Above average — CMS composite of the measures below.
A standard survey is most likely before around August 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 Health And Rehabilitation Center during CMS and state inspections, most recent first.
Surveyors found that drugs and biologicals were not securely stored in three units. A resident had inhalation medication left on a nightstand after refusing treatment, and another had prescription cream and pills left on an overbed table while talking on the phone, with no self-administration evaluations in place. In the memory care unit, pain-relieving gel was found in an unlocked cabinet accessible to residents. Staff and DON confirmed that medications should be stored securely according to facility policy.
Surveyors identified that several residents' MDS assessments did not accurately reflect their current diet orders, recent weight loss, or hospice status, despite supporting documentation in physician orders and weight records. Staff interviews confirmed that these inaccuracies were due to incorrect documentation and would need to be corrected.
The facility did not update care plans for two residents: one continued to have enhanced barrier precautions listed for COVID-19 after no longer being contagious, and another had outdated dialysis care plan interventions that did not reflect the use of a central venous catheter instead of a shunt. Required monitoring and documentation were also not completed as specified in the care plan and physician orders.
A resident received a physician's order for Voltaren Arthritis Pain External Gel 1% that did not specify the dosage or the area for application. The DON confirmed the omission and stated that orders are expected to include this information, in accordance with facility policy.
The facility did not ensure that two residents received medications as ordered, including a missed heparin flush for a central line and administration of acetaminophen outside prescribed pain parameters, and failed to change an enteral tube dressing daily for another resident due to unclear staff responsibilities.
A resident receiving oxygen therapy was observed with an unsecured oxygen cylinder in their room, contrary to facility policy and physician orders requiring proper securing of compressed gas cylinders. The DON confirmed that cylinders must be secured at all times to prevent accidents.
The facility did not ensure that prescribers documented the rationale for declining pharmacist recommendations during monthly medication regimen reviews for two residents. For one resident on a PPI for GERD, and another on multiple psychotropic medications, the prescribers either marked 'No change' or provided incomplete responses without explanations, contrary to facility policy. Staff interviews revealed a lack of understanding about the documentation requirement, and review of records showed missing progress notes and incomplete forms.
The facility did not maintain accurate and complete medical records for two residents, including one receiving enteral feeding whose daily wound care was not properly documented, and another whose immunization records lacked required consent and declination forms. Staff interviews revealed confusion over documentation responsibilities, and facility policies requiring proper recordkeeping were not followed.
Staff did not adhere to infection control protocols during enteral medication administration, IV therapy, and wound care for two residents. An LPN failed to rinse a flush syringe after use, leaving visible residue, while an RN neglected hand hygiene and gown use when providing IV therapy under enhanced barrier precautions. Another RN used unclean scissors stored in a pocket and did not change gloves or perform hand hygiene between wound care steps, all contrary to facility policy.
A resident who was at risk for falls and required a Hoyer lift did not have her call light within reach while in bed, as it was repeatedly placed on or inside her bedside table or clipped to the drawer pull. Staff interviews confirmed the call light was not accessible, and the resident's care plan and facility policy both required the call light to be within easy reach.
Failure to Securely Store Medications and Biologicals
Penalty
Summary
Surveyors observed that drugs and biologicals were not stored in accordance with accepted professional principles in three of five units. In one instance, a resident had two vials of Budesonide Inhalation Suspension left on their nightstand by nursing staff after refusing treatment, despite not having an order or evaluation for self-administration. The resident confirmed that the medication was left by the nurse, and both the LPN and DON acknowledged that there was no self-administration order or evaluation, and that medications should not be left unattended in resident rooms. In another case, a resident had prescription anti-itch cream and a cup with five pills left on their overbed table. The resident stated that the nurse left the medications because she was on the phone and did not want to take them at that time. The RN confirmed leaving the medications in the room and identified the medications. There was no evaluation or order for self-administration for this resident. Additionally, in the memory care unit, a pain-relieving gel was found in an unlocked cabinet accessible to residents. The Certified Dietary Manager and DON both confirmed that medications should be stored in locked areas and not accessible to residents. Facility policy requires all medications to be stored securely.
Inaccurate Resident Assessments Documented in MDS
Penalty
Summary
The facility failed to ensure that resident assessments accurately reflected the current status of several residents, as evidenced by discrepancies between physician orders, weight records, and Minimum Data Set (MDS) documentation. For three residents reviewed for nutrition, the MDS assessments did not indicate the correct diet texture or recent weight loss, despite physician orders and weight summaries showing otherwise. Specifically, one resident with a physician order for a pureed diet was not documented as having a mechanically altered diet in the MDS, and another with a mechanical soft diet order was similarly not reflected in the MDS. Additionally, a resident who experienced a 5.1% weight loss over a month was not identified as having significant weight loss in the MDS assessment. For a resident reviewed for hospice services, the admission MDS assessment failed to indicate that the resident was under hospice care, despite a physician order for hospice admission. Interviews with facility staff, including the MDS Coordinator RN and an LPN, confirmed that these sections of the MDS were incorrectly documented and would require correction. The facility's policy states that the Resident Assessment Coordinator is responsible for ensuring timely and accurate assessments, but these requirements were not met in the cases reviewed.
Failure to Revise Care Plans for Infection Control and Dialysis Access
Penalty
Summary
The facility failed to revise and update care plans to reflect the current needs of two residents. For one resident who had previously tested positive for COVID-19, the care plan continued to indicate the need for enhanced barrier precautions (EBP) even after the resident was no longer contagious. Observation revealed that there was no EBP signage on the resident's door, and the MDS Coordinator confirmed that the EBP focus should have been resolved once the resident was no longer infectious. The facility's policy requires care plans to be reviewed and revised by the interdisciplinary team after each assessment, but this was not done in this case. For another resident receiving dialysis, the care plan listed interventions related to a shunt in the left subclavian area, including monitoring for bruit and thrill, and avoiding blood pressure readings and blood draws from the shunted arm. However, the resident was actually using a central venous catheter (CVC) in the left groin for dialysis, and the care plan and physician orders were not updated to reflect this change. Additionally, there was no documentation of required checks for bruit and thrill at the shunt site in the treatment administration record. The DON acknowledged that the orders needed to be updated to match the resident's current dialysis access.
Medication Order Lacked Required Dosage and Application Site
Penalty
Summary
The facility failed to ensure that services were provided according to professional standards of practice for one resident reviewed for unnecessary medications. Specifically, a physician's order for Voltaren Arthritis Pain External Gel 1% (Diclofenac Sodium Topical) for the resident, dated 4/28/2025, did not specify the dosage or the specific area for application. During an interview, the DON confirmed that the order lacked both the dosage and the location for application, and stated that her expectation was for all orders to include this information. Review of the facility's medication administration policy indicated that medications should be administered as prescribed by the physician, and that unclear or excessive dosages should prompt staff to contact the physician or medical director for clarification.
Failure to Follow Physician Orders for Medication and Treatment Administration
Penalty
Summary
The facility failed to ensure that residents received medications and treatments as ordered by their physicians, as well as according to facility policy. In one instance, a registered nurse did not administer a prescribed heparin flush following a normal saline flush for a resident with a central venous catheter, despite a clear physician order to do so. The nurse was unaware of the heparin flush order, and the Director of Nursing confirmed that nurses are expected to follow physician orders and seek clarification if there is confusion. Another deficiency involved the administration of acetaminophen for pain management. A resident received acetaminophen for pain levels outside the parameters specified in the physician's order, which stated the medication was to be given only for mild pain (level 1-3). The medication was administered for higher pain levels, and the LPN responsible stated that she did not pay attention to the pain level parameters. The DON indicated that nurses are expected to assess pain levels and administer medication accordingly, as outlined in facility policy. Additionally, the facility failed to ensure that a resident's enteral tube dressing was changed daily as ordered. Observation revealed that the dressing had not been changed for several days, and staff interviews indicated confusion regarding responsibility for the dressing change. The wound care nurse and LPNs each believed the other was responsible, and the DON clarified that the wound care nurse should complete and document the dressing change, but nurses should verify and perform the task if it is not done.
Unsecured Oxygen Cylinder in Resident Room
Penalty
Summary
During an observation, a resident was found sitting in bed with an unsecured oxygen cylinder placed in the right corner of the room, rather than being properly secured on a stand. The resident had a physician's order for oxygen administration via nasal cannula, with instructions for monitoring skin integrity and using humidification as needed. The Director of Nursing confirmed in an interview that oxygen cylinders are required to be secured on a cart and should not be stored loose in resident rooms, acknowledging the risk of the cylinder falling. Review of the facility's policy and procedure on compressed gases and oxygen usage also specified that cylinders must be secured at all times to prevent them from falling.
Failure to Document Rationale for Declining Pharmacist Medication Recommendations
Penalty
Summary
The facility failed to ensure that the physician or prescriber documented the rationale for declining pharmacist recommendations during the monthly medication regimen review (MRR) for two residents who were receiving unnecessary medications. For one resident with a history of GERD, the pharmacist recommended a dose reduction of a proton pump inhibitor (PPI) and requested documentation of the necessity for continued use. The prescriber responded with 'No change' but did not provide a rationale for declining the recommendation, and the form lacked any explanation for the decision. In another instance, the pharmacist again recommended a review and possible reduction of the PPI, but the documentation was incomplete, with no length of time specified for continued therapy and no rationale provided for declining the recommendation. For a second resident, the pharmacist made recommendations regarding the use of multiple psychotropic medications, including the need for reassessment of PRN meclizine after 14 days and a gradual dose reduction (GDR) of psychotropic drugs as per federal guidelines. The prescriber responded with 'No change at this time after assessment: risk vs benefit,' but did not document any further information or rationale on the provided forms. Additionally, there were no progress notes addressing the use of meclizine or the symptoms it was prescribed for during the relevant months. Interviews with facility staff revealed that the DON managed the MRRs and did not request clarification or additional information if the provider marked a response. The ARNP involved stated that they were not initially educated about the requirement to provide an explanation when declining pharmacist recommendations. Review of the facility's policy confirmed that providers are required to document in the resident's medical record that the identified irregularity has been reviewed and what action, if any, has been taken, but this was not consistently done.
Failure to Maintain Accurate Medical Records for Wound Care and Immunizations
Penalty
Summary
The facility failed to maintain complete and accurate medical records for residents, as evidenced by two separate incidents. In the first case, a resident receiving enteral feeding via a gastric tube had a split gauze dressing dated three days prior, despite physician orders and facility policy requiring daily dressing changes. Documentation in the Treatment Administration Record (TAR) indicated the dressing was changed on days that did not match the date on the gauze, and staff interviews revealed confusion regarding responsibility for performing and documenting the dressing change. The wound care nurse, LPNs, and Director of Nursing (DON) each provided differing accounts of who was responsible for the task and for recording it in the medical record, resulting in incomplete and inaccurate documentation of care provided. In the second incident, a resident's immunization records were incomplete and inconsistent. The resident's record showed receipt of an influenza vaccine and refusal of a pneumococcal vaccine, but the informed consent form for the influenza vaccine was signed by the resident without granting permission for administration. Additionally, there was no documented informed consent or declination form for the pneumococcal vaccine, despite the record indicating it was refused. The DON confirmed that the facility's process required signed consent or declination forms to be uploaded into the medical record, but was unable to locate the necessary documentation for the pneumococcal vaccine. Facility policies required that all treatments, services, and changes in resident condition be documented in the clinical record by the appropriate staff, and that informed consent or declination for vaccinations be properly recorded. The failure to accurately document wound care and immunization consent resulted in incomplete medical records for the residents involved.
Failure to Follow Infection Control Practices During Enteral Feeding, IV Therapy, and Wound Care
Penalty
Summary
Staff failed to follow infection control standards during enteral feeding, wound care, and intravenous therapy for two residents. In one instance, an LPN administered medication via a gastric tube to a resident and placed the used flush syringe, which contained visible white residue, back into a clear bag without rinsing it. The LPN acknowledged not flushing the syringe and stated that typically a new syringe would be used. Facility policy required the syringe to be cleaned with warm water after use. In another case, an RN entered a resident's room with enhanced barrier precautions signage without performing hand hygiene or donning a gown, only putting on gloves. The RN handled the IV pole, connected IV tubing, and started the IV pump without changing gloves or performing hand hygiene. The RN later admitted that hand hygiene and gown use should have been performed, as required by facility policy and the resident's physician orders for enhanced barrier precautions. Additionally, during wound care for the same resident, another RN used bandage scissors stored in his pants pocket to cut dressings and did not clean the scissors before use. The RN also failed to remove gloves and perform hand hygiene between removing soiled dressings and applying prescribed cleanser to multiple wounds. The RN believed it was unnecessary to change gloves or perform hand hygiene between these steps, contrary to facility policy and competency requirements, which specify glove changes and hand hygiene at key points during wound care and prohibit storing scissors in personal pockets.
Call Light Not Kept Within Reach for Bedbound Resident
Penalty
Summary
A deficiency was identified when a resident, who was at risk for falls and required a Hoyer lift for mobility, did not have consistent access to her call light while in bed. The resident reported not having a call light and stated she was instructed to call out verbally for assistance. Multiple observations confirmed that the call light was placed out of reach, including being on the bedside table, inside a drawer, and clipped to the drawer pull, none of which were accessible to the resident from her bed. Photographic evidence was obtained during these observations. Interviews with staff revealed that the call light was intentionally clipped to the bedside table by a CNA during care, and both the RN and DON acknowledged that the resident would not be able to reach the call light in those locations. The resident's care plan specifically required the call light to be kept within reach due to her fall risk, and facility policy mandated that call lights be accessible to residents in bed or confined to a chair. Despite these requirements, the call light was repeatedly found out of reach, and the resident was unable to summon assistance as intended.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 107 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Inverness
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Avante At Inverness Inc | 0.3 mi | ★★★★★ | 0 | 0 |
| Arbor Trail Rehab And Skilled Nursing Center | 1 mi | ★★★★★ | 0 | 0 |
| Grove Healthcare And Rehabilitation Center And Reh | 7.6 mi | ★★★★★ | 0 | 0 |
| Aviata At Brentwood | 9.1 mi | ★★★★★ | 6 | 0 |
| Life Care Center Of Citrus County | 9.5 mi | ★★★★★ | 10 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Citrus Health And Rehabilitation Center.
100% money-back within 48 hours.
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.