Citrus Nursing Center

Inspectors wroteBased 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. A facility's janitor ([DATE]) removed multiple pillows from several trash containers and placed them on a handrail at the facility's rear entrance/exit next to the laundry room. These failures had the potential to spread infectious disease (disease caused by bacteria, viruses, fungi or parasite) to 85 medically compromised residents and staff in the facility.

Inspectors wroteBased 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.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure licensed nursing staff accurately and consistently monitored and documented fluid intake and output (intake refers to the total amount of fluids a person consumes, while output refers to the total amount of fluids the body eliminates) for one of one resident reviewed for urinary catheters (Resident 100), when Resident 100's intake and output record had blanks (no data recorded), documentation was not in the correct milliliter (ml - unit of measure) format, and there was no policy and procedure regarding monitoring and documenting intake and output as specified in Resident 100's care plan (an individualized plan for the medical care of a resident). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the Order Summary Diet Order (a list of provider orders) was followed for one of three residents (Resident 21) reviewed for dining observations when Resident 21 did not receive his physician ordered Boost VHC ( nutritional supplement, very high calories) with meals for lunch on July 29, 2025 and for breakfast on July 30, 2025. These failures had the potential to have contributed to Resident 21's weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain accurate records of controlled medications (medications that are controlled by the government because it may be abused or cause addiction) for one of three sampled medication carts (South Cart ) with narcotics when Resident 100's Controlled Drug Receipt/Record/Disposition Form (CDR - document used to record the administration or destruction of a controlled drug for tracking purposes) was found to be inaccurate. This failure had the potential to place the facility at risk for drug diversion (illegal distribution of controlled drugs for any illicit use) of controlled medications by staff .

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medical supplies were labeled and stored in accordance with currently accepted professional principles when an intravenous (giving medications through the vein) (IV) cart (a mobile cart used to store and transport medications and other supplies to patients) was found with expired supplies. These failures had the potential for the supplies to be less effective and compromised health and safety for the highly vulnerable population of 85 Residents in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to adequately protect and safeguard the healthcare identifiable information for two out of 25 sampled residents (Resident 7 and 89) when on July 30, 2025, the laptop screen of the Electronic Medical Record (EMR) (electronic form of record keeping) used by Licensed Vocational Nurse 3 (LVN 3) were:1. Left open, unsecured and unattended from 05:44 AM to 5:47 AM, for a total of 3 minutes in the North hallway for Resident 7.2. Left open, unsecured and unattended from 6:08 AM AM to 6:12 AM, for a total of 4 minutes in the North hallway for Resident 89. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure proper care was provided to prevent a blister (a painful swelling on the surface of the skin), for one of three sampled residents (Resident 1). This failure placed a clinically compromised Residents (Resident 1) health and safety at risk, when a facility acquired blister to the right heel (back of the human foot below the ankle) developed while in the facility.

Inspectors wroteBased 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. These foods were in addition to the foods that were already on the menu. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure wound care dressings were labeled in accordance with the facility's policy and procedure for four of five residents (Residents 61, 693, 53, 490) reviewed for pressure injury (or pressure ulcers- wounds that happen on areas of the skin that are under pressure). This failure had the potential for inconsistent care coordination, and for Resident's 61, 693, 53, 490, not to receive the optimal care they need, which would hinder the healing of their pressure injuries.

Inspectors wroteBased on interview and record review, the facility failed to ensure a process to routinely evaluate staff skill levels (range of tasks and duties to be performed) and develop individualized competency-based training (a process to acquire skills and knowledge to be able to perform a task to a specified standard) was implemented for three of four licensed nurses (Registered Nurse 1, Licensed Vocational Nurse 4, and Licensed Vocational Nurse 5). This failure had the potential to compromise the services and types of care necessary to safely meet the resident's needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain accurate records of controlled medications (medications that are controlled by the government because it may be abused or cause addiction) for four of four medication carts (South, South-Center, North, and North-Center carts). These failures placed the facility at potential for diversion (illegal distribution of controlled drugs for any illicit use) of controlled medications by staff in a highly vulnerable population of 92 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the menu, and serve the correct size of roast beef for the regular texture diets (food with no modifications) for lunch on June 7, 2022. This failure had the potential to impair the nutritional status of 58 out of 92 residents who receive food from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety when: 1. There were two open style rodent bait traps which had the potential to contaminate the area if a rodent was trapped. 2. There was a meatball, crumbs and loose trash under the food prep table and black grime and crumbs at the side of the stove which had the potential for microorganism (small organism like bacteria, virus, or fungus) growth and attract pests. 3. The underside of the dishwasher counter had a patch and repair area with foam installation and a T-shaped piece of wood supporting the counter. This area was not smooth and easily cleanable, which could lead to microorganism growth that could inadvertently be transferred to food. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain infection control practices when a Registered Nurse (RN 1) did not wear gloves when disconnecting the IV (a thin bendable tube that slides into one of your veins) tubing on June 10, 2022, for one of six residents (Resident 53) reviewed for intravenous therapy in accordance with the facility's policy and procedure. This failure had the potential to spread infectious disease (disease caused by bacteria, viruses, fungi, or parasites) to Resident 53.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure safe and sanitary food preparation and storage practices for dietary services when: 1. Plastic tray bins were found stacked and stored wet. 2. Ice machine Cooling Compartment (where the ice is made) had a build-up of yellowish orange residue, that was removable with a white paper towel. These failures had the potential to lead to harmful bacteria and cross contamination that could lead to foodborne illness for a medically compromised population of 91 residents who receive food and water from dietary services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two Licensed Vocational Nurses (LVN 1 and LVN 3) followed the facility policy and procedure for obtaining a fingerstick blood glucose level (blood sugar level) for four of seven residents sampled for blood sugar levels (Residents 66, 40, 78, and 50) when the staff tested the first drop of blood after using alcohol to clean the residents' finger, instead of discarding that drop and using the second drop for an accurate blood glucose reading. This failure had the potential to result in inaccurate blood sugar levels which may lead to alterations in treatment provided to the residents.

Inspectors wrote2. During an observation on August 19, 2019, at 9:10 AM, an oxygen concentrator (A device that provides concentrated oxygen by taking in air, purifying it, then delivering the oxygen) and oxygen tubing in a dated plastic bag was noted at Resident 87's bedside. During review of the clinical record for Resident 87, the admitting physician orders dated July 15, 2019, is written for Oxygen at 2 liters (liter-a unit of measurement) per minute via nasal cannula PRN (as needed) for SOB (shortness of breath). During an observation on August 19, 2019, at 9:32 AM, a Certified Nursing Assistant (CNA 4) observed placing a Oxygen in use/No smoking sign out outside of Resident 87's room (35 days after the oxygen use was initiated). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to safely store medications for one of one sampled residents (Resident 445) when two medications were stored beyond the expiration date. This failure had the potential to result in decreased efficacy of the medications for Resident 445.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a Licensed Vocational Nurse (LVN 1) followed the facility policy and procedure for medication administration when the LVN did not document the administration of one medication in the Medication Administration Record (MAR-a record used to document the administration of medications) for one of 16 Residents sampled for medication pass (Resident 340). This failure lead to the facility not having complete nor accurate medication administration records for Resident 340 which may put the residents' health and safety at risk.

Inspectors wroteBased observation, interview, and record review, the facility failed to ensure infection control prevention was implemented when: 1. For one of one residents (Resident 18) a urinary catheter (a hollow, flexible tube that collects urine from the bladder and leads to a drainage bag) tubing was dragging on the floor while the resident self-propelled in the wheelchair across the hallway. 2. For Resident 15 a Certified Nursing Assistant (CNA 4) was observed touching the sitting stool he sat on and then touching the straw multiple times of a resident's beverage. These failures had the potential for cross contamination and the spread of infection.