Citrus Grove Post Acute

In the surveyor’s words

From the most serious findings on record at Citrus Grove Post Acute, in the surveyor’s own words.

• Immediate jeopardy, patternF689Apr 5, 2023

  Based on observation, interview, and record review the facility failed to follow their policy for smoking for 13 of 14 residents who smoke. This failure resulted in Residents 1 & 2 receiving cigarette burns resulting in treatment and had the potential to jeopardize the health and safety of the facility's 14 vulnerable smokers resulting in an immediate jeopardy situation. On December 19, 2022, at 6:20 p.m., an Immediate Jeopardy (IJ-a crisis in which the health and safety of individuals are at risk) was identified and called in the presence of the Administrator (ADM) due to lack of supervision and safety measures per the facility's policy to ensure the safety of the facility's smokers. […]

• Actual harm, isolatedF689Aug 16, 2021

  Based on observation, interview, and record review, the facility failed to provide an environment that was free from accident hazards for one of 19 residents (Resident 1) reviewed for accident hazards, when the staff transferred Resident 1 using a torn sling (a tightly woven fabric that is placed under and around the resident) with the mechanical lift (a battery powered lift that utilizes a sling with loops that attach to the lift to transfer the resident). This failure resulted in Resident 1 falling from the lift and sustaining a femoral (thigh bone) fracture (broken bone) which required Resident 1 to be transferred to the acute hospital for medical treatment. Findings: Resident 1's medical record was reviewed. […]

• No harm, potential for more than minimal, widespreadF812Dec 11, 2025

  Based on observation, interview, and record review, the facility failed to ensure dietary staff were able to safely and effectively carry out the functions of food and nutrition services when one dietary staff did not perform testing of the sanitizing solution in accordance with the manufacturer instructions.This failure had the potential to result in kitchen equipment used for food preparation and service being maintained outside required chemical parameters, increasing the risk for cross-contamination. Findings:On December 10, 2025, at 8:09 a.m., a concurrent observation and interview were conducted with the Dietary Aide (DA). The DA was asked to demonstrate the sanitation testing process using the Quaternary (sanitation solution) test paper. […]

• No harm, potential for more than minimal, widespreadF812Jul 12, 2023

  Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food preparation and storage practices in the kitchen when: 1. The ice machine was dirty. 2. The two compartment prep sink did not have an air gap. 3. Dust found on the following areas: a) Silver storage shelves stored clean kitchen wares in juice area. b) Door stopper in juice area. c) Walk in refrigerator: Green color food storage shelves; wall, above door; copper pipe behind ventilator, black pipe behind ventilator. d) Silver storage shelves stored clean kitchen wares next to stove. e) Cart stored clean kitchen wares. f) Under steam table where stored clean serving pans. […]

• No harm, potential for more than minimal, patternF687Jul 8, 2026

  Based on observation, interview, and record review, the facility failed, for two of four residents reviewed for foot care (Residents 1 and 2), to ensure:1. For Resident 1, the facility arranged and completed a follow-up consultation with the podiatrist, as the resident was last seen on September 5, 2025; and2. For Resident 2, the facility arranged follow-up with the podiatrist and appropriately addressed the resident's repeated refusals of podiatry care since October 2024. Additionally, the facility did not initiate or develop a care plan to address Resident 1's multiple refusals of podiatry care.These failures resulted in Residents 1 and 2 going on an extended period without having their toenails clipped and/or monitored, resulting in untrimmed toenails and increasing their risk of… […]