Citrus Nursing Center

In the surveyor’s words

From the most serious findings on record at Citrus Nursing Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Aug 30, 2023

  Based on interview, and record review, the facility failed to provide routine supervision and monitoring for one of 93 residents (Resident 1) and failed to implement interventions developed to help prevent an elopement (unauthorized and unsupervised exit from the facility) when: 1) On August 1, 2023, staff was unaware Resident 1 (a confused resident with cognitive deficit and required assistance with walking) had eloped from the facility. In addition, it was not identified Resident 1 was missing from the facility despite Resident 1 not being present during the evening meal (Resident 1 required direct 1:1 [one to one] staff assistance during mealtime). […]

• No harm, potential for more than minimal, widespreadF880Jul 31, 2025

  Based on observation, interview, and record review, the facility failed to ensure safe infection control practices and sanitary environment were followed when:a. Resident 101's oxygen nasal cannula tubing (device used to deliver oxygen into the nose via a tube) was found unlabeled and undated.b. Resident 84's oxygen tubing (is a small flexible plastic tube that connects to an oxygen source) [like machine or tank] was not labeled and dated per facility's policy and procedure (P&P). c. […]

• No harm, potential for more than minimal, patternF921Jul 31, 2025

  Based on observation, interview, and record review, the facility failed to maintain a clean and sanitary environment for residents who reside in the facility when on July 29, 2025, the North hallway shower room was found to have black substance on the shower stalls.This failure had the potential to exposed the residents using this shower room to increased risks of developing allergies, skin irritation, and serious respiratory issues.Findings:During an observation on July 29, 2025, at 2:30 PM in the residents' shower room in North hallway, the three shower stalls were found to have a black substance on the shower stalls floors, walls, and where the wall meets the floor and the ceiling. The substance was also present on the wall joints, and on and between the tiles. […]

• No harm, potential for more than minimal, patternF692Jun 10, 2022

  Based on observation, interview, and record review, the facility failed to maintain acceptable parameters of nutrition status for 2 out of 40 residents (Residents 13 and 62) reviewed for nutrition when: 1. Resident 62 lost 18% of his body weight in the last 6 months. Since September 5, 2021, he had poor food intake. Three different registered dietitians recommended an appetite stimulant on September 28, 2021, October 7, 2021, and March 14, 2022. The appetite stimulant was ordered on April 10, 2022. Consequently, Resident 62 lost 26 pounds during that time. 2. Residents 13 and 62, who were on a fortified diet (diet to increase calories for residents who need to maintain or gain weight) were given fortified cereal for breakfast and fortified mashed potatoes for lunch and dinner daily. […]

• No harm, potential for more than minimal, patternF880Jan 7, 2021

  Based on observation, interview, and record review, the facility failed to ensure that all facility staff were screened for signs and symptoms of COVID-19 (Disease caused by the [DIAGNOSES REDACTED]-CoV-2 virus, a highly contagious and potential fatal respiratory infection) prior to or at the beginning of their shift, and prior to entering the facility, for one out of three sampled staff members (CNA 1). This failure had the potential for staff and resident harm, including severe harm and death for the 42 out of 70 vulnerable residents who were not actively infected with COVID-19, as the lack of consistent screening of all staff for signs and symptoms of COVID-19, prior to entering the facility, increased the likelihood and opportunity for infection control breaches of COVID-19. […]