Inspection Reports for Citrus Place

An unannounced visit was conducted to investigate a complaint alleging that staff did not give resident medication as prescribed.

The investigation found that facility staff mismanaged Resident 1's medication, resulting in hospitalization. Medication orders were incorrectly entered into the facility's system, and the facility failed to verify the pharmacy's entry, leading to medication errors.

The complaint alleging staff did not give resident medication as prescribed was substantiated based on interviews and records reviewed. The preponderance of evidence standard was met.

The visit was an unannounced complaint investigation triggered by an allegation that facility staff did not seek timely medical care for a resident.

The investigation found that staff immediately contacted the resident's Power of Attorney (POA) after observing an injury, and followed the POA's instruction not to seek emergency medical services initially. Medical personnel were contacted later when the resident's condition worsened, and the resident was transported to the hospital. The allegation was unsubstantiated due to insufficient evidence to prove a violation.

The complaint alleged that staff failed to transport a resident to the hospital in a timely manner after an injury was observed. The investigation determined that staff followed the POA's directive, causing a delay in emergency services. The allegation was unsubstantiated.

Unannounced complaint investigation visit conducted due to allegations including inadequate supervision of residents, staff leaving a resident on the floor for an extended period, and failure to administer medications as prescribed.

The investigation found the allegations of inadequate supervision, medication administration issues, and leaving a resident on the floor unsubstantiated. However, the allegation of staff engaging in physical and verbal altercations in the presence of residents was substantiated, posing a potential health and safety risk.

The complaint investigation was triggered by allegations received on 04/29/2024. The allegation that staff engage in physical and verbal altercations in the presence of residents was substantiated. Other allegations regarding supervision, medication administration, and leaving a resident on the floor were unsubstantiated.

The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2021-10-20 regarding multiple allegations about resident care and facility practices.

The investigation found three allegations unsubstantiated related to residents being left in soiled diapers, not treated with dignity, and toileting needs not met. However, three other allegations were substantiated: resident's hygiene needs were not met, staff did not notify the responsible party of a resident's change in condition, and staff did not safeguard resident's personal belongings. Deficiencies were cited accordingly.

The complaint investigation addressed allegations including residents left in soiled diapers, lack of dignity and respect, unmet toileting needs, unmet hygiene needs, failure to notify responsible party of change in condition, and failure to safeguard personal belongings. The investigation concluded three allegations unsubstantiated and three substantiated.

The inspection was an unannounced complaint investigation visit triggered by multiple allegations including failure to refill resident's medication, unqualified staff handling medication, serving cold meals, facility disrepair, staff neglect leading to a resident's fall, and unresponsiveness of the administrator to a resident's responsible party.

The investigation substantiated the allegation that staff failed to refill a resident's medication, resulting in missed doses and posing an immediate health and safety risk. The allegation that staff handling medication were unqualified was found to be unfounded. Other allegations regarding cold meals, facility disrepair, staff neglect, and administrator unresponsiveness were unsubstantiated based on interviews, documentation, and observations.

The complaint investigation was substantiated for failure to refill resident's medication. The allegation that staff handling medication were not qualified was unfounded. Allegations regarding cold meals, facility disrepair, staff neglect leading to a resident's fall, and administrator unresponsiveness were unsubstantiated.

An unannounced case management visit was conducted in conjunction with complaint investigation 18-AS-20240429160126 regarding alleged staff misconduct.

The investigation revealed that Staff 1 placed their hand over a resident's mouth and told the resident to 'Shut up,' constituting humiliation and intimidation. Staff 1 was terminated from employment. The resident was observed to be clean and well cared for during the visit.

Complaint investigation 18-AS-20240429160126 substantiated the allegation that Staff 1 humiliated and intimidated a resident by covering the resident's mouth and telling them to 'Shut up.'

The inspection was an unannounced complaint investigation visit triggered by allegations received on 05/10/2024 regarding staffing sufficiency, staff behavior towards residents, and discouragement of incident reporting.

The investigation found that staffing levels and qualifications were appropriate, staff denied yelling at residents or discouraging incident reporting, and residents confirmed being treated well. The allegations were deemed unsubstantiated due to lack of evidence.

The complaint investigation was unsubstantiated. Allegations included insufficient staff numbers and qualifications, staff yelling at residents, and discouragement of incident reporting. Interviews and documentation review did not corroborate these claims.

An unannounced visit was made to the facility to deliver amended complaint findings for two complaint control numbers: 18-AS-20231013143500 and 18-AS-20230918160404.

The Licensing Program Analyst met with the Executive Director to explain the purpose of the visit and conducted an exit interview. A copy of the report was provided to the Executive Director.

The visit was related to amended complaint findings for complaint control numbers 18-AS-20231013143500 and 18-AS-20230918160404.

An unannounced complaint investigation visit was conducted in response to a complaint received on 2024-04-15 alleging that staff did not prevent a resident from pushing another resident.

The investigation revealed that on 2024-04-13, a resident was pushed by another resident resulting in a fall and head injury. Both residents denied the altercation and staff confirmed presence during the incident. The allegation was deemed unsubstantiated due to insufficient evidence.

The complaint alleged that staff did not prevent a resident from pushing another resident. The allegation was investigated and found unsubstantiated, meaning there was not a preponderance of evidence to prove the violation occurred.

The inspection was an unannounced complaint investigation visit triggered by allegations received on 2024-05-07 regarding food safety protocols, falsification of medical documentation, incident reporting, medication administration without physician permission, and resident reassessment.

The investigation found no preponderance of evidence to substantiate any of the allegations. The kitchen was clean and followed food safety protocols, medical documentation was accurate, incidents were properly reported, medications were only crushed with physician orders, and residents were reassessed as required.

The complaint investigation was unsubstantiated. Allegations included staff not following food safety protocols, falsifying medical documentation, not reporting incidents, administering crushed medications without physician permission, and not reassessing residents as necessary. None of these allegations were substantiated based on the evidence gathered.

The inspection was an unannounced required annual inspection conducted by the Licensing Program Analyst to assess compliance with state regulations.

The facility was observed to be clean, well-maintained, and in good repair with no deficiencies cited. Records and files were reviewed with some noted issues in document organization, but no regulatory violations were found.

An unannounced case management visit was conducted in conjunction with a complaint investigation related to facility conditions and resident safety.

The facility failed to ensure that resident R1 was provided safe and healthful accommodations while a substantial repair was being done in the living room. The resident remained in their room despite the damage and repair work, and the responsible party refused to move the resident to another room.

The visit was triggered by complaint visit 18-AS-20211215084528. The complaint was investigated through interviews, record reviews, and observations. The citation was issued based on these findings.

Unannounced complaint investigation visit conducted due to allegations regarding disrepair of a resident's ceiling and electricity issues.

The investigation substantiated the allegations that a resident's ceiling had leaks and the electricity was in disrepair due to water in light switches causing breaker issues. The ceiling was observed repaired during the visit, but the facility failed to maintain a safe and healthful environment initially.

Complaint was substantiated. The investigation was triggered by allegations of disrepair in a resident's ceiling and electricity. The facility had ongoing issues with leaks and electrical safety hazards. Citations were issued accordingly.

An unannounced complaint investigation visit was conducted in response to an allegation that facility staff were not ensuring that a resident was adequately fed while in care.

The investigation included a review of meal tracking forms and staff interviews, which revealed the resident was on a meal plan and was provided meals, preferring to eat in their room. The allegation was found to be unsubstantiated due to lack of evidence.

The complaint was unsubstantiated as the investigation did not find sufficient evidence to prove the alleged violation occurred.

The inspection was an unannounced complaint investigation visit triggered by allegations received on 2023-06-21 regarding meal service timeliness, food quality, and adequacy of food availability at the facility.

The investigation found no preponderance of evidence to substantiate the allegations. Observations and interviews with residents, staff, and kitchen personnel indicated meals were served timely, food was not overcooked, and adequate food and snacks were available to residents.

The complaint investigation addressed allegations that the facility was not serving meals in a timely manner, was overcooking residents' food, was serving food that was not of quality, and did not ensure an adequate amount of food was available to residents. All allegations were deemed unsubstantiated due to lack of sufficient evidence.

An unannounced complaint investigation was conducted in response to a complaint received on 08/13/2024 regarding Personal Rights at Citrus Place facility.

The allegation was investigated through interviews, record reviews, and observations, and was determined to be unfounded as the resident in question does not reside at the facility and there were no health and safety concerns observed.

The complaint was related to Personal Rights. The allegation was found to be unfounded, meaning it was without merit or false and could not have happened.

The inspection was a required annual unannounced visit conducted to evaluate compliance with licensing requirements for the residential care facility for the elderly.

The facility was found to be in compliance with no deficiencies cited. Observations included infection control measures for COVID-19 positive residents, clean and well-maintained physical plant, adequate food service, proper medication management, and disaster preparedness with recent fire drill documentation.

The visit was an unannounced complaint investigation conducted to investigate allegations that staff did not maintain a comfortable temperature at all times for residents in care.

The investigation found that the facility had experienced air conditioning issues earlier in the month but had taken steps to ensure residents were kept comfortable using fans and portable air conditioning units. At the time of the visit, temperatures were comfortable, no residents complained or experienced heat-related symptoms, and there was a plan to repair the air conditioning system. Therefore, the allegation was unsubstantiated.

The complaint alleged that on 7/11/2023 the facility lobby, kitchen, and dining area were 90 degrees and that management stated the air conditioning system was "too costly" to fix, with staff using fans to cool the dining room. The allegation was found unsubstantiated after investigation.

The inspection visit was conducted to investigate a complaint alleging that the facility was not conducting fire drills.

The investigation found that the last fire drill was conducted on 2023-05-31, confirmed by the Maintenance Director, and therefore the allegation was unsubstantiated.

The complaint alleged that the facility was not conducting fire drills. The allegation was found to be unsubstantiated after review and interviews.

An unannounced visit was conducted to amend the finding of one allegation from October 22, 2021, related to a complaint.

The visit was focused on addressing a previous allegation from a complaint dated October 22, 2021. No additional findings or deficiencies are explicitly stated in the report.

The visit was related to complaint #18-AS-20210818134318 and involved amending the finding of one allegation from October 22, 2021.

An unannounced annual inspection was conducted with an emphasis on infection control to evaluate the facility's compliance with Community Care Licensing guidelines.

The inspection found no deficiencies. The facility demonstrated sufficient infection control measures including adequate hand hygiene supplies, cleaning provisions, proper PPE use, and a designated infection control lead. The facility also has plans for COVID-19 testing, isolation, and monitoring.