Based on record review, staff, and resident representative interviews, the facility failed to have processes in place to ensure accurate assessment of swallowing ability for 2 (Resident #1 and #3) of 3 residents reviewed with a diagnosis of dysphagia (difficulty swallowing). Resident #1 had a diagnosis of Parkinson's disease and oropharyngeal dysphagia. Resident #1's power of attorney complained to several staff members of episodes of choking during meals. Resident #1's assessment did not accurately reflect Resident #1's episodes of coughing and choking during meals, resulting in an inadequate individualized care plan to ensure supervision and safe swallowing during consumption of food. On [DATE] Resident #1 did not receive the necessary supervision during meals. …
F641 citations in Florida
Accuracy of assessments · Resident Assessment and Care Planning Deficiencies
Ensure each resident receives an accurate assessment.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Florida cites F641 more often than its own record predicts
1.24 times the share F641 takes of citations nationally.
Of every deficiency written in Florida in 2025, this is the portion that was F641.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Florida surveyors wrote
F641 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.
Through observation, interview and record review the facility failed to assure that Resident #9, #50 and #94 receives an accurate assessment, reflective of the resident's medical status in 3 out of 9 Residents reviewed for Minimum Data Set. Findings include: 1) Review of Resident #50's MDS (minimum data set) Medicare 5-day assessment dated [DATE], Section O IV Medications Read, Yes, Antibiotic, IV Access, Peripheral, Yes. Review of Resident #50's physician order dated 07/28/2026 reads, Cephazolin Sodium Injection Solution Reconstituted 1 GM (Cefazolin Sodium) Use 1 gram intravenously every 8 hours for POST SURGICAL until 09/02/2026. …
Based on record review and interview the facility failed to ensure an accurate Minimum Data Set (MDS) assessment for 1 of 12 sampled residents as evidenced by the failure to appropriately code the terminal diagnosis and provision of Hospice services for 3 of the 4 most recent MDS assessments for Resident #41.The findings included:Review of the record revealed Resident #41 was admitted to the facility on [DATE]. Review of the physician orders revealed the resident was admitted to Hospice services on 05/22/24. The care plan initiated on 05/22/24 documented Resident #41 had a terminal prognosis related to Chronic Obstructive Pulmonary Disease (COPD).Review of the Quarterly MDS assessment dated [DATE] documented in section J1400 that Resident #41 did not have a terminal diagnosis. …
The short window
Recent years
| Year | Share of Florida citations | vs expected |
|---|---|---|
| 2023 | 2.47% | 1.45× |
| 2024 | 2.53% | 1.50× |
| 2025 | 2.29% | 1.24× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Florida surveyors cite →
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