Citations in Florida
Comprehensive analysis of citations, statistics, 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
A deficiency was cited when a resident's right to request, refuse, or discontinue treatment, participate in or refuse experimental research, and formulate an advance directive was not honored by the facility. The facility did not ensure these rights were upheld as required.
The facility did not establish or maintain an infection prevention and control program as required, resulting in a deficiency identified during the survey.
Surveyors observed several containers of food in the walk-in cooler that were not labeled or dated, contrary to facility policy. The Dietary Manager confirmed that all food items should be labeled and dated when placed in the cooler, but this was not done for food from the breakfast meal.
The facility did not adequately protect resident-identifiable information or maintain medical records according to professional standards, as observed by surveyors during their review of documentation and information handling practices.
A resident's MDS assessment was not transmitted to CMS within the required 14 days after completion. The assessment, completed and marked as ready for submission, was not forwarded to the corporate office for review in a timely manner, resulting in a missed deadline for transmission.
The facility did not consistently administer insulin and cardiovascular medications as ordered for several residents, and nursing staff failed to notify the physician or document appropriately when medications were withheld due to abnormal blood sugar or blood pressure readings. Nurses often relied on their own judgment without following established parameters or facility policy, resulting in missed doses and lack of timely communication with providers.
A deficiency was cited when a resident’s drug regimen included medications that were not clinically indicated or were excessive, without proper justification documented.
Two residents were found with topical medications stored openly at their bedsides without physician orders or documented assessment for self-administration. Staff and the DON confirmed that neither resident was authorized to self-administer medications, and facility policy requires locked storage unless specific criteria are met.
Surveyors found that the facility did not maintain a clean and safe environment for several residents, including cracked bathroom fixtures, stained walls, a persistently dirty refrigerator that a resident could not clean due to physical limitations, unclean personal items for a bedbound resident, and a wheelchair with exposed foam. Staff interviews confirmed that CNAs were responsible for daily cleaning, and facility leadership acknowledged the issues.
A resident was not screened for safe smoking despite being observed smoking and having access to cigarettes, contrary to facility policy requiring a safe smoking assessment for all smokers. The resident's name was only informally added to the smoking list, and no documentation of a smoking screen was found in the medical record.
Failure to Honor Resident Rights Regarding Treatment and Advance Directives
Penalty
Summary
A deficiency was identified regarding the failure to honor a resident's right to request, refuse, or discontinue treatment, to participate in or refuse experimental research, and to formulate an advance directive. The report notes that the facility did not ensure these resident rights were upheld, as required by regulations. Specific actions or omissions by facility staff led to this deficiency, but no further details about the residents involved or their medical conditions are provided in the report. The deficiency centers on the lack of adherence to protocols that protect resident autonomy in making decisions about their care and participation in research, as well as the formulation of advance directives.
Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program. This deficiency was identified during the survey process, indicating that the required measures to prevent and control infections were not established or maintained as per regulatory standards. The report does not specify particular actions, inactions, or events, nor does it mention any specific residents or staff involved in the deficiency.
Improper Food Labeling and Storage in Kitchen Cooler
Penalty
Summary
During a walk-through tour of the kitchen, several containers of food were observed in the walk-in cooler without identifying labels or dates. The Dietary Manager confirmed that all items placed in the cooler should be labeled and dated, and acknowledged that there were no identifying labels on food that had been placed in the walk-in cooler from the breakfast meal. Facility policy requires that all foods stored in the refrigerator or freezer be covered, labeled, and dated, but this procedure was not followed for the observed items.
Failure to Safeguard Resident Information and Maintain Medical Records
Penalty
Summary
The facility failed to safeguard resident-identifiable information and/or did not maintain medical records for each resident in accordance with accepted professional standards. This deficiency was identified through surveyor observation and review of facility practices related to the handling and documentation of resident medical records. The report notes that the required standards for protecting confidential information and maintaining accurate, complete records were not met.
Failure to Transmit MDS Assessment Within Required Timeframe
Penalty
Summary
The facility failed to ensure that a resident's Minimum Data Set (MDS) assessment was transmitted to the Centers for Medicare and Medicaid Services (CMS) within the required 14 days after completion. Review of the electronic medical record showed that the annual MDS assessment for a resident was completed and marked as 'Production Batch' on 8/3/2025, indicating it was ready for submission. However, the assessment was not transmitted to CMS by the required deadline of 8/17/2025. Interviews with facility staff revealed that the process involved sending the completed MDS assessment to the corporate office for review before submission to CMS. The Care Plan Coordinator and the MDS Coordinator both confirmed that the assessment was not forwarded to the corporate office for initial review when completed, resulting in no validation report being received and the assessment not being transmitted on time. The delay in forwarding the assessment to the corporate office directly led to the failure to meet the CMS transmittal requirement.
Failure to Administer Medications and Notify Physician per Standards
Penalty
Summary
The facility failed to administer insulin and cardiovascular medications according to professional standards of practice for multiple residents. For one resident with a history of diabetes, chronic kidney disease, and heart disease, insulin was not administered as ordered on two occasions, and there was no documentation of physician notification when the medication was held or when the resident experienced hypoglycemia. The nurse involved stated uncertainty about the reason for holding the insulin and did not notify the physician, despite the absence of parameters to hold the medication. Facility policy required physician notification when medications are held due to abnormal vital signs or test results, but this was not followed. Another resident with hypertension had their prescribed Lisinopril withheld on multiple occasions due to low blood pressure or hypotension, as documented in the medication administration record. Nursing staff reported using their own judgment to hold the medication and did not consistently notify the physician, sometimes leaving notes for the charge nurse or physician instead. The Director of Nursing acknowledged that nurses should notify the physician when medications are held, but there was inconsistency in how and when this was done, and the facility's policy required notification in such cases. A third resident with diabetes had insulin and metformin held on certain days, sometimes without following the specific parameters in the physician's orders. In one instance, insulin was held despite the blood sugar being above the threshold for administration, and the nurse attributed this to confusion with another order. The Director of Nursing and the physician confirmed that nurses should follow parameters and document accurately, but there was a lack of consistent communication and documentation when medications were withheld. Facility policies required accurate documentation and physician notification when medications were held, but these procedures were not consistently followed.
Unnecessary Drugs in Resident Drug Regimens
Penalty
Summary
A deficiency was identified regarding the management of residents' drug regimens. The facility failed to ensure that each resident’s drug regimen was free from unnecessary drugs, as required by regulations. This indicates that at least one resident was prescribed or administered medications that were not clinically indicated or were excessive in dose or duration, without adequate justification documented in the medical record.
Improper Bedside Storage of Medications Without Authorization
Penalty
Summary
Surveyors observed that two residents had medications, specifically Arnica cream and Vicks Vaporub, stored openly on their bedside tables in their rooms. These medications were accessible to the residents without any documented physician orders permitting self-administration, and there was no evidence that the residents had been assessed or approved by the facility's interdisciplinary team to self-administer medications. Staff interviews confirmed that neither resident had orders to self-administer, and that the facility's policy required medications to be stored in locked compartments unless a resident was specifically authorized and provided with a lock box for self-administration. Further review of facility policies indicated that bedside medication storage is only permitted with a prescriber's written order and after an assessment of the resident's ability to self-administer. Despite these requirements, both residents had medications at their bedsides without the necessary orders or assessments. Staff and the DON acknowledged that medications should not be left unattended at the bedside and confirmed that the observed practice was not in accordance with facility policy.
Failure to Maintain Clean, Safe, and Homelike Resident Environment
Penalty
Summary
Surveyors observed that the facility failed to maintain a clean, safe, and homelike environment in several resident rooms. In one occupied room, the bathroom toilet lid was cracked and the ceiling near the entryway had a brown, rust-like substance between the tiles. Another occupied room had brown stains and scratched paint on the wall. A small refrigerator in a resident's room contained a foul odor, spilled brown liquid, unfinished bottles of soda, and ice cream spilled throughout the freezer compartment; the resident confirmed the refrigerator had not been cleaned for a long time and was unable to clean it herself due to physical limitations. Multiple follow-up observations confirmed the refrigerator remained dirty over several days. A bedbound resident was observed with a pillow and board used to hold a cell phone, both of which had stains and organic particles that remained uncleaned over several days. Another resident's wheelchair had an armrest with exposed foam. During an interview, an LPN stated that CNAs were responsible for wiping surfaces daily and as needed. The facility's Administrator, Maintenance Director, and Housekeeping Account Manager acknowledged these issues during a tour.
Failure to Screen Resident for Safe Smoking Practices
Penalty
Summary
The facility failed to ensure that a resident received adequate supervision and assistance to prevent accidents by not conducting a safe smoking assessment as required by facility policy. A review of the electronic medical record for the resident revealed no documentation of a safe smoker screening. The DON stated that a smoking screen is performed on every resident upon admission and that residents who smoke are provided with education and added to a smoking list managed by activities staff. However, the DON indicated that the resident in question did not smoke and would only be screened if she chose to start smoking. Contrary to the DON's statement, an activities assistant reported observing the resident smoking and confirmed that the resident had cigarettes stored in a lockbox designated for residents' smoking supplies. Upon review, the resident's name was found handwritten at the bottom of the smoking list, suggesting a lack of formal inclusion and oversight. The facility's policy requires a safe smoking assessment for all patients electing to smoke, but this was not completed or documented for the resident involved.
Some of the Latest Corrective Actions taken by Facilities in Florida
Explore Popular Searches
