Life Care Center: Infection Control Failures - FL
The resident, identified in inspection records only as Resident 17, carries a complicated medical history: cognitive communication deficits, protein calorie malnutrition, major depressive disorder, chronic Hepatitis C, and lymphedema. His physician had ordered Metoprolol Tartrate, a beta-blocker used to treat high blood pressure, twice daily, with explicit instructions: hold the dose if the systolic blood pressure dropped to 110 or below, or if the heart rate fell below 60. Call the doctor if the heart rate dropped below 50.
On February 1, at 8:00 in the morning, a nurse recorded his heart rate at 52 and gave the medication anyway. That same evening, a different nurse recorded his heart rate at 58, still below the threshold, and gave the dose again. On February 7, a third nurse recorded a heart rate of 58 and administered the drug. On February 11, a fourth nurse documented a blood pressure of 108 over 49 and a heart rate of 56, both outside the parameters, and gave the medication.
Nobody called the doctor. Nobody held the dose. Nobody wrote a progress note.
When inspectors interviewed the nurses afterward, each acknowledged the error plainly. The nurse who gave the medication on the morning of February 1, identified as Staff K, LPN, told inspectors: "I do see in the MAR on 2/1/2026 at 8 AM that I signed and the HR was 52. 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, the nurse who administered the evening dose on February 1, was equally direct. "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."
The advanced practice registered nurse who oversees Resident 17's care told inspectors she had never received a call from staff about the medication being given outside parameters. She noted the resident had experienced elevated blood pressure but had not required hospitalization. The Director of Nursing, interviewed the morning of February 12, offered a brief response: "Nurses need to follow the parameters and nursing orders."
A second resident, identified as Resident 35, had a similar problem involving a blood pressure medication. Her nurse told inspectors that a checkmark on the medication record normally means the medication was given, but expressed uncertainty about specific entries. "If I marked it off, I probably gave the medication," Staff D, LPN, said. Another staff member described the stakes plainly: if the medication was not given, the resident's blood pressure would go up. She has high blood pressure. The staff member said she planned to start checking parameters more carefully.
Metoprolol works by slowing the heart. When a physician sets a threshold for holding the dose, it is because pushing the heart rate lower in a patient already running slow carries real risk, including dangerously low blood pressure, dizziness, falls, and in severe cases, cardiac events. The physician who set the parameters for Resident 17 had identified 60 beats per minute as the line. His heart rate hit 52, and he still received the drug.
The advanced practice nurse told inspectors that Resident 17 has been stable. What she did not know, until inspectors arrived, was how many times his nurses had looked at his vitals, seen numbers outside the safe range, and given the medication anyway.
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.
Call the doctor if the heart rate dropped below 50.
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.