Life Care Center of Citrus County: Assessment Failures - FL
That happened on February 1, 2026. It happened again six days later. And again on February 11.
Federal inspectors who arrived at Life Care Center of Citrus County documented four separate instances in which nurses administered Metoprolol Tartrate, a blood pressure drug, to a resident whose vital signs had crossed the threshold where the prescribing physician had ordered the medication stopped. The resident, identified in inspection records only as Resident 17, carries diagnoses that include cognitive communication deficit, major depressive disorder, chronic Hepatitis C, and protein calorie malnutrition. He cannot easily speak for himself. His heart rate was recorded at 52 beats per minute at 8 a.m. on February 1, when LPN Staff K signed off on the medication. That evening, his rate was 58, and LPN Staff J gave it again. On February 7, his rate was again 58, and LPN Staff Q administered the drug. On February 11, his blood pressure had fallen to 108 over 49 and his heart rate to 56. LPN Staff P gave the medication.
In each instance, the doctor's order required nurses to hold the drug and contact the physician. None of them did.
When inspectors interviewed Staff K on February 12, she acknowledged what the record showed. "I do see in the MAR on 2/1/2026 at 8 AM that I signed and the HR was 52," she said. "The order stated hold if HR is less than 60 so I agree that the vitals are out of parameters. I should have notified the MD and at that time discussed the next protocol for the resident. I should have held the medication and made a progress note."
Staff J said much the same thing. "I did give his blood pressure medications out of parameter on 2/1/2026 at 8 PM," she told inspectors. "I should have notified the MD that his pulse was under 60 and then the MD would have advised me further on the next step."
Neither nurse had a clear explanation for why they hadn't.
The problem extended to a second resident. Resident 35, a woman with high blood pressure, had a physician order for blood pressure medication that included parameters for when it should be given and when it should be withheld. Inspectors found instances in which the medication was documented as given, but questions arose about whether the parameters had been followed consistently. A nurse told inspectors that a check mark on the medication record "normally means that the medication was given," then added: "I don't remember it's been some time. If I marked it off, I probably gave the medication."
The advanced practice registered nurse who oversees Resident 35's care told inspectors the resident had experienced elevated blood pressure but had not required hospitalization. She said she had received no calls from staff informing her the medication had not been given when vital signs were out of range.
The Director of Nursing, interviewed on the morning of February 12, offered a four-word response to the pattern inspectors had documented: "Nurses need to follow the parameters and nursing orders."
Metoprolol is a beta blocker. Giving it to a patient whose heart rate is already below the threshold where the drug is supposed to be withheld can slow the heart further. The physician who wrote Resident 17's order had anticipated exactly that risk and written an instruction to address it. The instruction was in the chart every time a nurse signed off on the drug.
Resident 17's heart rate was 52 beats per minute when the first nurse gave him the medication anyway. The physician was never called.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Life Care Center of Citrus County from 2026-02-12 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: August 4, 2026 · Our methodology
LIFE CARE CENTER OF CITRUS COUNTY in LECANTO, FL was cited for violations during a health inspection on February 12, 2026.
That happened on February 1, 2026.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.