Based on interview, and record review, the facility failed to follow the process for a verbal physician order for chest x-ray for 1 of 3 residents reviewed for diagnostic services out of a total sample of 5 residents, (#4). On [DATE] at 8 PM, the facility failed to obtain radiology diagnostic services for a resident with increased cough, 3 days post-surgery for fractured hip. A verbal order was given by the Advance Practice Registered Nurse (APRN) which was not entered into the electronic record and not processed by the nurse. …
F777 citations in Florida
Administration Deficiencies
Provide or obtain x-rays/tests when ordered and promptly tell the ordering practitioner of the results.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Florida cites F777 more often than its own record predicts
2.63 times the share F777 takes of citations nationally.
Of every deficiency written in Florida in 2025, this is the portion that was F777.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Florida surveyors wrote
F777 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, medical record review and interviews with staff, the Advanced Registered Nurse Practitioner (ARNP) and the facility Administrator, the facility failed to notify the medical care provider of an abnormal radiology report resulting in a delay in treatment for one (Resident #3) of five sampled residents. The resident complained of pain in the shoulder after a fall and had an x ray ordered on [DATE] at 5:11 pm. The X-ray found an acute impacted fracture to the humerus bone, results were sent to the facility on [DATE] at 9:43 pm. Facility staff were unaware of the X-ray results showing a fracture. The resident complained of severe pain the next day, 7/6/19, another x ray was ordered with the results being Impacted fracture right humeral head neck. No change. …
Based on record reviews and interviews, the facility did not ensure providers were notified of abnormal lab results for two residents (#1 and #4) out of three residents reviewed for labs.Findings included:1.) An interview was conducted on 10/28/25 at 10:10 a.m. with a Resident Representative (RR) for Resident #1. The RR said on 9/27/25 he was at the facility with Resident #1, and she was not herself. He said she was very lethargic, wanted to sleep and was in pain. I let the nurse and Certified Nursing Assistant (CNA) know my concern. He said at one point he nor the staff could find Resident #1's assigned nurse, Staff H, Licensed Practical Nurse (LPN) for over an hour. The RR said he was trying to find the nurse because the resident's medications were late, and she was in pain. …
The short window
Recent years
| Year | Share of Florida citations | vs expected |
|---|---|---|
| 2023 | 0.04% | 1.65× |
| 2024 | 0.06% | 1.91× |
| 2025 | 0.07% | 2.63× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Florida surveyors cite →
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