Jul 2024 – Jun 2025; the most recent 2 months are still being reported (dashed).
Penalties · by month
faded = still reportingTotal civil money penalty dollars imposed on the state's facilities each month — how hard the state is enforcing. The most recent 2 months are still being reported, and penalties often lag citations by several months.
Emerging tags
Tags that weren't established last period but surged — an early warning, distinct from movers (which track already-common tags). Criteria: fewer than 20 citations in the prior period, but at least 10 this period and 2.5× their prior volume. The sparkline shows monthly counts over the last 12 months (left = oldest).
Trusted data from CMS and state health departments
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