Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
of F578 citations were written at actual harm or above. The mark is the share across all tags, 5.4%.
Citations in 20251,026
Every F578 citation surveyors wrote nationally that year.
Facilities cited1,021
Distinct nursing homes with at least one F578 finding.
The harm level
How severely F578 is cited
2.6% of citations found actual harm or worse (level G and above).
Citations by CMS scope and severity. Rows are harm level, columns are how widespread the finding was.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
J871.9%
K110.2%
L30.1%
Actual harm
G170.4%
H—
I—
No harm, potential for more than minimal
D3,46776.0%
E91520.1%
F360.8%
No harm, potential for minimal
A—
B270.6%
C—
Every recorded F578 citation, by the harm level and scope the surveyor assigned.
In the surveyor’s words
What an F578 citation says
One finding from each severity level, most serious first.
Severity is as the surveyor wrote it. Some findings had already been corrected before the survey.
J · Immediate jeopardy, isolatedAugust 19, 2026
Based on interview, and record review, the facility failed to honor a resident's documented wishes for Do Not Resuscitate (DNR) status, as elected by the resident's healthcare surrogate, by failing to ensure the resident's executed Florida Do Not Resuscitate Order (DNRO) was readily accessible and available during a medical emergency for 1 of 10 residents reviewed for advance directives, (#1), of a total sample of 10 residents. This failure resulted in resident #1 receiving cardiopulmonary resuscitation (CPR) efforts contrary to the resident's documented wish for a natural and dignified death.On [DATE] at approximately 8:11 PM, resident #1 had a change in condition related to low blood pressure. …
Based on record review, staff, resident and law enforcement interviews, the facility failed to honor a resident's right to refuse treatment when the resident declined five hemodialysis (a life-sustaining procedure for kidney failure that uses a machine to filter waste, toxins, and excess fluids from the blood) treatments and the facility proceeded to file an involuntary commitment which deemed the resident a danger to herself. The resident reported once the local law enforcement officer had walked her out to the front entrance of the facility, the resident was asked to put her hands out and the officer placed handcuffs on both wrists in the front of her body and had her sit in the backseat of the police car. …
D · No harm, potential for more than minimal, isolatedSeptember 3, 2026
Based on record review and staff interview, it was determined the facility failed to ensure residents were offered the opportunity to implement their advance directive. This was true for 3 of 12 residents (#27, #37, and #38) whose records were reviewed for resident rights. This failure created the potential for poor outcomes if residents did not make their wishes known and were unable to communicate. Findings include:1. Resident #27 was admitted to the facility on [DATE], with multiple diagnoses including acute kidney failure, repeated falls, hearing loss, and depression.Resident #27's record did not include an advanced directive for healthcare.Resident #27's record did not include documentation of resources offered for assistance with formulating an advanced healthcare directive.2. …
B · No harm, potential for minimal, patternAugust 12, 2026
Based on record review, resident, and staff interviews, the facility failed to document and provide written information to residents/representatives regarding their right to refuse medical/surgical treatment or to formulate an advance directive (a legal document that states a person's wishes about receiving medical care if that person is no longer able to make medical decisions because of a serious illness or injury) for 9 of 13 residents reviewed for advance directives (Residents #6, #8, #16, #21, #48, #74, #88, #118, and #133).Findings included:
a. …
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Assess the resident when there is a significant change in condition
Cited in the same inspection, not caused by one another.
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