Based on record review, and interview, the facility failed to investigate allegation of neglect to ensure staff recognized change in resident condition and provided timely interventions for 1 out of 15 residents reviewed for advanced directives, (#2). On [DATE] after midnight, resident #2 was found unresponsive and staff initiated CPR. The resident was transferred to the hospital by Emergency Medical Services (EMS). The EMS and hospital records noted resident #2 was very rigid with stiff extremities and core body temperature of 90.7 degrees Fahrenheit. The records indicated the resident displayed signs and symptoms of rigor mortis indicating the resident had been deceased for some time, before staff had identified the resident to be unresponsive and initiated CPR. …
F610 citations in Florida
Investigating alleged violations · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Respond appropriately to all alleged violations.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Florida cites F610 less often than its own record predicts
0.67 times the national share — cited less often here than elsewhere.
Of every deficiency written in Florida in 2025, this is the portion that was F610.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Florida surveyors wrote
F610 findings written in Florida, one from each severity band recorded here, most serious first.
Severity is as the surveyor wrote it. Some findings had already been corrected before the survey.
Based on observation, interview, record review and policy review; the facility failed to thoroughly identify and investigate the alleged witnessed fall and unwitnessed fall for 1 of 2 sampled residents reviewed for accidents (Resident #11). The findings included: The facility's policy titled Change in Condition effective 1/2023 and updated 9/2023 revealed All completed incident reports must be forwarded to the Director of Nursing and Administrator for review within 24 hours of the event. …
Based on interview, and record review, the facility failed to conduct a thorough investigation of an allegation of physical abuse for 1 of 3 residents reviewed for abuse, of a total sample of 3 residents, (#1).Findings: Resident #1 was admitted to the facility on [DATE] with diagnoses including senile degeneration of brain, unspecified dementia unspecified severity with other behavior disturbance and major depressive disorder. Resident #1 also had contractures of the right hand, right wrist, right elbow, left hand, left wrist, left elbow, muscle of right shoulder and muscle of left shoulder. …
The short window
Recent years
| Year | Share of Florida citations | vs expected |
|---|---|---|
| 2023 | 0.89% | 0.69× |
| 2024 | 0.74% | 0.52× |
| 2025 | 1.01% | 0.67× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Florida surveyors cite →
Deficiency Index is independent and is not affiliated with, endorsed by, or approved by CMS, Medicare, or any government agency. About this data · Report a correction