Above average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Citrus Nursing Center during CMS and state inspections, most recent first.
Staff failed to label and date oxygen tubing for two residents with respiratory conditions, contrary to facility policy, and a janitor removed pillows from trash bins and placed them on a handrail near the laundry area instead of discarding them, resulting in lapses in infection control as confirmed by the DON and Infection Preventionist.
Surveyors observed black substances, including mold, on the floors, walls, and ceilings of multiple shower stalls in the North hallway, which were confirmed by a CNA, the ESD, and the DON. The facility's cleaning policies and procedures for routine bathroom sanitation and mold inspection were not followed, resulting in unsanitary conditions unsuitable for resident use.
Surveyors found that appropriate care was not provided for residents regarding bowel/bladder continence, catheter management, and UTI prevention, resulting in a deficiency.
A resident with significant weight loss and multiple medical conditions did not receive the physician-ordered Boost VHC nutritional supplement with meals on multiple occasions. Staff confirmed the order was not followed, and there was no documentation of supplement intake, contrary to facility policy.
A resident with multiple medical conditions, including neuropathic pain, received Pregabalin 25 mg, but a dose was not documented on the Controlled Drug Record (CDR) as required, leading to a discrepancy between the medication count and the records. The nurse involved acknowledged the omission, and the DON confirmed that facility policy requiring accurate documentation in both the CDR and EMR was not followed.
Surveyors found multiple expired medical supplies, including alcohol swabs, antiseptic swab sticks, and IV caps, in an IV cart during an inspection. The DON acknowledged the expired items and stated that licensed staff are responsible for checking expiration dates each shift, but also revealed that the facility lacks a policy for supply storage and management.
The facility did not adequately protect resident-identifiable information or maintain medical records according to professional standards, as observed by surveyors.
A resident with type 2 diabetes and muscle atrophy developed a blister on the right heel after admission to the facility, despite having no wounds upon entry. The blister was identified as a new in-house skin issue, indicating a failure in the facility's pressure injury prevention and management practices.
Failure to Follow Infection Control Practices for Oxygen Equipment and Linen Handling
Penalty
Summary
The facility failed to follow safe infection control practices and maintain a sanitary environment in several instances. For one resident with chronic respiratory failure, an oxygen nasal cannula tubing in use was found to be unlabeled and undated, despite a physician order requiring the cannula to be changed every Sunday and as needed. A Licensed Vocational Nurse confirmed the tubing was not labeled as required, and the Director of Nursing acknowledged that the facility's policy, which mandates weekly changes and labeling, was not followed. Similarly, another resident with acute respiratory failure and heart failure was observed using a nasal cannula oxygen tubing that was also not labeled or dated. Both a Licensed Vocational Nurse and a Registered Nurse were unable to confirm when the tubing was last changed, and the Director of Nursing again confirmed that the facility's policy was not adhered to in this case. Additionally, a janitor removed multiple pillows from trash containers and placed them on a handrail near the laundry room, believing they were mistakenly discarded. The Environmental Services Director and Infection Preventionist both stated that items removed from trash should not be reused or placed in common areas due to contamination risks. The facility's infection prevention and control policy requires contaminated reusable items to be bagged and labeled for processing, and linens to be handled in a way that prevents the spread of infection. These actions were not followed, as the pillows were left exposed in a high-traffic area after being removed from trash bins containing dirty linen and waste from resident rooms.
Failure to Maintain Clean and Sanitary Shower Facilities
Penalty
Summary
On July 29, 2025, during an observation in the North hallway shower room, surveyors identified a black substance present on the floors, walls, wall joints, and ceilings of all three shower stalls. This substance was also found between the tiles and where the wall meets the floor and ceiling. Certified Nursing Assistant 1 confirmed that this shower room is used by all residents in the North hallway. The Environmental Services Director of Maintenance acknowledged the presence of the black substance and suggested it might be a buildup from shampoo oils and soap scum, noting that the ceiling issue was new to him since his employment began in April 2025. The Director of Nursing inspected the area and confirmed the presence of black substances, including black mold, on the tiles, walls, and ceilings, and stated that the showers were not suitable for resident use in their current state. A review of the facility's policy and procedure for routine bathroom cleaning revealed requirements for cleaning and inspecting for mold, which were not followed. Both the Administrator and the Environmental Services Director of Maintenance acknowledged that the facility's cleaning policies and procedures had not been adhered to.
Deficient Bowel/Bladder and Catheter Care Practices
Penalty
Summary
The report identifies a deficiency related to the provision of care for residents who are continent or incontinent of bowel and bladder, as well as the management of catheter care and the prevention of urinary tract infections (UTIs). Surveyors found that appropriate care was not provided in these areas, indicating lapses in the facility's practices for maintaining continence care, catheter hygiene, and UTI prevention. Specific details regarding the actions or omissions that led to this deficiency, as well as information about the residents involved, are not provided in the report.
Failure to Provide Physician-Ordered Nutritional Supplement with Meals
Penalty
Summary
A deficiency occurred when the facility failed to follow the physician's order for a resident who was to receive Boost VHC, a very high-calorie nutritional supplement, three times daily with meals. The resident, who had diagnoses including myocardial infarction, dementia, and immunodeficiency, experienced significant weight loss over several months. The Order Summary Diet Order, dated July 18, 2025, specified the need for Boost VHC with meals, as recommended by the Registered Dietitian due to the resident's poor meal intake and ongoing weight loss. During direct meal observations on two separate occasions, the resident did not receive the ordered Boost VHC with either lunch or breakfast. Staff interviews and record reviews confirmed that the supplement was not provided and that there was no documentation of its intake. The facility's policy required the provision of nutritional supplements according to assessed needs, but this was not followed for the resident in question.
Failure to Accurately Document Controlled Medication Administration
Penalty
Summary
The facility failed to maintain accurate records of controlled medications for one of three medication carts, specifically regarding a resident who was prescribed Pregabalin 25 mg for neuropathic pain. During an inspection, it was found that the Controlled Drug Receipt/Record/Disposition Form (CDR) for this medication was inaccurate, as the number of tablets documented as administered did not match the actual count in the medication bubble pack. A licensed vocational nurse acknowledged that one dose was given to the resident but was not recorded on the CDR, although it was documented in the electronic medical record (EMR). Facility policy requires that all administered doses of controlled substances be documented both in the CDR and the EMR, and that the physical count of medication matches the records to prevent drug diversion. The Director of Nursing confirmed that the policy was not followed in this instance, as the nurse failed to document the administration of a controlled medication on the required CDR form, resulting in a discrepancy between the medication count and the documentation.
Expired Medical Supplies Found in IV Cart Due to Lack of Storage Policy
Penalty
Summary
During an inspection of the facility's intravenous (IV) cart, surveyors observed that multiple medical supplies were expired and still available for use. Specifically, the expired items included alcohol swabs, povidone-iodine swab sticks, Chlora prep triple swab sticks, luer lock tip caps, and red end caps, with some items being expired for over two years. The Director of Nursing (DON) acknowledged the presence of these expired supplies and confirmed that they should have been discarded. The DON also stated that licensed staff are responsible for checking the expiration dates in the IV cart every shift. However, it was revealed during the interview that the facility does not have a policy for supply storage and management. This lack of a formal policy contributed to the failure to ensure that drugs and biologicals were labeled and stored in accordance with professional standards, as required.
Failure to Safeguard Resident Information and Maintain Medical Records
Penalty
Summary
The facility failed to safeguard resident-identifiable information and/or did not maintain medical records for each resident in accordance with accepted professional standards. This deficiency was identified through surveyor observation or review, indicating that the required protocols for protecting confidential resident information or proper record-keeping were not followed as expected. No additional details regarding specific residents, staff actions, or the circumstances leading to the deficiency are provided in the report.
Failure to Prevent Blister Development in Resident
Penalty
Summary
The facility failed to provide appropriate care to prevent a blister from developing on the right heel of a resident, who was clinically compromised. The resident was admitted with diagnoses including type 2 diabetes mellitus, muscle wasting and atrophy, and depression. Upon admission, the resident's skin was noted to be warm, dry, and within normal limits, with no external devices present. However, a fluid blister was observed on the resident's right heel on October 30, 2024, which was not present upon admission on October 5, 2024. The blister was documented as a new skin issue acquired in-house. Interviews with the resident and facility staff, including the Wound Treatment Nurse and the Assistant Director of Nursing, confirmed that the blister developed after the resident's admission. The facility's policy on pressure injury prevention and management, revised in September 2023, emphasizes the commitment to preventing avoidable pressure injuries and providing treatment to heal and prevent further injuries. Despite this policy, the resident developed a blister, indicating a lapse in the facility's adherence to its own procedures for pressure ulcer prevention and management.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Fontana
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Laurel Convalescent Hospital | 3.3 mi | ★★★★★ | 26 | 0 |
| Rialto Post Acute Center | 4.6 mi | ★★★★★ | 14 | 1 |
| Riverside Heights Healthcare Center, Llc | 4.7 mi | ★★★★★ | 0 | 0 |
| Jurupa Hills Post Acute | 5.1 mi | ★★★★★ | 7 | 0 |
| Vista Pacifica Convalescent Hospital | 5.5 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.