Above average — CMS composite of the measures below.
The next survey window likely opens around March 2027
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 Crystal River Health And Rehabilitation Center during CMS and state inspections, most recent first.
Surveyors determined that the facility did not maintain required documentation for its automatic sprinkler system. Record review showed the sprinkler system was past due for the mandated 5-year internal inspection, and the facility could not produce the most recent 5-year inspection report. During interview, the Maintenance Director confirmed that this inspection report was missing, and the deficiency was cited as affecting the entire facility.
Surveyors identified that the facility did not fully comply with NFPA 99 requirements for electrical receptacle maintenance and testing. Review of the electrical receptacle testing log showed that only tension testing was documented, with no evidence of polarity testing being conducted. During interview, the Maintenance Director confirmed that staff had never tested receptacle polarity. This deficiency was cited as affecting the entire facility and was noted as potentially causing faulty electrical equipment which can result in fire.
Surveyors identified that the facility did not maintain its fire alarm system in accordance with NFPA 72 when the fire alarm control panel was observed displaying a trouble signal. During the observation, the Maintenance Director confirmed that the trouble condition was related to a faulty heat detector. This unresolved trouble indication showed that the fire alarm system was not being properly maintained to ensure it functioned as designed for the entire building.
Surveyors found that a circuit breaker panel cover in one smoke compartment was improperly fastened with sheet metal screws instead of appropriate blunt-end fasteners, in violation of NFPA 70 requirements. The maintenance director acknowledged the use of sheet metal screws on the panel cover, and the report notes that this noncompliance could result in electric or fire hazards.
Surveyors identified a deficiency when the facility could not provide documentation that backup generator batteries were being tested in accordance with NFPA 110 and NFPA 99 requirements. During record review, no records of generator battery testing were available, and the Maintenance Director confirmed he was unable to locate the requested documentation. This failure concerns the essential electrical system that supports life safety and critical functions during power loss.
Surveyors found that patient-care related electrical equipment was not inspected and maintained in accordance with NFPA 99 requirements. Biomedical inspection records showed that inspections were not current, and an observation in the gym revealed two microwaves, a toaster oven, and an "E Stem" device with overdue inspection stickers from 2024. During an interview, an assistant reported that this equipment was supplied by the corporate office and maintained by a different company, yet the items remained in use in a patient-care area without up-to-date inspections, affecting one of seven smoke compartments.
Surveyors found that gas cylinders were improperly stored and unsecured, with 38 cylinders in an outside storage room lacking the required oxidizing gas signage and with full and empty cylinders comingled, and an additional 25 cylinders stored adjacent to this area without any means to prevent unauthorized access. During an interview, the Maintenance Director acknowledged the issues and reported being unaware of the specific NFPA 99 storage requirements.
Surveyors found that the facility’s emergency preparedness communication plan did not include required information on how to report facility occupancy through the Healthcare Facility Reporting System. During record review and a concurrent interview, the Administrator acknowledged that the plan lacked a specified means of providing occupancy information to the incident commander, resulting in a facility-wide deficiency in the communication plan.
Surveyors found that hazardous cleaning chemicals, including Virex II 256 and Virex TB, were stored in an unlocked, easily accessible lower cabinet in the main dining room, which is open to ambulatory residents throughout the day. The cabinet lacked any locking mechanism or security measures. SDS information for both products indicated they are industrial/institutional disinfectants that can cause eye, skin, and respiratory irritation or burns and must be stored safely to prevent exposure. The Administrator acknowledged the chemicals were not secured and stated that all cleaning products are expected to be secured when not in use by staff.
The facility did not maintain an effective pest control program, as evidenced by repeated observations of live and dead insects in resident bathrooms, hallways, and areas adjacent to and within the kitchen and dishwashing room where food contact items are processed. Staff reported that pest issues were referred to Maintenance, which coordinated with a contracted pest control company that made weekly visits and reviewed pest logs. Despite these measures and documented exterminator reports noting recurring pest concerns across all wings and the kitchen, staff, including an LPN, continued to see roaches on the units, showing that the facility’s pest control efforts were not successfully preventing ongoing pest activity.
Surveyors found that several resident rooms were not maintained in a safe, clean, and homelike condition, including missing baseboards, peeling and missing paint, exposed walls, holes near baseboards, loose door handles, missing toilet paper holder mounts, stained floor tiles, cracked and gapped sink walls, and dirty bathroom vents. The Maintenance Director confirmed these conditions, acknowledged awareness of at least one problematic room for about a month, and reported relying on calls and texts for repair requests while awaiting access to the electronic maintenance log. Review of the maintenance work history showed no entries for these needed repairs, despite the DON and Administrator describing processes in which staff should enter issues into the maintenance log or verbally report them, resulting in the identified room deficiencies remaining uncorrected.
A resident was transferred to a hospital for evaluation and treatment of a right hip concern after the attending practitioner directed staff to send the resident to the closest hospital, and non-emergent transport was arranged with the resident’s family in agreement. Although a transfer/discharge notice and a hospital transfer form were completed, surveyors found no documentation that the required written bed-hold notice—detailing the state bed-hold policy, any reserve bed payment policy, and the facility’s bed-hold and return policies—was provided at or before the time of transfer. In interviews, an LPN/medical records staff member acknowledged that the bed-hold notice “must not have been done,” and the DON stated that floor nurses or unit managers are responsible for completing bed-hold forms and obtaining family signatures when present, confirming that this process was not followed for this hospitalization.
A resident with physician orders for PRN O2 at 2 L/min via nasal cannula for shortness of breath was observed receiving oxygen and had multiple progress notes documenting ongoing O2 therapy and corresponding O2 saturations. However, the Significant Change MDS did not code oxygen use in Section O (Special Treatments, Procedures, Programs). An LPN responsible for MDS acknowledged that oxygen use was documented in the record and should have been coded, resulting in an assessment that did not accurately reflect the resident’s respiratory treatment status.
A resident with dementia, seizure disorder, right foot drop, heart failure, and other conditions had a physician order and care plan intervention for bilateral floor mats at the bedside when in bed due to fall risk. Surveyor observations on multiple occasions found only one floor mat placed on the right side of the bed, with no mat on the left side. A CNA reported not knowing the resident should have mats on both sides and stated the resident had always had just one mat, while an RN needed to verify the order. The DON stated that staff are expected to follow physician orders and that the resident should have mats on each side, demonstrating the facility’s failure to implement the comprehensive, person-centered care plan as written.
A resident with a history of HTN and other conditions was scheduled for cataract surgery with pre-op instructions from the surgery center to be NPO after midnight but to continue heart and BP medications, excluding diuretics. The resident had multiple ordered antihypertensives scheduled for morning administration, yet nursing staff held all morning BP medications due to NPO status. An LPN relied on shift report, did not review the MAR or physician orders, and did not contact the physician, while an RN received verbal pre-op instructions but failed to enter them into the system and only communicated the NPO portion. No NPO or related medication orders were entered into the electronic orders, the MAR documented the medications as held for NPO, and the resident’s surgery was cancelled at the surgery center due to elevated systolic BP.
A resident with chronic neuropathic pain and multiple comorbidities did not receive 12 scheduled doses of Lyrica over several days, despite an active physician order and a care plan calling for medication-based pain control. MAR entries cited the drug as unavailable or awaiting insurance approval, yet staff did not document the problem in progress notes, did not effectively communicate with the prescriber about alternatives, and did not utilize an available dose in the automated dispensing machine. The resident reported increased right arm pain and was observed holding the arm protectively while propelling his wheelchair with his feet, as multiple LPNs and a unit manager failed to follow through on obtaining or substituting the ordered pain medication.
A resident had an order for midodrine 5 mg three times daily with instructions to hold the dose if systolic BP exceeded a specified parameter. Review of the MAR showed 13 documented administrations of midodrine outside these ordered parameters. Two LPNs reported that they always check BP before giving parameter-based medications and believed the entries were documentation errors, while the DON stated that nursing staff are expected to follow physician orders, including specific parameters. The discrepancy between the physician order and the documented administrations resulted in a deficiency related to unnecessary drugs.
Surveyors found multiple failures in infection control practices related to respiratory equipment. One resident received O2 via nasal cannula using tubing that had not been changed for an extended period, with additional tubing left unbagged on top of an O2 concentrator and on a wheelchair. Another resident had a nebulizer machine on the floor behind the bed, with an uncovered mask and undated tubing lying across it, despite not having current nebulizer orders. A third resident had a nebulizer on the bedside table with an uncovered mask and undated tubing, and this resident also had no active nebulizer orders. Staff interviews and the facility’s written policy confirmed that tubing and masks were to be changed weekly, dated, covered or bagged when not in use, and removed and cleaned when treatments were discontinued, but these practices were not followed.
The facility failed to properly store, label, and discard food in the kitchen and nutrition rooms, with unlabeled and undated items found in the walk-in cooler, freezer, and nutrition rooms. The CDM confirmed these issues, acknowledging the need for proper labeling and dating of food items.
A facility failed to ensure an accurate MDS assessment for a resident with chronic venous hypertension and ulcers. The MDS did not document the presence of venous or arterial wounds, despite evidence from a wound assessment report and physician orders. An LPN admitted to overlooking the facility's wound assessment, relying instead on hospital documentation, leading to the inaccurate assessment.
The facility failed to document all relevant diagnoses in the PASRR screenings for two residents. One resident's screening omitted entries for mental illness despite having multiple related diagnoses, while another resident's screening documented schizophrenia but missed an anxiety disorder diagnosis. The DON confirmed these omissions.
A resident with a skin tear did not receive daily dressing changes as ordered by the physician. Observations showed the dressing was not changed for several days, contrary to the daily care instructions. Interviews with staff revealed inconsistencies in wound care responsibilities, with the DON expecting daily completion and documentation of wound care tasks.
The facility failed to secure medications in resident rooms, as observed in two incidents. A resident had nasal spray and lidocaine unsecured on their bedside table, and another resident had a medication cup left on their meal tray. An LPN confirmed that medications should not be at the bedside without proper assessment and physician orders. The DON stated that medications should be administered under supervision and stored in locked compartments.
A resident's wound care was not accurately documented, with observations showing an unchanged dressing despite orders for daily changes. Staff interviews revealed inconsistencies in documentation, and the DON confirmed the expectation for accurate daily records, which was not met.
The facility failed to perform proper hand hygiene during wound care and meal delivery. A CNA did not sanitize hands between handling meal trays for two residents, and an LPN did not wash hands before changing a dressing after using a phone. Both staff members acknowledged the lapses, and facility policies were reviewed, confirming the need for hand hygiene before and after resident contact.
Missing 5-Year Internal Sprinkler System Inspection Report
Penalty
Summary
Surveyors found that the facility failed to maintain proper inspection documentation for its automatic sprinkler system in accordance with NFPA 25. During record review at 10:50 AM, the most recent sprinkler system report showed that the facility was past due for the required 5-year internal inspection. The facility was unable to provide the most recent 5-year internal inspection report for review. During a concurrent staff interview, the Maintenance Director acknowledged that the 5-year internal inspection report was missing. This deficiency was determined to affect the entire facility’s sprinkler system coverage. No residents or specific patient conditions were mentioned in the report, and no additional clinical details were provided.
Plan Of Correction
This Plan of Correction constitutes written compliance for the deficiencies cited. However, submission of this Plan of Correction is not an admission that a deficiency exists or that one was cited correctly. This plan of correction is submitted to meet requirements established by State and Federal Law. To comply with K0353 and assure continued compliance, the following plan has been put in place: K0353 - Sprinkler System Testing (5-Year Internal) Immediate Correction: A licensed fire sprinkler vendor was to perform the 5-year internal piping inspection per NFPA 25 to ensure the system is free of obstructions. Identification of Others: All fire protection systems were audited. The internal pipe inspection report is now maintained in the Life Safety binder for immediate surveyor review. Systemic Changes: A Master Regulatory Calendar was implemented to track multi-year NFPA requirements. The service contract was updated to require the vendor to provide 90-day advance notice of all upcoming 3-year and 5-year tests. Monitoring (QA): The Maintenance Supervisor will audit the Master Calendar monthly. Results will be reported to the QAPI Committee quarterly.
Failure to Perform Required Polarity Testing of Electrical Receptacles
Penalty
Summary
The facility failed to properly maintain and test electrical receptacles in accordance with NFPA 99 requirements for electrical systems maintenance and testing. During record review, surveyors found that the facility’s electrical receptacle testing log documented only tension testing of receptacles and did not include any indication that polarity testing was performed. In a concurrent interview, the Maintenance Director acknowledged that facility staff had never tested the polarity of the receptacles. The deficiency was cited as affecting the whole facility and was noted as potentially causing faulty electrical equipment which can result in fire.
Plan Of Correction
This Plan of Correction constitutes written compliance for the deficiencies cited. However, submission of this Plan of Correction is not an admission that a deficiency exists or that one was cited correctly. This plan of correction is submitted to meet requirements established by State and Federal Law. To comply with K0914 and assure continued compliance, the following plan has been put in place. K0914 - Electrical Receptacle Testing Immediate Correction: Re-testing of electrical receptacles in affected patient care areas was performed. Outlets were verified for polarity and grounding continuity in addition to tension requirements. Identification of Others: A comprehensive re-testing of all receptacles in resident care areas was initiated. The Testing Log was revised to include dedicated columns for Polarity, Grounding integrity, and Tension.Systemic Changes: The facility procured UL-listed polarity analyzers. Staff were trained on NFPA 99, Section 6.3.4.1 regarding hospital-grade electrical verification.Monitoring (QA): The Maintenance Supervisor will audit 10% of testing logs monthly. Findings will be reported to the QAPI Committee to ensure all data points are consistently recorded.
Failure to Maintain Fire Alarm System in Proper Working Order
Penalty
Summary
Surveyors found that the facility failed to maintain its fire alarm system in accordance with NFPA 72 requirements. During an observation at 3:30 PM, the fire alarm control panel was noted to be displaying a trouble signal. Upon concurrent interview, the Maintenance Director acknowledged the trouble condition and stated it was due to a faulty heat detector. This unresolved trouble signal on the fire alarm control panel constituted a failure to ensure the fire alarm system was maintained and functioning as designed for the entire facility. No residents or specific patient conditions were mentioned in the report, and no additional clinical details were provided.
Plan Of Correction
This Plan of Correction constitutes written compliance for the deficiencies cited. However, submission of this Plan of Correction is not an admission that a deficiency exists or that one was cited correctly. This plan of correction is submitted to meet requirements established by State and Federal Law. To comply with K0345 and assure continued compliance, the following plan has been put in place. K0345 - Fire Alarm System Maintenance Immediate Correction: A fire alarm provider diagnosed and repaired the trouble signal, restoring the system to a "System Normal" state. Residents in the affected zone were monitored for safety during the repair. Identification of Others: A 100% audit of the Fire Alarm Control Panel (FACP) was conducted to ensure no other trouble or supervisory signals were present facility-wide. Systemic Changes: Maintenance and administrative staff were re-educated on responding to trouble signals within 24 hours and documenting all actions in the maintenance log. Monitoring (QA): The Maintenance Supervisor will conduct daily visual inspections of the FACP. The Safety Committee will review all service reports monthly, reporting findings to the QAPI Committee.
Improper Fastening of Circuit Breaker Panel Cover with Sheet Metal Screws
Penalty
Summary
Surveyors identified a deficiency in the facility’s maintenance of electrical utility equipment in accordance with NFPA 70. During an observation at 3:15 PM, they noted that the cover of a circuit breaker panel was fastened using sheet metal screws instead of appropriate fasteners. This condition was found in 1 of 7 smoke compartments. The facility’s maintenance director, present during the observation, acknowledged that sheet metal screws were being used on the circuit breaker panel cover. The report states that this failure to comply with NFPA 70 could result in electric or fire hazards. No residents or specific patient conditions were mentioned in the report, and no additional events beyond the improper fastening of the circuit breaker panel cover were described.
Plan Of Correction
This Plan of Correction constitutes written compliance for the deficiencies cited. However, submission of this Plan of Correction is not an admission that a deficiency exists or that one was cited correctly. This plan of correction is submitted to meet requirements established by State and Federal Law. To comply with K0511 and assure continued compliance, the following plan has been put in place. K0511 - Electrical Panel Fasteners Immediate Correction: Unauthorized sheet metal screws were removed from the cited circuit breaker panel and replaced with OEM-approved, blunt-end machine screws to prevent internal wire damage. Identification of Others: A facility-wide audit of all electrical panels, sub-panels, and pull boxes was conducted. Any non-compliant fasteners found were immediately replaced with blunt-end hardware. Systemic Changes: The Electrical Safety Policy was updated to prohibit self-tapping or pointed screws. Maintenance staff were trained on NFPA 70 hardware requirements to maintain equipment integrity. Monitoring (QA): "Panel Fastener Integrity" was added to the Monthly Life Safety Walkthrough. Audit logs will be reviewed during quarterly QAPI meetings.
Failure to Maintain Required Generator Battery Testing Documentation
Penalty
Summary
The deficiency involves the facility’s failure to maintain and inspect the backup generator batteries in accordance with NFPA 110 requirements. During a record review, surveyors requested documentation of generator battery testing, which is required to ensure the reliability of the prime mover starting system. At the time of review, no documentation was provided to demonstrate that these battery tests had been performed as required. Concurrently, during an interview, the Maintenance Director acknowledged the issue and stated that he could not locate the requested documentation of generator battery testing. The cited regulations include NFPA 99 (2012 Edition) sections 6.4.4.1.3 and 6.4.4.2, and NFPA 110 (2010 Edition) section 8.3.7, which govern maintenance and testing of essential electrical systems, including generator batteries. The report notes that failure to conduct these tests could result in the loss of power to the facility, affecting life support and life safety features.
Plan Of Correction
This Plan of Correction constitutes written compliance for the deficiencies cited. However, submission of this Plan of Correction is not an admission that a deficiency exists or that one was cited correctly. This plan of correction is submitted to meet requirements established by State and Federal Law. To comply with K0918 and assure continued compliance, the following plan has been put in place. K0918 - Generator Battery Testing Immediate Correction: A comprehensive generator battery test, including specific gravity and conductance testing, was performed and recorded in the EPSS Log to ensure peak cranking capacity. Identification of Others: The EPSS was audited to ensure all maintenance components were documented. The Life Safety binder was reorganized to house these records separately for easy retrieval. Systemic Changes: The Generator Maintenance Log was revised to include specific fields for weekly visual checks and monthly battery conductance/voltage testing. Staff were re-trained on NFPA 110 battery maintenance standards. Monitoring (QA): The Maintenance Director will conduct a monthly audit of the generator log. These audits will be presented to the QAPI Committee quarterly to identify any trends in battery degradation.
Failure to Maintain and Inspect Patient-Care Electrical Equipment per NFPA 99
Penalty
Summary
Surveyors identified a deficiency in the facility’s inspection and maintenance of patient-care related electrical equipment (PCREE) as required by NFPA 99. During record review at 10:40 AM, biomedical inspection records showed that patient electrical equipment inspections were not current, indicating that required testing and maintenance had not been performed in accordance with established intervals. The report notes that the facility failed to inspect PCREE in accordance with NFPA 99, which governs testing, maintenance, and documentation of such equipment. During an observation at 2:45 PM in the gym, surveyors found multiple pieces of patient-care related electrical equipment with overdue inspection stickers from 2024, including two microwaves, one toaster oven, and an "E Stem" device. In a concurrent staff interview, the Assistant stated that this equipment was outsourced from the corporate office and that a different company, not the facility, was responsible for the equipment. The deficiency was cited as affecting one of seven smoke compartments and was linked to noncompliance with NFPA 99 (2012 Edition) sections 10.3 and 10.5.2.1.
Plan Of Correction
This Plan of Correction constitutes written compliance for the deficiencies cited. However, submission of this Plan of Correction is not an admission that a deficiency exists or that one was cited correctly. This plan of correction is submitted to meet requirements established by State and Federal Law. To comply with K0921 and assure continued compliance, the following plan has been put in place. K0921 - Electrical Equipment Testing & Stickers Immediate Correction: Non-compliant items (microwaves, toaster, E-Stim machine) were removed and inspected by a licensed Biomedical vendor. All items passed and now bear current 2026 inspection stickers. Identification of Others: A "Wall-to-Wall" audit of all electrical equipment was conducted. Any item found with an expired or missing sticker was sequestered for testing and repair. Systemic Changes: The Master Equipment Inventory (MEI) was updated to track Last Test and Next Due dates. Staff were re-educated on checking for stickers before use and "Red Tagging" expiring equipment. Monitoring (QA): The Maintenance Director will perform monthly spot checks of 10 random electrical items. Results will be presented at the monthly Safety Committee and quarterly QAPI meetings.
Improper Storage and Security of Gas Cylinders
Penalty
Summary
Surveyors identified a deficiency in the storage of gas cylinders in one of seven smoke compartments. During an observation of the outside storage room, they found 38 cylinders stored without the required precautionary signage indicating oxidizing gas storage. The signage was also required to indicate the presence of oxidizing gases and to include the mandated wording, but this was not present. In addition, full and empty cylinders were observed to be comingled, rather than being segregated as required by NFPA 99. Adjacent to this storage area, surveyors observed 25 additional cylinders that were not properly secured from unauthorized use, and the facility did not have any means in place to prevent unauthorized access to these cylinders. During a concurrent staff interview, the Maintenance Director acknowledged these findings and stated that he was not aware of the requirements for gas cylinder storage. The surveyors cited these conditions as noncompliance with NFPA 101 and NFPA 99 standards for gas equipment and cylinder storage.
Plan Of Correction
This Plan of Correction constitutes written compliance for the deficiencies cited. However, submission of this Plan of Correction is not an admission that a deficiency exists or that one was cited correctly. This plan of correction is submitted to meet requirements established by State and Federal Law. To comply with K0923 and assure continued compliance, the following plan has been put in place. K0923 - Gas Cylinder Storage & Security Immediate Correction: All 38 cylinders in the storage room were segregated and labeled. The 25 cylinders located outside were moved to a secured, locked enclosure. Identification of Others: All medical gas storage areas were audited. Permanent "Full" and "Empty" signs and "No Smoking" signage were installed at all entrances. Systemic Changes: A lockable enclosure was established for outdoor storage with a new "Key Control" log. Staff were re-trained on Medical Gas Safety and the mandatory requirement for locked storage. Monitoring (QA): The Maintenance Director will perform daily rounds for 30 days, then weekly thereafter, to ensure segregation and security.Findings will be reviewed at monthly QAPI meetings.
Emergency Preparedness Communication Plan Lacked Required Occupancy Reporting Information
Penalty
Summary
Surveyors identified a deficiency in the facility’s emergency preparedness communication plan related to the requirement to provide information on occupancy. During record review at 2:00 PM, the surveyor determined that the written communication plan did not include any information on the Healthcare Facility Reporting System, which is the mechanism used to report the facility’s occupancy. The plan therefore lacked a specified means of providing information about the facility’s occupancy as required by the applicable emergency preparedness regulations. In a concurrent staff interview, the Administrator acknowledged that the communication plan did not contain the required information about occupancy reporting. The Administrator confirmed the absence of this information in the plan. The deficiency was determined to affect the entire facility, as the missing occupancy reporting component related to communication of resident needs to the incident commander during an emergency.
Plan Of Correction
This Plan of Correction constitutes written compliance for the deficiencies cited. However, submission of this Plan of Correction is not an admission that a deficiency exists or that one was cited correctly. This plan of correction is submitted to meet requirements established by State and Federal Law. To comply with E0034 and assure continued compliance, the following plan has been put in place. E0034 ~ Communication Plan (HFRS) Immediate Correction: The Emergency Preparedness Communication Plan was updated to include a dedicated section for the Health Facility Reporting System (HFRS), explicitly outlining requirements for reporting emergency status, planning, and operations. Identification of Others: All residents have the potential to be affected by communication failures. The Administrator audited the entire Emergency Plan to ensure HFRS Superuser access, login procedures, and technical support contacts (850-412-4303/4304) were included. Systemic Changes: Administrative and nursing leadership were trained on the AHCA HFRS manual and internal procedures for updating census and .utility data. A screenshot of the facility's HFRS registration was added as an appendix to the Plan. Monitoring (QA): The Safety Committee will review the plan semi-annually to ensure protocols remain current. Results will be documented in the QAPI meeting minutes.
Unsecured Hazardous Cleaning Chemicals in Accessible Dining Room Cabinet
Penalty
Summary
Surveyors observed that the facility failed to keep hazardous cleaning chemicals secured in the main dining room, an area accessible to ambulatory residents throughout the day. During an observation, a lower cabinet in the dining room was found unlocked and accessible, with no locking mechanisms or other security measures in place. Inside the cabinet were two bottles of cleaning chemicals: Virex II 256 One-Step Disinfectant Cleaner and Deodorant and Virex TB Ready-to-Use Disinfectant Cleaner. Review of the Safety Data Sheets (SDS) for these products documented that Virex II 256 is classified as corrosive and may cause eye and skin burns and may be harmful if inhaled, absorbed through the skin, or swallowed, and that Virex TB may cause irritation to the eyes, skin, and respiratory tract via inhalation, ingestion, skin, and eye contact. Both products are labeled for industrial/institutional use and are intended to be handled with appropriate precautions and stored safely to prevent exposure. In an interview, the Administrator acknowledged that the cleaning products in the dining room cabinet were not secured, confirmed that the dining room is open to ambulatory residents throughout the day, and stated that his expectation is that all cleaning chemicals are stored in a secure manner when not in use by staff.
Failure to Maintain Effective Pest Control in Resident and Food Service Areas
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by multiple observations of live and dead insects in resident care and food service areas. Surveyors observed live brown-colored insects on a wall and a dead insect on a windowsill in a training room adjacent to the kitchen and dining area, as well as a live insect under a cabinet in the dining area. Additional observations included a live insect on the floor outside a resident’s doorway in the West Wing near the kitchen entrance, a dead insect on the floor near the exit door from the kitchen food preparation area, and a live insect around the drain area of the dishwashing machine where food contact items are processed. In resident areas, a live brown-colored insect was seen by the baseboard in one resident’s bathroom, and three small dark brown insects were seen running toward the baseboard when another resident’s bathroom door was opened and the light turned on. Interviews and record review showed that, although a pest control process was in place, it was not effective in preventing ongoing pest activity. The Dietary Manager reported that pest concerns were relayed to Maintenance, which was responsible for contacting the pest control company. The Maintenance Director stated that each wing maintained a pest log and that a contracted pest control company conducted weekly visits, reviewed logs, and provided service reports, which he said were reviewed with corrective actions taken as needed. However, exterminator reports over several months documented repeated pest concerns in the kitchen and all three resident wings, and an LPN stated that although spraying occurred weekly for roaches, it did not seem to be helping and roaches were still seen on the unit. The Administrator confirmed the expectation that the environment be pest-free, and the facility’s “Resident Environment Quality” policy required maintaining an effective pest control program so the facility is free of pests and rodents, which was not achieved based on the ongoing observations and documented activity.
Failure to Maintain Safe, Clean, and Homelike Resident Rooms
Penalty
Summary
Surveyors identified that the facility failed to provide a safe, clean, comfortable, and homelike environment on one of three units, as required by 42 CFR 483.10(i). During observations of multiple resident rooms, surveyors noted missing baseboards, peeling paint, exposed wall surfaces, holes near baseboards, cracked and gapped walls, loose door handles, missing toilet paper holder mounts, stained floor tiles, and dirty bathroom vents. In one room, the bathroom doorway lacked baseboards, the wall was peeling with black stains, tiles around the toilet were lifting or missing, there was a brown substance on the tiles, and the bathroom vent was covered in gray matter. Other rooms had missing or peeling paint exposing the wall, holes near the baseboard, loose bathroom and room door handles, a missing toilet paper holder mount, and heavily stained floor tiles. The Maintenance Director accompanied surveyors on follow-up observations and confirmed the poor conditions in the identified rooms, describing one room as "horrible" and acknowledging that the vent looked filthy and that the sink appeared to be coming off the wall. The Maintenance Director stated that he had been informed about one problematic room about a month earlier and had been looking for a plumbing company to address it, but he had not been able to determine which room it was. He also acknowledged that the door handle needed adjustment and the toilet paper holder needed replacement in another room. The Maintenance Director reported that he had taken over the position in January and was focusing on large projects, delegating smaller details to his assistant. Record review and staff interviews revealed that the facility’s system for reporting and tracking maintenance issues was not effectively used for these deficiencies. Review of the electronic maintenance system work history from January through March showed no entries for the needed repairs in the affected rooms. The Maintenance Director stated he typically received calls or text messages about repairs and was waiting for a laptop to access the maintenance repair log, making it difficult to look back and verify reported issues. The DON reported that she typically entered items into the maintenance repair log and also communicated verbally or via messages to maintenance and unit managers when repairs were needed, and the Administrator stated that staff were expected to enter needed repairs into the maintenance log during rounds or communicate directly with maintenance. Despite these processes and the facility’s written policy on maintaining resident environment quality and preventive maintenance, the needed repairs in the identified rooms were not documented in the maintenance system and remained unaddressed at the time of survey.
Failure to Provide Required Bed-Hold Notice During Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to provide a required written bed-hold notice to a resident who was transferred to the hospital. Federal regulations at 42 CFR 483.15(d)(1)-(2) require that, before a resident is transferred to a hospital or goes on therapeutic leave, the facility must provide written information specifying the duration of the state bed-hold policy, any reserve bed payment policy, the facility’s bed-hold policies, and related return information, and must again provide written notice at the time of transfer specifying the duration of the bed-hold policy. Surveyors reviewed the record of one resident who was sent to the hospital and found no documentation of a 3‑day bed-hold policy or bed reserve payment notice in the resident’s chart. Record review showed that on 01/28/2026 the resident’s physician office requested that the resident be sent to a named hospital for evaluation of the right hip. The facility contacted the hospital’s orthopedic floor, which stated they could not accept the resident without a direct admission. The facility then contacted the physician, who instructed staff to send the resident to the closest hospital for assessment of the right hip. A non-emergent transport company picked up the resident at 5:45 PM and transported the resident to the hospital emergency room for evaluation and treatment. The resident’s son was at the bedside and was documented as agreeable with the plan of care. A Nursing Home Transfer and Discharge Notice and a Hospital Transfer Form were completed, indicating the resident was sent to the hospital emergency room for evaluation and treatment. Despite the transfer documentation, the surveyors determined that the required bed-hold notice was not provided. During interview, the LPN/Medical Records staff member stated there was no 3‑day bed-hold policy or bed reserve payment notice for this resident in the paper chart and concluded it “must not have been done.” In a separate interview, the Director of Nursing explained that the floor nurse or unit manager is responsible for completing bed-hold forms when a resident leaves the facility and that, if family is present at the bedside, staff should have the family sign the bed-hold form. The absence of any such form or written bed-hold notice for this resident’s hospitalization led surveyors to cite noncompliance with the federal bed-hold notice requirements.
Inaccurate MDS Coding for Resident Receiving Oxygen Therapy
Penalty
Summary
The facility failed to ensure accurate coding of the Minimum Data Set (MDS) assessment for a resident receiving respiratory services. The resident had a physician’s order dated 2/2/2026 for oxygen at 2 liters per minute via nasal cannula as needed for shortness of breath. On observation, the resident was lying in bed receiving oxygen at 2 liters per minute via nasal cannula. Progress notes documented oxygen therapy, including entries on 2/21/2026 noting oxygen at 2 liters via nasal cannula with an oxygen saturation of 90%, and on 2/22/2026 noting pulmonary/respiratory service with oxygen therapy at 2 liters and an oxygen saturation of 95%. Despite this documented and observed oxygen use, the resident’s Significant Change MDS dated 2/23/2026 did not code oxygen under Section O, Special Treatments, Procedures, Programs. During an interview, the LPN responsible for MDS acknowledged that oxygen use had been documented in the notes several times and stated it should have been coded as in use on the MDS. The facility’s RAI policy required comprehensive, accurate, and standardized assessments of each resident’s functional capacity using the RAI specified by the state, but the resident’s oxygen therapy was not accurately reflected in the MDS assessment.
Failure to Implement Care-Planned Bilateral Floor Mats for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to implement a person-centered comprehensive care plan and physician orders for a resident with identified fall and seizure risks. The resident was re-admitted with diagnoses including right foot drop, bradycardia, heart failure, dementia, abnormal auditory perceptions, psychotic disturbance, mood disturbance and anxiety, and absence epileptic syndrome. A physician order dated 6/2/2025 directed that bilateral floor mats be in place at the bedside when the resident was in bed. The resident’s care plan, initiated 4/11/2025 and updated 3/23/2026, identified a focus on potential for falls, seizure disorder, and foot drop, and included an intervention for bilateral floor mats at the bedside when in bed. Multiple observations on different days showed that only one floor mat was consistently placed on the right side of the resident’s bed, with no mat on the left side, despite the order and care plan specifying bilateral mats. During these observations, the bed was in the low position with side rails up, but only a single mat was present. A CNA stated that he did not know the resident should have floor mats on both sides and reported that the resident had always had just one mat. An RN also indicated she would need to check the orders to verify whether bilateral mats were required. The DON stated an expectation that staff follow physician orders and confirmed the resident should have fall mats on each side of the bed. The facility’s “Person Centered Care Plans” policy states that care plan interventions outside of routine care are to be entered into the electronic record to provide CNAs with individualized information, but the observations and staff interviews showed that the bilateral floor mat intervention was not implemented as ordered and care planned.
Failure to Administer Antihypertensive Medications Prior to Scheduled Surgery
Penalty
Summary
The deficiency involves the facility’s failure to ensure necessary care and services related to medication administration for blood pressure control prior to a scheduled surgery. A resident admitted with diagnoses including hypertension, anxiety, depression, and anemia was scheduled for right cataract surgery with pre-operative instructions from the surgical center specifying NPO after midnight and to continue heart and blood pressure medications (excluding diuretics) the day of surgery. The resident’s physician orders included multiple antihypertensive medications (Amlodipine, Metoprolol tartrate, Hydralazine, and Lisinopril) to be administered at specific times, including morning doses. Nursing documentation from an earlier consultation noted orders for NPO after midnight and to continue medications as ordered except diuretics. However, there were no NPO orders entered into the physician order system. On the morning of surgery, the resident’s MAR showed that all ordered antihypertensive medications were held due to NPO status, despite the pre-operative instructions to continue these medications. An LPN reported holding the resident’s morning medications, including blood pressure medications, based solely on shift report information that the resident was NPO, without reviewing the physician orders or MAR and without contacting the physician for clarification. An RN stated that she had received the pre-operative instructions verbally from the eye center but did not enter the orders into the computer and only recalled the NPO instruction, which she communicated during shift reports. The written pre-operative instructions, which included the directive to continue blood pressure medications, were later found in the resident’s room after the surgery was cancelled due to elevated systolic blood pressure readings, and the DON confirmed that no NPO or related medication orders had been entered into the system.
Failure to Provide Ordered Neuropathic Pain Medication Due to Communication and Follow-Through Gaps
Penalty
Summary
The deficiency involves the facility’s failure to ensure effective pain management for a resident with chronic pain, as required by physician orders, the care plan, and facility policy. The resident, admitted with diagnoses including epilepsy, history of traumatic brain injury, multiple muscle contractures, parkinsonism, and chronic pain, reported right shoulder/arm pain and was observed propelling himself in his wheelchair using only his feet while holding his right arm protectively against his body. His care plan identified chronic pain and a need for pain management related to impaired mobility, contractures, and muscle spasms, with goals that he would not have unrelieved pain and approaches including administering medications as ordered and referral to pain management. Review of the physician’s orders and MAR showed that the resident was prescribed Lyrica (pregabalin) 25 mg orally twice daily for neuropathic pain, with the order active from 01/10/2026 through 04/01/2026. However, from 3/26/2026 through 3/31/2026, 12 scheduled doses of Lyrica were not administered. The MAR documented these missed doses as due to “Drug/Item Unavailable,” “Drug/Item Unavailable ODS,” and comments indicating the medication was awaiting insurance approval. During this same period, progress notes contained no documentation that the medication was not administered or that any alternative scheduled pain medication was provided, despite the resident’s MDS indicating frequent pain that limited day-to-day activities and the use of high-risk medications including anticonvulsants for pain control. Interviews revealed multiple staff inactions and communication failures that contributed to the missed pain medication. The resident stated he had more pain in his right arm and had not received his routine pain medication for several days. The Unit Manager acknowledged she had not documented discussions with the pharmacy or efforts to obtain an alternative. The DON stated nurses were expected to contact the pharmacy and then the physician if there were problems obtaining medications, but the APRN and PA managing the resident’s pain reported they had not been contacted about the lack of Lyrica or the need for an alternative, and there was no prior authorization request noted. One LPN reported receiving notice from the pharmacy that the medication was not covered and that the facility would need to pay, but he did not withdraw the available e-kit dose, did not administer Lyrica, and did not seek an alternative medication. Another LPN called the pharmacy and was told there was an insurance issue but did not document the call or contact the physician herself. A third LPN, in training, followed instructions to simply request a refill in the electronic record when the medication was unavailable. Additionally, a report showed that pregabalin 25 mg was available in the automated dispensing machine, but it was not used for the resident during the period when doses were missed.
Unnecessary Drug Administration Due to Failure to Follow Midodrine Parameters
Penalty
Summary
Surveyors identified a deficiency related to unnecessary medications involving one resident whose drug regimen included midodrine 5 mg, ordered to be given orally three times daily at 8:00 AM, 12:00 PM, and 5:00 PM, with instructions to hold the dose if the systolic blood pressure was over 110. Review of the resident’s March 2026 Medication Administration Record (MAR) showed that midodrine was documented as administered 13 times outside of the physician-ordered blood pressure parameters. During interviews, two LPNs who administered the medication stated that they always check blood pressure prior to giving medications with parameters and would not administer midodrine if the blood pressure was outside the ordered range, attributing the MAR entries to documentation errors. The DON stated that her expectation is that nursing staff follow physician orders, including specific parameters, before administering medications. The documented administrations outside ordered parameters formed the basis of the cited deficiency under the requirement that each resident’s drug regimen be free from unnecessary drugs.
Improper Handling and Maintenance of Respiratory Equipment
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control practices related to respiratory equipment for multiple residents receiving or previously ordered to receive oxygen or nebulizer treatments. For one resident with a PRN order for oxygen at 2 liters per minute via nasal cannula, oxygen tubing dated 3/14/2026 was observed coiled on top of an oxygen concentrator without being bagged when the resident was out of the room. On a subsequent observation, the same resident was in bed receiving oxygen via nasal cannula using tubing still dated 3/14/2026, and an additional nasal cannula was seen coiled around the armrest of the resident’s wheelchair, also not bagged. Staff interviews revealed inconsistent knowledge about how often oxygen tubing should be changed, with one LPN unsure and stating it was done on night shift, while a unit manager stated tubing was changed weekly on Fridays. The DON later stated tubing was changed weekly, dated, and stored in a bag when not in use, which did not align with the observed practice. For another resident, a nebulizer machine was observed lying on the floor behind the bed, with the nebulizer mask and tubing lying across the machine on the floor and the tubing not dated. This condition was observed on two consecutive days. The resident reported not having used the nebulizer “in forever.” The DON stated that the mask must be covered when not in use, tubing must be dated when changed, and that this resident did not have current orders for nebulizer treatments and had not been receiving them. The DON also stated the machine and mask should have been removed, cleaned, and stored, which contrasted with the observed condition of the equipment remaining in the resident’s room on the floor. A third resident’s room was observed to contain a nebulizer machine on the bedside table with an uncovered nebulizer mask lying across it and tubing that was not dated, with the same conditions noted on two separate days. An RN stated that nebulizer masks should be covered after each use, tubing should be changed weekly and dated, and that if a resident no longer had nebulizer orders, the machine should be removed, cleaned, and stored, and the tubing discarded. The RN further stated that this resident did not have current orders for nebulizing treatments and had not received such treatments since October 2025. Review of the facility’s “Oxygen Administration” policy dated 1/13/2026 indicated that cannulas and masks should be changed weekly and stored in a plastic bag when not in use, which was not followed in the observed instances for these residents.
Deficiency in Food Storage and Labeling Practices
Penalty
Summary
The facility failed to ensure that food was safely stored, covered, labeled, or discarded in the kitchen's walk-in cooler, walk-in freezer, and nutrition rooms. During a tour of the main kitchen, surveyors observed opened and undated containers of potato salad, ricotta cheese, and sour cream with an expired date in the walk-in cooler. Additionally, there were unlabeled and undated trays of vegetables and frozen pizzas without any opened, use by, or expiration dates in the walk-in freezer. The Certified Dietary Manager (CDM) confirmed these findings, acknowledging that the foods should have been labeled and dated. In the nutrition rooms, similar issues were found. In one room, there were opened, unlabeled bottles of sport hydration drink, take-out sandwich bags with half-eaten sandwiches, and a grocery store bag containing various food items, all unlabeled and undated. The microwave in this room was also found to be unsanitary. In another nutrition room, there were opened, unlabeled, and undated food items in the freezer. The CDM confirmed these findings and stated that all foods should be labeled with the resident's name, room number, and the date it was brought in. The facility's policies on food preparation and storage were reviewed, but no specific policy for unlabeled and undated foods in the kitchen was provided.
Inaccurate MDS Assessment for Resident with Venous Ulcers
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected the status of a resident with skin conditions. Specifically, the MDS for a resident with chronic venous hypertension and ulcers on both lower extremities did not document the presence of venous or arterial wounds, despite evidence to the contrary. The resident's wound assessment report indicated a venous ulcer on the left lower leg with specific measurements and treatment orders, yet this was not reflected in the MDS. The deficiency was identified during an interview with an MDS Licensed Practical Nurse (LPN), who admitted to overlooking the wound assessment conducted by the facility's nurse and instead relied on hospital documentation. This oversight led to an inaccurate MDS assessment, which is a violation of the facility's policy and procedure for conducting comprehensive and accurate resident assessments as required by federal regulations.
PASRR Documentation Deficiency for Two Residents
Penalty
Summary
The facility failed to ensure accurate documentation in the Preadmission Screening and Resident Review (PASRR) for two residents. Resident #83's Level I PASRR screening, dated July 17, 2023, lacked entries in Section I: PASRR Screen Decision-Making under Section A for Mental Illness (MI) or suspected MI, despite the resident having diagnoses of generalized anxiety disorder, brief psychotic disorder, and other specified persistent mood disorders. Similarly, Resident #107's Level I PASRR screening, dated August 18, 2024, documented schizophrenia but omitted the diagnosis of other specified anxiety disorders, which was present on the resident's face sheet. The Director of Nursing confirmed these omissions during an interview on October 24, 2024.
Failure to Follow Daily Wound Care Orders
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards for a resident with a skin condition. During observations on two consecutive days, it was noted that a resident had a pink gentle border foam dressing on her right lower leg, dated several days prior. The resident had a physician's order for daily dressing changes, which included specific instructions to cleanse the wound with normal saline and cover it with a medipore dressing. However, the dressing had not been changed daily as per the order, indicating a lapse in following the prescribed wound care protocol. Interviews with staff revealed inconsistencies in the execution of wound care responsibilities. A Licensed Practical Nurse (LPN) admitted to changing the dressing on the day of the interview, noting that the previous dressing was dated four days earlier. The Wound Care Nurse described a routine where she communicated her wound care activities to other nurses, but it was unclear if this process ensured compliance with daily dressing changes. The Director of Nursing expressed an expectation that nurses assigned to residents with daily wound care orders would complete and document these tasks daily, highlighting a gap between expectations and actual practice.
Failure to Secure Medications in Resident Rooms
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored securely, as observed in two separate incidents involving residents. In the first incident, a bottle of nasal spray and a bottle of 4% lidocaine were found unsecured on the bedside table of a resident's room on multiple occasions. The resident stated that they kept these medications at their bedside because they needed them frequently. A Licensed Practical Nurse (LPN) confirmed the presence of the unsecured medications and acknowledged that medications should not be at the bedside unless the resident has been assessed for self-administration, and even then, they must be secured. The Director of Nursing reiterated that facility policy requires a physician's order for self-administration and that medications should not be in the resident's room unless these conditions are met. In the second incident, a resident was observed with a medication cup containing a thick brown liquid on their meal tray while eating breakfast in their room. The resident indicated that the medication was left by the nurse for consumption after breakfast. An LPN explained that the resident preferred to take their medication after eating and would become upset if pressured to take it immediately. The Director of Nursing stated that medications should not be left at the bedside and should be administered under supervision. The facility's policy on medication storage specifies that bedside medications require a physician's order and should be stored in a locked compartment within the resident's room.
Inaccurate Documentation of Wound Care
Penalty
Summary
The facility failed to accurately document wound care dressing changes for a resident with a skin condition. During observations on two consecutive days, the resident was found with a dressing dated several days prior, despite physician orders for daily dressing changes. The treatment administration history inaccurately documented that the dressing changes were completed on those days, which was contradicted by the physical evidence of the unchanged dressing. Interviews with staff revealed inconsistencies in the documentation and execution of the wound care orders. A Licensed Practical Nurse admitted to changing the dressing on a later date, acknowledging the discrepancy with the documented dates. The Director of Nursing confirmed that the expectation was for daily dressing changes to be completed and accurately documented, which was not adhered to in this case. The facility's policy emphasized the need for concise, accurate, and complete documentation, which was not followed, leading to the deficiency.
Failure in Hand Hygiene During Wound Care and Meal Delivery
Penalty
Summary
The facility failed to adhere to proper hand hygiene protocols during wound care and meal delivery, as observed in two separate incidents. In the first incident, a Certified Nursing Assistant (CNA) did not perform hand hygiene between handling meal trays for two residents. The CNA placed a meal tray in one resident's room, assisted with repositioning the resident, and then proceeded to another resident's room to deliver and assist with feeding without using hand sanitizer or washing hands in between. This lapse in hand hygiene was acknowledged by the CNA during an interview. In the second incident, a Licensed Practical Nurse (LPN) failed to perform hand hygiene before donning gloves and changing a dressing on a resident's wound. The LPN was observed texting on a cellular phone before entering the resident's room and proceeded to change the dressing without washing hands. The Infection Control Preventionist and the Director of Nursing both confirmed that hand hygiene should be performed before and after resident contact, and that gloves do not substitute for hand hygiene. The facility's policies on hand hygiene and dressing changes were reviewed, which clearly outlined the need for hand washing before and after resident contact and during dressing changes.
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Illustrative
What surveyors actually found near you
We read the 37 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
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Illustrative
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Nursing homes near Crystal River
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Cypress Cove Care Center | 2.1 mi | ★★★★★ | 2 | 0 |
| Life Care Center Of Citrus County | 5.2 mi | ★★★★★ | 10 | 0 |
| Diamond Ridge Health And Rehabilitation Center | 5.7 mi | ★★★★★ | 0 | 0 |
| Aviata At Brentwood | 6.4 mi | ★★★★★ | 6 | 0 |
| Grove Healthcare And Rehabilitation Center And Reh | 8.1 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.