INVERNESS, FL - A comprehensive inspection at Citrus Health and Rehabilitation Center revealed multiple deficiencies in medication management, infection control practices, and resident safety protocols that placed residents at potential risk.
Medication Storage and Administration Failures
Inspectors documented serious lapses in medication security and administration protocols across multiple units at the facility. These violations represented fundamental failures to protect residents from medication errors and potential harm.
On May 12, 2025, surveyors discovered two vials of Budesonide inhalation suspension sitting unattended on a resident's nightstand. The respiratory medication, prescribed twice daily for respiratory failure, had been left in the room after the resident refused treatment. The facility had no physician's order authorizing the resident to self-administer medications, and no evaluation had been conducted to determine if self-administration would be appropriate.
When questioned, the resident explained that nursing staff sometimes left medications in the room when treatments were refused. The nurse working that shift confirmed the practice, stating that the previous nurse "must have left it in the room" when the resident declined the breathing treatment. This practice violated basic medication safety protocols requiring all medications to remain under nursing supervision unless specific self-administration orders exist.
A second medication storage violation involved another resident who was found with prescription antifungal cream sitting in medication cups on the overbed table. The facility had no self-administration order for this resident either. On a subsequent day, inspectors observed five pills left unattended in a medication cup on the same resident's table because the individual was talking on the telephone and didn't want to take them immediately. The medications included Carbidopa-Levodopa for Parkinson's disease and Gabapentin for neuropathy—both requiring careful administration monitoring.
These practices create multiple safety risks. Medications left unattended can be accidentally taken by confused residents, taken at incorrect times, or accessed by other individuals. For residents with cognitive impairments or those in memory care settings, unsecured medications present particularly serious hazards.
The third medication storage violation occurred in the memory care unit, where inspectors found pain-relieving gel stored in an unlocked cabinet accessible to residents with dementia. Medications must be secured in locked storage areas to prevent residents from accessing them unsupervised, especially in specialized units housing individuals with cognitive impairments who may not understand the risks of improper medication use.
Inadequate Medication Review and Documentation
The facility's medication regimen review process revealed significant deficiencies in how prescribing providers responded to pharmacist recommendations. Federal regulations require monthly medication reviews by consulting pharmacists to identify potential problems including unnecessary medications, inadequate monitoring, and opportunities for dose reduction.
One resident had been prescribed Meclizine as needed for dizziness complaints. Federal guidelines require reassessment of as-needed medications after 14 days of use to determine if ongoing therapy remains appropriate. The consulting pharmacist made this recommendation twice—in July 2024 and again in March 2025. Both times, the provider's response indicated "no change at this time after assessment: risk vs benefit," but failed to document any actual assessment findings or clinical rationale. Physician progress notes contained no documentation addressing either the dizziness symptoms or the ongoing need for Meclizine therapy.
The same pattern occurred with recommendations for gradual dose reduction of psychotropic medications. Federal guidelines require facilities to attempt dose reductions for psychotropic drugs at least twice yearly in the first year, then annually thereafter, to verify residents receive the lowest effective dose. When the pharmacist recommended attempting dose reductions for a resident taking three psychotropic medications (Perphenazine, Trazodone, and Sertraline), the provider checked a box indicating reductions were contraindicated but provided no clinical explanation.
Similar documentation gaps appeared in responses to recommendations about proton pump inhibitor (PPI) therapy. These acid-reducing medications require periodic review due to potential adverse effects with long-term use, including increased infection risk, bone fractures, and nutrient deficiencies. When asked to document the rationale for continuing PPI therapy, the provider left the documentation section blank despite marking that continued therapy was appropriate.
These documentation failures prevent meaningful clinical review of medication appropriateness. Without documented rationale for continuing medications or declining recommended changes, other healthcare providers cannot understand the clinical decision-making or identify when circumstances may have changed. The facility's Director of Nursing acknowledged that staff simply accepted whatever response providers marked on forms without requesting clarification or additional information, even when documentation was incomplete.
Infection Control Breaches During High-Risk Procedures
Multiple infection control violations were documented involving both basic hand hygiene failures and improper technique during invasive procedures. These lapses increased residents' risk of healthcare-associated infections.
During administration of intravenous antibiotics to a resident on enhanced barrier precautions for wound care, a nurse entered the room without performing hand hygiene and failed to wear a gown as required. The nurse then handled the IV pole, connected tubing to medication, and accessed the resident's IV line without changing gloves or performing hand hygiene between tasks. Enhanced barrier precautions require gowns and gloves during high-contact care activities including device care and wound care. These precautions are implemented specifically to prevent transmission of multidrug-resistant organisms, making compliance essential for protecting both the resident and others in the facility.
Proper IV medication administration requires meticulous attention to sterile technique. Nurses should perform hand hygiene before gathering supplies, don appropriate personal protective equipment, perform hand hygiene again before handling sterile components, scrub the needleless connector, and connect IV tubing using aseptic technique. Failure to follow these steps can introduce bacteria directly into the bloodstream, potentially causing serious infections.
A second infection control violation involved wound care for a resident with multiple lower extremity wounds. The nurse used bandage scissors carried in his pants pocket to cut dressings and wound packing material. After removing soiled dressings, the nurse applied prescribed wound cleanser without removing gloves or performing hand hygiene. When questioned, the nurse stated he didn't believe glove changes were necessary because the wound was "dirty" until after cleanser application.
This reasoning contradicts fundamental infection control principles. Soiled dressings and wound drainage contain high concentrations of bacteria. Without removing contaminated gloves and performing hand hygiene, nurses transfer these organisms to cleansing products, wound surfaces, and surrounding intact skin. The facility's own competency testing materials specified that nurses should change gloves appropriately during wound care procedures and that scissors must be cleaned before and after use rather than stored in pockets.
During enteral feeding, another nurse failed to rinse a medication administration syringe after use, returning it to storage with visible medication residue inside. Facility policy required rinsing syringes with warm water after each use and replacing them every 24 hours. Medication residue provides a growth medium for bacteria, and inadequately cleaned equipment can harbor organisms that multiply and potentially cause infections.
Medical Record Documentation Failures
Inspectors identified incomplete and inaccurate medical record documentation affecting two residents. Accurate medical records are essential for coordinating care, tracking treatment effectiveness, and ensuring continuity when staff members change.
One resident had a gastric tube for nutrition and medication administration. Physician orders specified daily dressing changes to the tube insertion site, to be performed during day shift. When surveyors observed the resident on May 14, the gauze dressing was dated May 11—three days prior. The treatment administration record showed dressing changes documented for May 12 and May 14, but not for May 13.
Nursing staff expressed confusion about responsibility for the dressing changes. The day shift nurse stated she relied on the wound care nurse to perform and document the procedure. The wound care nurse believed regular nursing staff handled gastric tube site care. The Director of Nursing clarified that wound-related care fell under the wound care nurse's responsibility, and whoever performed treatments should document completion.
This lack of role clarity created gaps in essential care. Regular assessment and dressing changes for feeding tube sites help identify early signs of infection, skin breakdown, or tube displacement. When responsibilities remain undefined and documentation incomplete, residents may not receive ordered care consistently.
A second documentation issue involved vaccine administration. One resident's immunization record indicated Influenza vaccine refusal, documented on a signed consent form dated August 7, 2024. However, the medication administration record showed the resident received Influenza vaccine on that same date. When asked about the discrepancy, the Director of Nursing explained that the facility obtained signed consents before ordering vaccines, and residents occasionally changed their minds between signing forms and vaccine arrival. However, staff apparently failed to obtain a new consent form when the resident decided to accept the vaccine after initially declining.
The same resident's record showed documentation of Pneumococcal vaccine refusal in October 2023, but no signed declination form could be located in the medical record. Facility policy required documentation of vaccine refusals in residents' records, with residents or representatives signing declination forms. These forms serve important purposes: they document that education about vaccine benefits and risks was provided, that the resident made an informed decision, and they create a clear record for future reference.
Call Light Access Violation
One resident who required mechanical lift assistance for all transfers was found on three separate occasions without her call light within reach. On different days, inspectors observed the call light sitting on top of the bedside table, inside the table drawer, and clipped to the drawer handle. The resident stated she had not moved the call light herself and that she had been instructed to call out verbally if she needed help.
Call lights represent a critical safety tool, particularly for residents with mobility limitations. This resident could not get out of bed independently and could not reach her call light in any of the observed positions. Her care plan specifically included an intervention to keep the call light within reach due to fall risk. One nursing assistant acknowledged clipping the call light to the drawer pull during personal care but apparently failed to reposition it within the resident's reach afterward.
Facility policy required call lights to remain within easy reach when residents were in bed or chairs, with regular checks for residents unable to use call lights independently. Failure to ensure call light access left this resident unable to summon assistance for toileting needs, medication requests, or emergency situations.
Additional Issues Identified
Beyond the major violations detailed above, inspectors noted several other concerns. The facility's process for responding to consulting pharmacist recommendations lacked rigor, with providers marking checkbox responses without providing required clinical justification. Staff expressed limited understanding of documentation requirements when declining pharmacist recommendations.
The inspection revealed patterns suggesting inadequate staff education about medication safety protocols, infection control procedures, and documentation requirements. Multiple nurses demonstrated incomplete knowledge of proper techniques despite facility policies clearly outlining expectations.
Federal regulations require nursing facilities to maintain comprehensive quality assurance programs identifying and addressing care deficiencies. The violations documented during this inspection suggest opportunities for strengthened oversight, staff education, and monitoring systems to ensure consistent adherence to safety protocols.
The facility must develop and implement corrective action plans addressing each identified deficiency, with plans subject to state survey agency review and approval.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Citrus Health and Rehabilitation Center from 2025-05-15 including all violations, facility responses, and corrective action plans.
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