Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Citizens Medical Center Ltcu during CMS and state inspections, most recent first.
A resident with a complex medical history, including vascular dementia and atrial fibrillation, did not have their care plan updated to include the use of Dermasaver sleeves for skin protection, despite a physician's order. Observations showed inconsistencies in the application of the sleeves, and staff interviews revealed a lack of awareness of the care plan requirements. The facility's policy required regular review and revision of care plans, which was not adhered to, resulting in a deficiency.
A facility failed to complete a recapitulation of a resident's stay, which is crucial for ensuring continuity of care. The resident, admitted for short-term rehabilitation with multiple diagnoses, was discharged without a comprehensive summary of their stay. The facility's discharge policy did not require such a recapitulation, leading to a risk of unmet care needs.
A resident with multiple health conditions and on anticoagulant medication was not consistently provided with Dermasaver sleeves and sheepskin padding as per her care plan, leading to a risk of skin injuries. Observations showed the protective measures were not properly applied, and staff interviews confirmed the oversight.
A resident with a Stage 4 pressure ulcer was not repositioned as required by their care plan, which directed staff to reposition the resident every hour while seated. Observations showed the resident remained in the same position for extended periods without staff assistance. Interviews revealed a lack of adherence to the care plan, with staff unaware of the specific repositioning instructions. The facility's policies required adherence to care plans and management of pressure injuries, which was not followed in this instance.
A facility failed to ensure a licensed pharmacist conducted a thorough monthly drug regimen review for a resident with hypertension and orthostatic hypotension. The pharmacist did not identify the lack of physician rationale for continued use of psychotropic medications without attempting a gradual dose reduction. Additionally, staff failed to administer PRN blood pressure medications as ordered, placing the resident at risk for uncontrolled blood pressure. The pharmacist's reviews did not report these irregularities, contrary to the facility's Pharmacy Review policy.
A resident with orthostatic hypotension and hypertension did not receive blood pressure medications as ordered by the physician. The Medication Administration Records showed multiple instances where PRN medications were not administered despite the resident's blood pressure exceeding or falling below the set parameters. This failure to follow physician orders placed the resident at risk for blood pressure-related effects.
A facility failed to obtain a written risk versus benefit rationale from the physician for the continued use of four psychotropic drugs for a resident with multiple diagnoses, including Parkinson's disease and anxiety disorder. Despite recommendations for gradual dose reductions (GDR) from the consultant pharmacist, the physician did not document why the benefits of continuing the medications outweighed the risks. This oversight placed the resident at risk for unnecessary psychotropic medications and related side effects.
A resident with COPD and a history of respiratory failure did not receive continuous oxygen therapy as ordered, leading to a medical emergency. During a bath, the resident was without oxygen for 45 minutes, resulting in unresponsiveness and low oxygen saturation. Staff intervened by administering oxygen and transferring the resident to a higher level of care.
Failure to Revise Care Plan for Protective Sleeves
Penalty
Summary
The facility failed to revise the care plan for Resident 3 to include the use of Dermasaver sleeves, which were intended to prevent skin injury. Resident 3 had a complex medical history, including vascular dementia, hypertensive heart disease, chronic kidney disease, a psychotic disorder with hallucinations, and atrial fibrillation. The resident was dependent on staff for personal hygiene, dressing, mobility, and toileting, and did not ambulate. Despite a physician's order dated January 19, 2024, directing staff to apply Dermasaver sleeves and remove them at bedtime, the care plan did not include this directive. Observations on August 5 and 6, 2024, revealed inconsistencies in the application of the sleeves, and the resident was observed without the sleeves and sheepskin on the wheelchair arms, which were supposed to be in place for protection. Interviews with staff indicated a lack of awareness and adherence to the care plan. A Certified Nurse Aide noted that Resident 3 had a recent skin tear and was supposed to have the Dermasaver sleeves and sheepskin on the wheelchair arms for protection. An Administrative Nurse acknowledged that the sleeves had been ordered for the resident's fragile skin but had been inadvertently deleted from the care plan. The facility's care planning policy required individualized care plans to be reviewed and revised quarterly and as resident needs changed, but this was not followed, leading to the deficiency.
Failure to Complete Recapitulation of Resident's Stay
Penalty
Summary
The facility failed to complete a recapitulation of a resident's stay, which is a concise summary of the resident's stay and course of treatment in the facility. This deficiency was identified during a review of the records and interviews. The resident, who was admitted for short-term rehabilitation, had multiple diagnoses including Parkinson's disease, dementia, and a malignant neoplasm of the prostate. The resident required substantial assistance with daily activities and had a goal of discharging back to an apartment with his spouse. Despite the discharge being planned and executed, the facility did not provide a recapitulation of the resident's stay, which is essential for ensuring continuity of care. The facility's discharge policy, dated 12/12/16, outlines the procedure for discharging residents but does not include the requirement for a recapitulation of the resident's course of stay. The administrative nurse confirmed that while nurses, social services, and therapy each complete their discharge summaries, a comprehensive recapitulation was not done for this resident. This oversight placed the resident at risk of unmet care needs upon discharge, as the receiving healthcare provider may not have had all necessary information about the resident's stay and treatment in the facility.
Failure to Implement Skin Protection Measures for Resident
Penalty
Summary
The facility failed to provide necessary care and interventions for a resident, identified as R3, who was at risk for skin injuries due to her medical conditions and use of anticoagulant medication. R3 had a history of vascular dementia, hypertensive heart disease, chronic kidney disease, psychotic disorder with hallucinations, and atrial fibrillation. Her care plan included the use of Dermasaver sleeves and sheepskin padding to protect her fragile skin. However, observations revealed that the Dermasaver sleeves were not properly applied, and the sheepskin padding was missing from her wheelchair arms on multiple occasions. Despite physician orders and care plan updates directing the use of these protective measures, staff failed to consistently implement them. Interviews with staff members, including a CNA and an administrative nurse, confirmed that the Dermasaver sleeves were intended for R3's protection but were not always in place. The facility's Skin Integrity Management policy required staff to report any abnormal skin conditions, but the necessary interventions were not consistently provided, placing R3 at risk for further skin injury.
Failure to Implement Pressure Ulcer Care Plan
Penalty
Summary
The facility staff failed to implement necessary interventions to prevent the development and promote the healing of pressure ulcers for a resident with a Stage 4 pressure ulcer. The resident, who had moderately impaired cognition and was dependent on staff for most activities of daily living, was observed sitting in a wheelchair for extended periods without being repositioned as per the care plan. The care plan required the resident to be repositioned every hour while sitting up in a chair, and if in a recliner or wheelchair, to be stood and encouraged to walk or lie down for 15 minutes every hour. However, observations revealed that the resident remained in the same position for over two hours on one occasion and for over an hour on another, without staff assistance to stand, reposition, or encourage lying down. Interviews with facility staff, including a Certified Nurse Aide and the facility's wound care nurse, indicated a lack of adherence to the care plan. The wound care nurse expressed uncertainty about whether the lack of repositioning could delay the healing of the pressure ulcer, noting that the plan was to maintain it rather than expect healing. Additionally, the administrative nurse confirmed that the care plan required hourly repositioning, but the CNAs' ADL plan did not include these instructions. The facility's policies on care planning and skin integrity emphasized the responsibility of all associates to follow the care plan and manage pressure injuries, which was not adhered to in this case.
Failure in Medication Review and Administration
Penalty
Summary
The facility failed to ensure that a licensed pharmacist conducted a thorough monthly drug regimen review for a resident, identified as R7, who had a history of orthostatic hypotension and hypertension. The review did not identify the lack of a documented physician rationale for the continued use of certain psychotropic medications without attempting a gradual dose reduction (GDR). The medications in question included clonazepam, risperidone, trazodone, and Zoloft, which were prescribed for anxiety disorder, psychotic disorder with delusions, insomnia, and recurrent depression, respectively. Despite recommendations for GDR by the consultant pharmacist, the physician did not provide adequate documentation explaining why the benefits of continuing these medications outweighed the risks. Additionally, the facility's staff failed to administer as-needed (PRN) blood pressure medications according to the physician's orders. The Medication Administration Records for May, June, July, and August showed multiple instances where PRN metoprolol and Midodrine were not administered when R7's blood pressure readings were outside the specified parameters. This oversight placed R7 at risk for issues related to uncontrolled blood pressure. The consultant pharmacist's monthly reviews in June and July did not report any irregularities, despite the documented failures in medication administration and the lack of physician rationale for psychotropic medication use. The facility's Pharmacy Review policy required the pharmacist to review medication administration for timely administration and reasons for non-administration, as well as to document any irregularities and actions taken. However, these steps were not adequately followed, leading to the deficiency identified in the report.
Failure to Administer Blood Pressure Medications as Ordered
Penalty
Summary
The facility failed to administer blood pressure medications as ordered by the physician for a resident with diagnoses of orthostatic hypotension and hypertension. The resident's care plan required staff to administer medications as ordered and monitor for side effects, but the Medication Administration Records for May, June, July, and August showed multiple instances where the PRN medications, metoprolol and Midodrine, were not administered according to the physician's orders. Specifically, there were numerous occasions where the resident's systolic blood pressure exceeded or fell below the parameters set by the physician, yet the corresponding medications were not given. On one occasion, a licensed nurse administered medications to the resident after obtaining a blood pressure reading of 185/112 mm/Hg, which included both the scheduled and PRN doses of metoprolol. An administrative nurse confirmed that staff failed to administer the PRN medications as ordered on several occasions, noting that some high blood pressure readings were taken just before the scheduled dose of metoprolol. The facility's medication administration policy mandates that all medications be administered as ordered by a physician, ensuring the drug regimen is free from unnecessary drugs. The failure to adhere to these orders placed the resident at risk for the effects of high or low blood pressure.
Failure to Document Risk vs. Benefit for Psychotropic Medications
Penalty
Summary
The facility failed to obtain a written risk versus benefit rationale from the physician for the continued use of four psychotropic drugs for a resident, identified as R7. R7's medical history included Parkinson's disease, anxiety disorder, recurrent major depressive disorder, delusional disorders, psychotic disorder, and insomnia. The resident's care plan required gradual dose reductions (GDR) for psychotropic drugs when clinically appropriate, yet the facility did not ensure this was documented. The facility's policy stated that residents using psychotropic drugs should receive periodic GDRs and behavioral interventions unless clinically contraindicated. Despite recommendations from the consultant pharmacist for GDRs of risperidone, Trazodone, and clonazepam, the physician did not provide adequate documentation explaining why the benefits of continuing these medications outweighed the risks. Observations confirmed that the resident was administered these medications without the necessary risk versus benefit rationale. The facility's failure to adhere to its policy and obtain the required documentation placed the resident at risk for unnecessary psychotropic medications and related side effects.
Failure to Provide Continuous Oxygen Therapy
Penalty
Summary
The facility failed to provide continuous oxygen therapy to a resident with a history of respiratory failure and COPD, as ordered by the physician. On the morning of the incident, a Certified Nurse Aide (CNA) did not administer the resident's continuous oxygen at 4 liters per minute while assisting with a bath. This lapse lasted for approximately forty-five minutes, during which the resident was without the necessary oxygen support. After the bath, when the resident was assisted back to his wheelchair, he became unresponsive. Staff members, including a Certified Medication Aide (CMA) and Licensed Nurses (LNs), observed the resident's deteriorating condition, noting his pale and greyish skin color, lack of respirations, and low oxygen saturation of 76%. It was then discovered that the resident did not have his oxygen on, prompting immediate action to administer oxygen at the prescribed rate. Despite the administration of oxygen, the resident's condition remained critical, with irregular and labored breathing, necessitating transfer to a higher level of care. The resident was eventually stabilized with the use of a CPAP device and continuous oxygen, but the initial failure to provide the ordered respiratory care resulted in significant distress and a medical emergency.
Removal Plan
- Reeducation for all nursing staff on the importance of providing the necessary care including administering oxygen appropriately per orders.
- Appropriate staff completed an oxygen competency check-off.
- The incident was reviewed by the Quality Assurance Committee.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Colby
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Colby Operator, Llc | 0.2 mi | ★★★★★ | 0 | 0 |
| Logan County Senior Living Inc | 20.1 mi | ★★★★★ | 7 | 0 |
| Good Samaritan Society - Atwood | 30.2 mi | ★★★★★ | 0 | 0 |
| Topside Manor Inc | 35.8 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.