Resident 95 told inspectors in June that nurses "usually would just leave the medications at the bedside and she would take the medications later." When inspectors first spotted her on June 18, a medication cup containing three tablets sat on her bedside table with no licensed staff in the room.
The resident explained that "the nurse gave the medications to her so she could eat her breakfast first, then she would take the medications." An hour later, inspectors returned to find the resident had taken her medications — for itching, cholesterol, and pain — from a cup left on her breakfast tray.
Licensed Vocational Nurse 3 confirmed the practice. She told inspectors she hadn't given medications directly to Resident 95 "because the resident wanted to take her medications later." The nurse acknowledged that "licensed staff were not supposed to leave the medications at bedside."
Medical records revealed Resident 95 had been assessed with moderate cognitive impairment. Despite this documented condition, the facility allowed unsupervised medication self-administration without following its own safety protocols.
The facility's 2008 policy requires multiple safeguards before residents can self-administer medications. A licensed nurse must complete a detailed assessment of the resident's physical and cognitive ability. The interdisciplinary team must review and approve the assessment. The team must reassess residents quarterly and require return demonstrations.
None of these steps occurred for Resident 95.
Registered Nurse 1 confirmed during interviews that the facility assesses residents upon admission for self-administration capability. But she verified that Resident 95 "did not have a physician's order, assessment, and care plan for the self-administration of medications."
The medication violations were part of broader safety failures inspectors documented during their June visit.
Three residents couldn't reach their call lights when they needed help. Resident 81 was observed lying in bed with her call light on the floor during multiple visits on June 19. When Certified Nursing Assistant 2 was summoned to the room, she found the call light still on the floor and acknowledged "it should not be in the floor."
Resident 96 sat upright in bed watching television while his call light hung on the wall out of reach. When asked if he could reach it, he said no. An hour later, inspectors found the same resident's call light had fallen to the floor. Licensed Vocational Nurse 3 confirmed "it should be within resident reach."
Resident 540 was discovered asking for her call light while lying in bed. Inspectors found the call button underneath her pillow, making the cord unreachable. Licensed Vocational Nurse 13 verified the finding when summoned to the room.
The facility's October 2022 policy explicitly states that staff must ensure call lights are "within reach of resident and secured, as needed."
Perhaps most troubling was the confusion surrounding Resident 32's end-of-life wishes. The resident told inspectors about a frightening incident when she was transferred to a hospital and heard the nurse tell ambulance personnel that she was "do not resuscitate" — when she actually wanted full resuscitation efforts.
"Resident 32 stated she felt scared when the facility staff thought she was DNR, but she was not," inspectors wrote.
The resident also questioned "why the facility allowed another person she did not even know to sign her POLST form, indicating she was DNR."
Medical records revealed the depth of the confusion. Resident 32 had physician orders for full cardiopulmonary resuscitation. But her care plan stated she "desired no life-prolonging measures" and included interventions for "no CPR" and ensuring she had a "signed DNR order."
On the day of her hospital transfer, Registered Nurse 3 gave a copy of a POLST form to ambulance personnel indicating DNR status. But when inspectors asked to see this form, the nurse couldn't locate it in the facility's POLST binder.
The Medical Records Director produced two conflicting POLST forms for the same resident. One from an earlier date showed full resuscitation and treatment. Another showed DNR status and comfort-focused care — but this form wasn't signed by Resident 32.
The Social Services Director confirmed that someone else had signed Resident 32's POLST form. She verified that "the individual who signed Resident 32's POLST form was the daughter of another resident residing in the facility who was not in any way related to Resident 32."
The director stated she was "not sure how a different person, not the resident herself could have signed the POLST form for Resident 32."
During the incident, Registered Nurse 3 had provided the hospital with documentation indicating Resident 32 was DNR, despite the resident's stated wishes for full resuscitation. The nurse couldn't explain the discrepancy when questioned by inspectors.
The Social Services Director acknowledged that her department was responsible for ensuring POLST forms were completed accurately. She said the interdisciplinary team, including the Director of Nursing and Administrator, reviewed residents' POLST forms to verify code status.
Yet somehow a cognitively capable resident's clearly expressed wishes for full resuscitation were contradicted by official documentation signed by a stranger's family member.
Resident 32's medical records showed she had "capacity to understand and make medical decisions." Her fear during the ambulance transfer — hearing staff describe her as DNR when she wanted full life-saving measures — illustrated the human impact of the facility's documentation failures.
The violations occurred at a facility that operates under the name St Edna Subacute and Rehabilitation Center but is listed in inspection records as Citrus Post-Acute. The 85-page inspection report documented numerous other deficiencies beyond these medication, call light, and advance directive failures.
For Resident 32, the confusion over her end-of-life wishes created a moment of terror during a medical emergency. For Resident 95, unsupervised access to medications despite cognitive impairment created ongoing safety risks. For three residents, unreachable call lights meant potential delays in receiving needed care.
The facility's own policies outlined the proper procedures. Staff acknowledged knowing the requirements. But implementation failed at critical moments when residents were most vulnerable.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Citrus Post-acute from 2024-06-21 including all violations, facility responses, and corrective action plans.