Citrus Grove Post Acute

Inspectors wroteBased 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 complications such as injury and infection from inadequate monitoring of foot care and services.

Inspectors wroteBased on interview and record review the facility failed for two of two residents reviewed for change in condition (Residents 1 and 2), to consistently monitor and assess residents following a significant change in condition. These failures had the potential for changes in a resident's condition to go unrecognized, which could delay recognition of worsening neurological status, recurrent elopement behaviors, or other complications requiring timely nursing or physician intervention.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adequate supervision and implement appropriate interventions to prevent the elopement of one of three residents reviewed for accidents (Resident 2) after the resident had been identified as being at risk for leaving the facility without notice. This failure resulted in Resident 2 leaving the facility without staff knowledge on June 20, 2026, and had the potential to place Resident 2 at risk for serious harm.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the front door exit alarm was maintained in proper operating condition. This failure had the potential to delay staff awareness of residents exiting the facility and place residents at risk for elopement.

Inspectors wroteBased on interview and record review, the facility failed to ensure that a significant change in condition, an unwitnessed fall with development of a black eye, was immediately reported to the physician and responsible party for one of four residents reviewed for falls (Resident 1). This failure had the potential to place the resident at risk for delayed medical evaluation and treatment of injuries related to the fall.

Inspectors wroteBased on interview and record review, the facility failed to ensure timely and ongoing assessment, monitoring, and care-plan revision following a change in condition (unwitnessed fall) for one of four residents reviewed for falls (Resident1). This failure resulted in delayed recognition of injury (black eye) and had the potential to compromise the resident's physical and psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure a safe and appropriate discharge for one of three residents reviewed for discharge (Resident) 1 when the resident's identified care needs and required caregiver support were not coordinated through the Interdisciplinary Team (IDT - consists of Director of Nursing, Social Services, and Rehabilitation) prior to discharge to home. The facility discharged the resident without confirming that necessary caregiver support and services were arranged to meet the resident's care needs. This failure resulted in the resident returning to the facility the day following discharge and had the potential to result in unmet needs and harm.

Inspectors wroteBased on interviews and record review, the facility failed to ensure one of three sampled residents (Resident 1) was discharge to a safe and appropriate setting. The facility did not verify that the receiving environment could meet the resident's care needs and discharged the resident to an unlicensed room and board (a living accommodation where individuals are offered a place to stay along with meals). These failures resulted in Resident 1 remaining confined to the kitchen area at the room and board, as the resident could not maneuver stairs or access the restroom on his own. Two days later, Resident 1 was transferred to the General Acute Care Hospital (GACH).

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff provided timely incontinence care consistent with the resident's care needs for one of two sampled residents (Resident B). This failure resulted in Resident B remaining in a soiled brief for approximately an hour, placing the resident at risk for skin breakdown, infection, discomfort, and compromised dignity.

Inspectors wroteBased on interview and record review, the facility failed to ensure the timely reordering and availability of a prescribed controlled pain medication (oxycodone) for one of three sampled residents (Resident A). This failure resulted in a missed scheduled dose when the medication was not available, placing the resident at risk for unmanaged pain.

Inspectors wroteBased 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.

Inspectors wroteBased on observation, interview, and record review, the facility failed to treat residents with dignity and respect for three of three residents reviewed for dignity (Residents 6, 123, and 124) when:1. Resident 123 did not receive her meal at the same time as her roommate. 2. Resident 6's Foley catheter drainage bag was left uncovered and exposed; and3. A staff entered Resident 124's room without knocking. These failures had the potential to negatively affect the resident's dignity, comfort, and psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to provide a written notice of bed hold (holding or reserving a resident's bed while the resident is absent from the facility for therapeutic leave or hospitalization) to the resident or resident representative (RP) at the time of transfer to an acute care hospital for one of three residents reviewed for closed records (Resident 3). This failure had the potential for residents and/or their RPs not being fully informed of bed-hold rights or the right to return to the facility following hospitalization which could lead to an inappropriate discharge.

Inspectors wroteBased on interview and record review, the facility failed to follow facility's policy and procedures for two of five residents reviewed (Residents 1 and 51) when:1. Staff did not properly identify a resident (Resident 51) and ensure the correct breakfast was served. This failure had the potential to result in adverse reactions due to receiving an incorrect diet and to cause emotional distress. 2. Staff did not change the resident's nasal cannula (a medical device used to deliver supplemental oxygen) on a weekly basis. This failure had the potential to result in cross-contamination and increased risk of infection. 1. On December 10, 2025, at 8:05 a.m. an interview was conducted with Resident 51. Resident 51 stated the breakfast tray that was initially served had another resident's name on the meal ticket and was not intended for him. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the necessary care and services to maintain cleanliness and proper hygiene when staff failed to clean and trim the resident's fingernails, leaving them long and discolored for one of three residents reviewed (Resident 6). This failure had the potential for Resident 6 at risk for infection and injury due to the unhygienic condition of the resident's fingernails.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services to meet the needs of one of seven sampled residents (Resident 49) when one medication was documented as administered on December 7, 2025, could not be accounted for as being available for administration as the medication was not received by the facility until December 9, 2025. This deficient practice had the potential for Resident 49's health and well-being to be negatively impacted due to unintended consequences, including decreased medication effectiveness and the potential for adverse reactions (an unwanted effect caused by the administration of a drug).

Inspectors wroteBased on interview and record review, the facility failed to ensure the physician reviewed and addressed the Consultant Pharmacist (CP) recommendations during the monthly Medication Regimen Review (MRR), for one of five residents reviewed for unnecessary medications (Resident 13) when Resident 13's recommended gradual dose reduction of buspirone (antianxiety medication) was not addressed by the physician. This failure had the potential to result in continued unnecessary psychotropic medication use.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement required Enhanced Barrier Precautions (EBP-an infection control intervention to reduce transmission of multidrug-resistant organisms [MDRO- bacteria that have become resistant to multiple antibiotics), for one of ten residents reviewed (Resident 93) when Licensed Vocational Nurse (LVN 5) did not don required personal protective equipment (PPE - equipment, such as gloves and gown, used to protect against infection or illness) while providing direct bedside care to Resident 93, who was on enhanced barrier precaution. This failure had the potential to result in cross-contamination, increasing the risk for transmission of infection among a vulnerable resident population.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one bedroom (room [ROOM NUMBER]) did not accommodate more than four residents. This failure had the potential to affect the health and safety of the residents residing in this room.

Inspectors wroteBased on interviews and record reviews, it has been determined that the facility did not ensure that wound and skin documentation accurately reflected the conditions of the residents during daily and weekly assessments, in accordance with current professional standards of practice, for all four sampled residents (Residents 1, 2, 3, and 4). This failure had the potential to result in inadequate monitoring of wounds and skin integrity. missed changes in condition, and delayed interventions, placing residents at risk for complications and worsening existing conditions.

Inspectors wroteBased on observation, interview and record review the facility failed to conduct an ongoing monitoring and supervision for use of bed rails for four of six residents reviewed, (Residents 1, 2, 5 and 6)This had the potential to cause Residents 1, 2, 5, and 6 to be at risk for entrapment or injury for falls.

Inspectors wroteBased on interview and record review, the facility failed to ensure that food provided to a resident on a puree diet ( a type of texture-modified diet where all foods are blended to a smooth, pudding-like consistency) was given as ordered by the physician, when a cotton candy was given for consumption for one of three sampled residents (Resident 1). This failure had the potential to place Resident 1 at risk for choking or aspiration.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that reasonable accommodation were made for one of three sampled residents reviewed (Resident A), when the call light was placed on the weaker side. This failure had the potential to result in Resident A being unable to request assistance, leading to unmet needs and possible delays in care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adequate linens for two of three residents (Resident 2 and 3). This failure had the potential to delay care and unmet needs for Resident 2 and 3.

Inspectors wroteBased on interview and record review, the facility failed to complete a post-dialysis (a medical treatment that removes waste, excess fluids, and toxins from the blood when the kidneys are no longer able to function properly) assessments on December 27, 2024, and December 31, 2024, for one of three sampled residents (Resident 1). This failure had the potential to result in an increased risk of undetected complications post hemodialysis and delayed medical interventions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide hand hygiene before a meal to one of three sampled residents (Resident 1). This failure had the potential to expose Resident 1 to bacterial contamination from unclean hands and increasing the risk of infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that staffing information was accesible to residents and visitors. This failure had the potential for residents and visitors from being able to view the level of care provided, including the number of certified nursing assistants, licensed nurses, and other available staff to assist.

Inspectors wroteBased on interview and record review, the facility failed to ensure the food preferences of one of three residents (Resident A) were honored when pork loin was served on Resident A's dinner tray. This failure had the potential in the resident eating less or skipping meals, leading to weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow and conduct a self-administration assessment for one of two residents reviewed for self-administration of medication (Residents 34). This failure had the potential to result in an unsafe administration of medication for Resident 34.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure expired medications were discarded and not readily available for use when multiple oral medications were observed in the medication cart. This failure had the potential to result in the administration of expired medications to residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two dietary staff members were able to provide proper nutrition services for a population of 95 residents who eat in the facility when: 1. The Dietary Aide was unable to accurately demonstrate the concentration of the chlorine sanitizing solution (solution used killing bacteria on food contact surfaces); and 2. The [NAME] was unable to verbalize proper cool down process for food. These failures had the potential to expose residents to foodborne illnesses (illnesses resulting from eating contaminated food).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper infection control measures were implemented when: 1. The Licensed Vocational Nurse (LVN 1) did not change gloves and perform hand hygiene during wound care for one of one resident reviewed for pressure injury (Resident 67). 2. Two clean linen closets were not kept clean. 3. A licensed nurse did not wear PPE (Personal Protective Equipment- equipment use to protect against infection or illness) in transmission based precaution room (room used to isolate residents). These failures had the potential to result in cross-contamination, increasing the spread of infection to an already vulnerable population of residents in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure dignity was provided for two of two residents reviewed for dignity (Residents 2 and 27) when: 1. The Certified Nursing Assistant (CNA) did not provide assistance and allowed Resident 2 to soil herself; and 2. Resident 27's lunch tray was not provided at the same time as the other residents. These failures had the potential to affect Residents 2 and 27's self-worth and self-esteem.

Inspectors wroteBased on interview and record review, the facility failed to report an allegation of physical abuse involving Residents 30 and 310 to the California Department of Public Health (CDPH) immediately, and no later than two hours after the allegation was made, for two of two residents reviewed for abuse (Residents 30 and 310). This failure had the potential to delay the implementation of appropriate action and protection for the residents, placing them at risk for further abuse.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the plan of care (POC) was updated for one of 21 residents reviewed (Resident 83). This failure resulted in the licensed nurse being unaware of Resident 83's current condition and POC.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that two out of three residents reviewed for quality of care (Residents 34 and 55) had a physician's order for medication administration. This failure had the potential to result in medical complications and unforeseen side effects related to unprescribed medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the care plan intervention for fall was implemented for one of one resident reviewed for fall (Resident 209). This failure had the potential to increase the risk of further falls or injury for Resident 209.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that proper care and treatment services for oxygen (O2) were provided for two of three sampled residents (Residents 34 and 59) when: 1. Oxygen tubing for Residents 34's and 59's was not date-labeled. 2. Resident 59 did not have a physician's order for oxygen therapy. These failures had the potential to place Residents 34 and 59 at risk of respiratory infection and unnecessary respiratory care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that food brought by visitor and family members was not expired and was safe for consumption. This failure had the potential for the residents to be exposed to foodborne illness.

Inspectors wroteBased on interview and record review, the facility failed to ensure a physician order was transcribed into the resident's electronic medical record (EMR) for one of 21 residents reviewed (Resident 83). This failure had the potential to affect Resident 83's overall health and well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident's call light was functioning at all times, for one of two residents reviewed for environment (Resident 67). This failure had the potential for Resident 67 to not be able to call for assistance when needed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one bedroom (room [ROOM NUMBER]) did not accommodate more than four residents. This failure had the potential to affect the health and safety of the residents residing in this room.

Inspectors wroteBased on interview and record review, the facility failed to notify the Resident Representative (a person assigned by the resident to make medical decisions in the event the resident is unable), when a new medication Lorazepam (a medication used to manage feelings of anxiety [feeling of worry, nervousness, or unease about something]) was added to the resident's medication regimen, for one of three sampled residents (Resident 1). This failure had the potential for the Resident 1's Representative to be unaware of Resident 1's care which could affect the resident's health and safety.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care and services to maintain good personal hygiene when one of four sampled residents' (Resident 2) fingernails were not cleaned as part of daily grooming. The resident was observed to have dark brown debris under her fingernails on her right hand. This failure had the potential to negatively affect the resident's physical and psychosocial well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a clean and safe environment, as: 1) 3 out of 10 residents ' toilets were observed to be dirty with a black ring inside the toilet bowl at the water line. 2) The entrance/exit to nursing station1 was blocked with a trash can, and 20-gallon console, to prevent RN1 ' s puppy from exiting the nursing station. This failure had the potential to spread microorganisms and infections to the residents from the dirty toilets, and could result in a delay of care to the Residents if a staff member was unable to reach a Resident in a timely manner in the event of an emergency due to a blocked doorway at the nurses station.

Inspectors wroteBased on interview and record review, the facility failed to provide the following in accordance with the physician order: 1. For Resident B, the morning long-acting insulin; and 2. For Resident C the injectable Humira. These failures increased the risk of complication for Residents B and C's current medical condition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an outbreak was reported on September 6, 2023, when a staff and a resident was reported with symptoms and had tested positive for COVID-19 infection (an infectious disease caused by SARS-CoV-2 Virus). The facility failure had delayed early intervention to monitor and prevent virus spread and proliferation as reporting was intended to facilitate timely intervention.

Inspectors wroteBased on interview, and record review, the facility failed to ensure the call lights (devices that emit a tone and light up indicating the location of the call, used by the residents to signal a need for assistance from facility staff), were answered timely, when four out of four residents (Residents 1, 2, 3, and 4), who required assistance from staff with activities of daily living (ADLs), verbalized their concerns of facility staff not answering their call lights and/or attending to their needs in a timely manner. This failure had the potential for delayed medical management and unmet care needs.

Inspectors wroteBased 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: [NAME] 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. g) Cabinet under steam table which stored clean pot and pans. h) Three ventilator funs inside Reach in refrigerator. 4. The kitchen's cutting boards surface was heavily marred. 5. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the facility was free from a medication error rate of 5% or greater when two medication errors were observed out of 34 opportunities. The Licensed Vocational Nurse (LVN) administered Ipratropium-Albuterol inhalation solution (medication that help control the symptoms [wheezing and shortness of breath] caused by a lung disease) instead of budesonide inhalation suspension (steroid - help prevent the symptoms and decrease the number and severity of asthma [lung disease] attacks) for one of five residents reviewed during medication administration (Resident 500). This failure resulted in medication error rate of 5.88%.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that Dietary staff safely and effectively carried out the functions of food and nutrition services when: 1. Two Dietary Aide did not know the proper procedures using 2 compartment sinks to clean kitchen wares. 2. One Diet Aide did not know the right location to test sanitizer of dish machine and unable to accurately test the concentration of dish machine chlorine. These failures had the potential to cause foodborne illness (stomach illness acquired from ingesting contaminated food), negatively impact the residents' nutritional status and further in a medically compromised 94 out of 101 sample residents who received foods from the kitchen. 1. [...]

Inspectors wroteBased on dietary observation, interview and record review, the facility failed to follow its policy on Menus to served planned menu for four of 101 sampled residents (Resident 11, 21, 56, 84). This failure had the potential to negatively impact the residents' nutritional status and further compromising resident's medical status.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow its policy on Serving Foods and Dining Service to provide appetizing food at appropriate temperatures according to residents' preferences for Nine of 101 sampled residents (Resident 5, 11, 33, 51, 53, 67, 83, 93, 500). This failure had the potential risk to decrease nutritional intake and affect the residents' nutritional status and further compromising residents' medical status.

Inspectors wroteBased on observation, interview, and record review, the facility failed to promote dignity and independence while dining, for one of one resident reviewed for dignity (Resident 21), when the resident was provided a disposable plastic spoon. This failure had the potential to affect Resident 21's self-esteem and psychosocial wellbeing.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the call light button was within reach of the resident, for one of two residents reviewed for accommodation of needs (Resident 25). This failure placed Resident 25 at risk for not being able to contact staff for assistance when needed.

Inspectors wroteBased on observation, interview, and record review, the facility failed for two of 24 residents reviewed for quality of care (Residents 48 and 72) to ensure Residents 48 and 72s' medications at bedside had a physician's order. This failure had the potential for Residents 48 and 72 to receive medications without appropriate monitoring for side effects.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the activity that met the interest for one of two residents reviewed for activities (Resident 62), when resident was not offered his preferred activity of music. This failure had the potential to result in a decline in the physical, and emotional well-being of Resident 62.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were assessed before and after administering pain medications for two of six residents reviewed for pain (Residents 3 and 151). This failure had the potential for Residents 3 and 151's pain not adequately managed leading to adverse physical, mental, and psychosocial outcome.

Inspectors wroteBased on observation, interview and record review, the facility failed to dispose of garbage and refuse properly when trashes were found surrounding the dumpsters. This failure had the potential to attract pests and rodents.

Inspectors wroteBased on interview and record review, the facility failed to ensure physician's orders were written in accordance with professional standards of practice, for one of three residents (Resident 11), when a wound care order was transcribed incorrectly for the wrong wound site. This failure had the potential to negatively impact Resident 11's care and delay in wound healing.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection control practices were implemented for two of 24 residents reviewed (Residents 72 and 300) when: 1. Resident 72's nebulizer mask (device used to administer breathing medications) was undated and not stored in a bag; and, 2. Resident 300's peripheral intravenous line (IV- device used to give medication and or fluids to a person through their veins) dressing was not changed according to facility's policy and procedure. These failures had the potential to increase the risk of infection, and affect the overall health and wellbeing for Residents 72 and 300 .

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one bedroom (room [ROOM NUMBER]) did not accommodate more than four residents. This failure had the potential to affect the health and safety of the residents residing in this room.