The assault was discovered through the facility's security camera system.
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Federal inspectors found no care plan existed for any of the three residents during a December 30 complaint investigation.
The director told inspectors on December 30 that she relied on nurses to inform her of concerns from the reports rather than reviewing them herself.
Resident 1 had been placed in isolation due to suspected scabies and received a doctor's order for permethrin cream.
Resident 1 approached department heads complaining that items were missing related to use of their bank card.
Resident 3 was classified as high risk for falls and required frequent visual checks.
Resident 1, admitted in late 2025 with a urinary tract infection and weakness, had an uncovered urinal stored in the bottom drawer of their closet.
The assessment painted a picture of serious respiratory distress.
She had come in with Type 1 diabetes, muscle wasting, and dehydration.
The fall happened on December 22, 2025.
When an inspector arrived at his room on December 30, 2025, just before noon, Resident 2 was visibly upset.
Federal inspectors found that Citrus Grove Post Acute failed to ensure a safe discharge for the resident on December 17, 2025.