Federal inspectors found that Citrus Grove Post Acute failed to ensure a safe discharge for the resident on December 17, 2025. The facility's own discharge documentation showed the resident was dependent for walking and needed assistance with basic activities of daily living.
Yet staff sent the resident to a room and board placement anyway.
The Enhanced Case Manager with a local foundation told inspectors that the resident "did not meet the criteria for room and board placement because Resident 1 was unable to perform activities of daily living without assistance." The case manager, who assists unhoused people with housing and healthcare, had been working with the facility to arrange a safe discharge.
The facility's Administrator acknowledged during interviews that "a resident could be discharged to a room and board if they were high functioning, meaning the resident could perform most activities independently." The Social Services Director stated the resident was wheelchair bound.
Nobody assessed whether the discharge location could actually care for the resident.
"Facility staff did not assess the discharge location for Resident 1," the Administrator told inspectors on January 13, 2026.
The discharge planning process broke down at multiple points. The Social Services Director provided a third-party Business Development Director with a packet containing the resident's face sheet, physician orders, and medical history. But the packet included no documentation of the resident's functional status or activities of daily living needs.
The Business Development Director, who was working with the facility on placement, told inspectors he "met Resident 1 in person and was unaware of the care needs for Resident 1."
How could he be unaware? The facility's own discharge documentation, dated December 17, 2025, clearly indicated the resident needed assistance with bed mobility, toileting, household tasks and transfers. The resident was marked as "dependent" for walking and required a wheelchair van for transportation.
The Social Services Director received a call on December 16 from the Business Development Director stating "he was able to find resident room and board placement and has it all arranged for him to discharge tomorrow morning." A physician's order the same day authorized discharge for December 17.
The Social Services Director told inspectors she "did not follow-up with the RABM [Room and Board Manager] after becoming aware of Resident 1's placement."
The facility's Director of Nursing said "the room and board manager should assess the resident in person prior to discharge and social services should arrange the discharge after acceptance." That didn't happen.
Multiple coordinators assessed the resident several times before discharge, according to inspection records. But the Social Services Director denied having any communication with the Room and Board Manager before sending the resident there.
The facility's own policy requires staff to assist residents "in selecting a post-acute care provider that is relevant and applicable to the resident's goals of care and treatment preferences" when transferring to certain types of facilities. The policy, revised in December 2016, doesn't specifically address room and board placements.
Federal inspectors classified the violation as causing minimal harm or potential for actual harm to few residents. But for this wheelchair-bound resident who needed help with basic daily activities, the consequences of an inappropriate discharge could have been severe.
The Enhanced Case Manager confirmed the resident was ultimately discharged from the facility on December 17, 2025, despite not meeting criteria for the placement. Where the resident went after that remains unclear from inspection records.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Citrus Grove Post Acute from 2025-12-31 including all violations, facility responses, and corrective action plans.