Above average — CMS composite of the measures below.
The next survey window likely opens around June 2027
Estimate from public CMS data, current as of October 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.
The facility failed to complete required annual performance reviews for four CNAs who had been employed for over a year. Administrative staff reported the reviews had not been done for the past two years after a platform change, and an administrative nurse verified the missing evaluations. The facility policy states performance management is continuous and annual documentation is due by year-end.
Failure to verify background and license for an LN. The facility could not provide documentation of a criminal background check or nurse registry/license verification for an LN hired in 2022. Staff reported the records could not be located in HR, despite the facility policy requiring job-related background checks for conditional hires and current associates.
PRN Ativan Order Lacked Required Stop Date or Rationale: A resident with anxiety, dementia, pain, and a terminal diagnosis had a PRN Ativan order for anxiety that lacked a stop date. The record also lacked a specified duration and physician rationale for continuing the psychotropic medication beyond 14 days, and staff stated the resident was on comfort care and receiving PRN Ativan without a stop date being considered.
The facility failed to provide two residents and their representatives with written bed-hold notices that included the per diem rate to hold a bed, and failed to document transfer notices with appeal rights and state ombudsman information after hospital transfers. The records also lacked evidence that the LTC ombudsman was notified of the hospital transfers, and an admin staff member stated the facility had not been notifying the ombudsman for hospital transfers and that bed-hold forms had not been completed.
A resident with severe cognitive impairment, total ADL dependence, and fragile skin sustained repeated bruises, abrasions, and skin tears during transfers and personal care. The injuries were documented as occurring when her arm or hand rubbed against a lift sling, wheelchair armrest, or staff clothing, and when she struck her toe on the lift. Staff repeatedly provided education after each event, while the resident continued to have healing skin tears and wore Geri sleeves for protection.
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.
Missing Annual Performance Reviews for Nurse Aides
Penalty
Summary
The facility failed to ensure required annual performance reviews were completed for four randomly selected nurse aides who had been employed for over a year. Certified Nurse Aide O, employed 10/23/24, CNA P, employed 03/12/24, CNA Q, employed 10/05/10, and CNA R, employed 12/06/23, were identified as lacking annual performance reviews during record review. On 07/07/2026 at 02:30 PM, Administrative Staff A reported that the CNAs did not have annual performance reviews and stated the facility had changed the platform system, with performance reviews not completed for the past two years. On 07/08/2026 at 10:56 AM, Administrative Nurse D verified that the annual performance reviews had not been completed. The facility policy states performance management is a continuous process, with annual goal setting and final performance documentation due by December 31.
Failure to Verify Background and License for an LN
Penalty
Summary
The facility failed to implement its policy to screen potential employees for a history of abuse, neglect, exploitation, or misappropriation when it did not obtain a criminal background check and nurse registry/license verification for a Licensed Nurse I at hire. Record review showed the LN I had an employee start date of 02/14/2022, but the facility could not provide documentation of the criminal background check or nurse registry check. On 07/07/2026 at 02:30 PM, Administrative Staff A reported there had been a change in the system related to verification of criminal background checks and licensing documentation. Administrative Staff A also stated the facility was unable to locate the information that would have been maintained through the human resources department. On 07/08/2026 at 10:56 AM, Administrative Nurse D reported the human resources department was responsible for criminal background and license verification checks. The facility's Personnel Policies and Code of Conduct, dated 01/01/24, states that individuals receiving conditional offers of employment will be subject to a job-related background check, and that current associates may be subject to background checks including criminal history checks and other inquiries based on job requirements.
PRN Ativan Order Lacked Required Stop Date or Rationale
Penalty
Summary
The facility failed to ensure a 14-day stop date or a specified duration with a rationale for a resident’s ongoing PRN antianxiety medication. The resident had diagnoses of anxiety, malignant neoplasm of the colon, pain, and dementia, and the MDS documented severely impaired cognition, dependence on staff for multiple ADLs, and use of antianxiety and antidepressant medications daily. A significant change MDS later documented severely impaired cognition, dependence on staff for toileting, hygiene, showers, dressing, transfers, and mobility, and that the resident had inattention and fluctuating disorganized thinking and did not receive any medications. The resident’s care plan addressed a terminal diagnosis and medication administration as ordered, and a physician’s order directed staff to give Ativan 2 mg/ml, 0.25 ml every four hours as needed for anxiety. The order did not include a stop date, and the medical record lacked evidence of a specified duration or physician rationale for extending the PRN Ativan beyond 14 days. Staff interviews indicated the resident was on comfort care and received PRN Ativan for anxiety, while the administrative nurse stated the facility normally placed an automatic 14-day stop date on initial Ativan orders but did not consider stop dates for residents on comfort care.
Failure to Provide Bed-Hold and Transfer Notices
Penalty
Summary
The facility failed to ensure that Resident 2 and Resident 17, and their representatives, were provided with a bed-hold policy that included the facility’s per diem rate to hold a bed. For both residents, the electronic medical record lacked documentation that the required written bed-hold information had been provided after their transfers to the hospital, and the facility was unable to produce the documentation when requested. The facility also failed to ensure that Resident 2 and Resident 17, and their representatives, were given written transfer notifications that included a statement of the right to appeal and state ombudsman information when they were transferred to the hospital. Their records lacked documentation of these notices being provided as soon as practicable after transfer. In addition, the facility was unable to provide the requested documentation for either resident. The records showed that both residents had an unplanned discharge to an acute hospital with return anticipated, followed by re-entry to the facility. The facility’s monthly ombudsman notification lists also did not include the hospital transfers for either resident. During interview, Administrative Staff A stated that the facility had not been notifying the ombudsman when residents were transferred to the hospital and acknowledged that paper bed-hold forms had not been completed as they should have been.
Repeated skin tears during staff-assisted care
Penalty
Summary
The facility failed to ensure Resident 14 maintained skin integrity during staff-assisted care. Resident 14 had diagnoses including malignant neoplasm of the bone, lung, and brain, edema, hypertension, and pain, and the MDS documented severely impaired cognition, total dependence for all ADLs, bilateral upper and lower functional impairment, and a turning and repositioning program. The care plan included weekly full-body skin assessments, observation for skin changes, repositioning every two hours, and use of Geri sleeves. The record showed repeated skin injuries over time, including bruising, abrasions, and multiple skin tears to the hands, forearms, elbows, and finger. Several injuries were documented as occurring during transfers with the sit-to-stand lift or while staff were providing personal care, bathing, or dressing. In multiple instances, the resident’s arm or hand rubbed against the sling, wheelchair armrest, or staff clothing, and the resident also struck her toe on the lift. The documentation repeatedly noted that staff were educated after these events, including reminders to use protective sleeves and to be careful during transfers. On observation, Resident 14 was seen in a recliner wearing short sleeves with Geri sleeves on both arms that extended from the tops of her hands to just below her elbows, and she had a healing skin tear on her left elbow. Staff stated she had sustained many skin tears during care and needed the sleeves for protection. Nursing staff also stated her skin was very fragile, that she had been caught on wheelchair armrests, and that she had longer sleeves available, while another nurse noted the resident preferred short-sleeved shirts. The facility’s skin integrity policy identified interventions such as protective elbow pads and arm protectors for residents at risk for skin breakdown, but the resident continued to sustain repeated skin tears during staff-assisted 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 | ★★★★★ | 9 | 1 |
| Good Samaritan - Atwood | 30.2 mi | ★★★★★ | 0 | 0 |
| Topside Manor Inc | 35.8 mi | ★★★★★ | 12 | 0 |
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