Life Care Center of Citrus County: Treatment Failures - FL
The pattern repeated itself across multiple shifts and multiple nurses over a span of weeks before inspectors arrived.
One resident, identified in the report as Resident 17, carried diagnoses including cognitive communication deficit, protein calorie malnutrition, major depressive disorder, and lymphedema. His physician had written a clear order: give Metoprolol Tartrate twice daily for high blood pressure, but hold it if his heart rate dropped below 60, and call the doctor if it dropped below 50.
It dropped below 60 four times. The medication was given anyway.
On the morning of February 1, LPN Staff K recorded a heart rate of 52 and administered the drug. That same evening, LPN Staff J recorded a heart rate of 58 and gave it again. On February 7, LPN Staff Q gave it with a heart rate of 58. On February 11, LPN Staff P administered it when the resident's blood pressure had fallen to 108/49 and his heart rate was 56, both outside the physician's parameters.
Nobody called the doctor. Nobody held the medication. Nobody wrote a progress note.
When inspectors sat down with Staff K on February 12, she did not dispute what the records showed. "I do see in the MAR on 2/1/2026 at 8 AM that I signed and the HR was 52," she told them. "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 was equally direct. "I did give his blood pressure medications out of parameter on 2/1/2026 at 8 PM," she said, "but I didn't look at any other months. 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."
The second resident, identified as Resident 35, had high blood pressure and was on medication with physician-ordered parameters governing when it should be given. Inspectors found instances in which a checkmark on the medication record indicated the drug had been administered, but the documented vital signs showed the parameters had not been met.
Staff D, an LPN, told inspectors she couldn't be certain what had happened. "A check mark documented on the medication record normally means that the medication was given," she said. "I don't remember, it's been some time. If I marked it off, I probably gave the medication."
Another nurse who cared for Resident 35 was more candid about the broader problem. "We get so used to the residents," she told inspectors, adding that she would begin checking parameters more carefully going forward.
The resident's prescribing provider, an advanced practice registered nurse, told inspectors she had never received a call from staff reporting the medication had been given outside parameters. Resident 35, she said, had experienced elevated blood pressure but had not required hospitalization.
The Director of Nursing, interviewed on the morning of February 12, offered a single sentence: "Nurses need to follow the parameters and nursing orders."
Metoprolol is a beta-blocker. Giving it when a patient's heart rate is already low can slow the heart further, causing dizziness, fainting, or worse. The physician's order existed precisely to prevent that. Four times, across four different nurses, on four different dates, it was ignored for Resident 17 alone.
Resident 17 has cognitive communication deficits and dysarthria. He cannot speak clearly. Whether he felt his heart slow, whether he felt dizzy or weak or frightened on any of those four mornings and evenings, is not something he could easily have reported to anyone.
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.
The pattern repeated itself across multiple shifts and multiple nurses over a span of weeks before inspectors arrived.
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.