Citizens Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Havre De Grace, Maryland.
- Location
- 415 South Market Street, Havre De Grace, Maryland 21078
- CMS Provider Number
- 215039
- Inspections on file
- 21
- Latest survey
- January 29, 2026
- Citations (last 12 mo.)
- 15
Citation history
Health deficiencies cited at Citizens Care Center during CMS and state inspections, most recent first.
A resident with an order for morning Tylenol Extra Strength 500 mg for pain reported pain at a level of 8/10 and received the medication, but staff did not document any follow-up assessment to determine the effectiveness of that dose. Later the same day, the physician ordered Tylenol Extra Strength 500 mg every 8 hours for pain, and the first dose under this new order was associated with a documented pain level of 0. Review of the MAR and staff interviews, including with the DON, confirmed there was no evidence that nursing staff reassessed the resident’s pain after the initial morning administration.
A resident's wishes regarding life-sustaining treatment were not timely updated or clearly documented, despite the resident expressing a desire for CPR and being alert and oriented. Staff failed to complete a timely capacity evaluation after changes in the resident's condition, resulting in discrepancies and unclear documentation about the resident's code status and decision-making authority.
A resident exhibited increased confusion and tearfulness, which was documented by both nursing and social work staff. However, there was no evidence that the provider was notified of this change in mental status, as required. Nursing leadership confirmed that the notification did not occur or was not documented.
A resident's TAR indicated that heel protector boots were applied as ordered, but progress notes from multiple staff and the physician documented that the boots were missing and unavailable for several days. The DON confirmed discrepancies between the TAR and progress notes, showing that the resident's care was not accurately documented.
The facility failed to maintain water temperatures within an acceptable range, with multiple rooms showing elevated temperatures. The Director of Maintenance confirmed the issue was due to the boiler system, but could not provide documentation of temperature checks. The Administrator admitted that water temperatures in resident rooms were not being monitored, leading to the deficiency.
A facility failed to ensure proper follow-up and care for residents, including a missed urology appointment for a resident with a Foley catheter, improper positioning and timing of enteral nutrition, and incorrect oxygen administration. Additionally, pain management orders were not transcribed, leading to unclear medication administration. These deficiencies were observed in several residents, highlighting lapses in adherence to physician orders and care protocols.
A resident was not assisted out of bed for four out of five days and was not dressed in their own clothing, instead wearing a soiled hospital gown. Staff interviews revealed the resident preferred the gown, but the GNA did not inform the nurse about the resident's prolonged bed stay. The Unit Manager stated that residents typically get out of bed after breakfast unless they refuse, in which case the nurse should be notified.
A facility failed to issue a bed hold notice to a resident or their representative during a hospitalization. The deficiency was identified during a recertification survey when a surveyor found no documentation of the notice in the medical record. The DON confirmed the absence of such documentation.
A facility failed to follow the care plan for a resident with a suprapubic catheter, missing a required urology follow-up. The resident, with Multiple Sclerosis and Benign Prostatic Hyperplasia, did not receive a urology consultation within six months as planned. The DON acknowledged the oversight, attributing it to the physician's inability to accommodate the resident on a stretcher.
An LPN failed to ensure a resident consumed their medication before leaving the room, placing a protein supplement on the bedside table without instructions. The MAR audit showed discrepancies in medication administration times, not adhering to the standard practice of administering within an hour of the scheduled time.
The facility did not conduct annual performance reviews for its GNAs as required. During a survey, it was found that no evaluations were completed for the years 2022 and 2023 for four GNAs. The DON admitted to being behind on evaluations, and a staff educator stated that conducting evaluations was not part of her role. This issue was discussed with the administrative team during the survey exit conference.
A facility failed to timely address a pharmacy recommendation for a resident prescribed PRN lorazepam. The pharmacist's MRR highlighted the need for a stop date or documented rationale for extending the PRN order, but the physician did not respond, and the order remained active without necessary documentation. The issue was identified during a review, and the PRN lorazepam was eventually discontinued after a delay.
A resident prescribed Zyprexa was not monitored for side effects, as required by an existing order. The MAR and TAR lacked documentation of monitoring, despite staff acknowledging the need to report and document behavioral changes. This deficiency was identified during a survey, highlighting a lapse in the facility's monitoring process.
Surveyors found deficiencies in medication management and storage, including an unattended and unlocked medication cart with Baclofen, expired medications, and improperly stored supplies. Temperature logs for biologicals and supplements were inconsistently recorded, and expired items were found in medication rooms. Staff acknowledged these issues, indicating lapses in the facility's practices.
The facility failed to document and maintain accurate inventory sheets for residents' personal effects and ensure the accuracy of medical orders. Two residents' inventory sheets lacked signatures and dates, and staff were uncertain about a resident's denture status. Additionally, a discrepancy was found between a medical order and a wound consult for a resident with a pressure ulcer, with the order directing care on the wrong side of the body.
The facility failed to document that four GNAs completed the required 12 hours of annual clinical training for 2022 and 2023. The DON could not provide evidence of training completion during a survey, and the staff educator indicated that staff education was not her primary role. This issue was discussed with the administrative team during the survey exit conference.
Failure to Document Follow-Up Pain Assessment After PRN Analgesic Administration
Penalty
Summary
Facility staff failed to provide appropriate follow-up assessment for a resident who reported serious pain after receiving pain medication. Clinical record review showed that the resident had an existing order for Tylenol Extra Strength 500 mg to be administered in the morning for pain. On 12/30/25, the resident reported pain rated 8 out of 10 and was given the ordered Tylenol at approximately 9:00 AM. However, there was no documented evidence that nursing staff returned to reassess the resident’s pain level or evaluate the effectiveness of the medication after administration. Further review of the clinical record showed that later that same day, at 5:00 PM, the physician added a new order for Tylenol Extra Strength 500 mg, one tablet every 8 hours, for the diagnosis of pain. The resident received the first dose under this new order at 6:02 PM and had a documented pain level of 0 afterward. During an interview, the DON was shown the December 2025 MAR, including the documented pain level of 8 on 12/30/25 and the absence of a follow-up pain assessment. After reviewing the concern with the unit manager, the DON confirmed they could not find evidence that a nurse had followed up on the effectiveness of the morning pain medication dose.
Failure to Timely Update and Document Resident's Life-Sustaining Treatment Preferences
Penalty
Summary
The facility failed to update and accurately document a resident's wishes regarding life-sustaining treatment and did not assess the resident's decision-making capacity in a timely manner. The resident, who was their own responsible party, had a Maryland MOLST form indicating a DNR (Do Not Resuscitate) order, but subsequent documentation by staff indicated the resident expressed a desire to attempt CPR and was alert and oriented at that time. Despite this, the MOLST was not updated to reflect the resident's clarified wishes, and there were discrepancies between the resident's expressed preferences and the orders documented in the medical record. Further review revealed that after the resident experienced changes in condition and was transferred to and from the hospital, staff expressed discomfort discussing code status and requested a re-evaluation of the resident's capacity. However, no timely capacity evaluation was completed, and the medical records remained unclear about who the decision maker was during this period. Both the DON and the social worker confirmed these discrepancies and the lack of timely assessment, resulting in unclear and inconsistent documentation of the resident's life-sustaining treatment preferences.
Failure to Notify Provider of Resident's Change in Mental Status
Penalty
Summary
The facility failed to ensure timely notification to a physician regarding a resident's change in condition. Specifically, a resident was observed by a registered nurse to be tearful and experiencing increased confusion, which was also documented by a social worker. Despite these documented changes in the resident's mental status, there was no evidence in the medical record that the provider was notified of the change. Interviews with the Assistant Director of Nursing and the Director of Nursing confirmed that such changes should be communicated to the provider and documented, but no such documentation or notification was found for this incident.
Inaccurate Documentation of Resident's Treatment Administration Record for Heel Protector Boots
Penalty
Summary
The facility failed to ensure accurate documentation of a resident's Treatment Administration Records (TAR) regarding the use of heel protector boots. During the investigation, it was found that although the resident's TAR indicated that the boots were applied during all shifts from 5/14/25 to 5/18/25, progress notes from multiple staff members documented that the boots were missing and could not be located. Staff notes included reports from both nursing staff and the attending physician, who noted the resident's requests for the boots and the need to order replacements, indicating the boots were not available as required by the physician's order. The discrepancy was confirmed during a review of the records with the Director of Nursing, who acknowledged that the TAR documentation did not match the progress notes. The resident had an active order for heel protector boots to be worn at all times except during bathing, but the documentation failed to accurately reflect the resident's actual care and the absence of the boots during the specified period.
Failure to Maintain Safe Water Temperatures
Penalty
Summary
The facility failed to ensure that water temperatures remained within an acceptable range, as observed during a survey of the Harbor View Unit. On multiple occasions, water temperatures in resident rooms were found to be significantly above the recommended levels, with temperatures ranging from 120 degrees Fahrenheit to as high as 137.5 degrees Fahrenheit. The Director of Maintenance (DOM) was notified and confirmed the elevated temperatures, attributing the issue to the facility's boiler system, which had been powered down for the use of the chiller. However, the DOM could not provide documentation of water temperature checks during this process. Residents in the affected rooms, including two specific residents, were interviewed, and while they did not report any burns or issues, the elevated temperatures posed a potential risk. Further observations revealed that water temperatures in several other rooms were also above the acceptable range. The surveyor and the DOM conducted dual observations, confirming the elevated temperatures. During an interview, the Administrator and the DOM admitted that water temperatures in resident rooms were not being monitored, as they had assumed the temperatures were being taken at the boiler. This oversight led to the deficiency, as the facility failed to ensure a safe environment free from accident hazards related to water temperature.
Multiple Deficiencies in Resident Care and Treatment
Penalty
Summary
The facility failed to ensure that a resident followed up with a urologist for the management of a Foley catheter. Resident #18, who was admitted with multiple sclerosis and benign prostatic hyperplasia, had an indwelling catheter and was recommended to follow up with a urologist within six months. However, the follow-up did not occur as the resident missed an appointment due to the physician's inability to accommodate the resident via a stretcher. The Director of Nursing acknowledged the need for arrangements to be made for the follow-up. Resident #59 experienced multiple deficiencies in care. The resident was observed with a dark red dried substance on the left earlobe, which was not addressed until brought to the attention of an LPN. A physician's order to apply bacitracin to the left ear every morning and evening was not followed. Additionally, the resident was not properly positioned for enteral nutrition, with the head of the bed not elevated to the required 35-degree angle, risking aspiration. The enteral nutrition was also not administered during the ordered times, and medications were given outside the prescribed time frame. Resident #33 was observed receiving 3L of oxygen via nasal cannula, contrary to the physician's order of 2L. The LPN was unaware of the discrepancy and had not assessed the oxygen concentrator. Similarly, resident #100 was on 4.5 liters of oxygen instead of the ordered 2 liters. Furthermore, resident #1 had a physician order for pain management using a pain scale that was not transcribed or processed, leading to a lack of clarity in administering Tylenol and Tramadol for pain relief.
Failure to Uphold Resident Dignity and Personal Preferences
Penalty
Summary
The facility staff failed to uphold the resident's right to be treated with respect and dignity by not getting a resident out of bed for four out of five days and not dressing the resident in their own clothing. This deficiency was observed in one resident during the survey. On multiple occasions, the resident was found in bed wearing a soiled hospital gown, with uncombed hair, and the blinds closed. Interviews with staff revealed that the resident preferred to wear a hospital gown while in bed, and the Geriatric Nursing Assistant (GNA) assigned to the resident did not get them out of bed on several days. The GNA was also unable to confirm if the assigned nurse was informed about the resident not being dressed in their clothing and not getting out of bed for several days. The Unit Manager described the typical routine for residents, which includes getting out of bed after breakfast, but noted that if a resident refuses, the nurse should be informed.
Failure to Issue Bed Hold Notice
Penalty
Summary
The facility failed to issue a bed hold notice to a resident or their representative during a hospitalization event. This deficiency was identified during the facility's recertification survey. The surveyor reviewed the medical record and found a nursing progress note indicating that the resident was transferred to the hospital. However, there was no documentation in the medical record to show that the facility had issued the required bed hold notice. The surveyor requested documentation from the Director of Nursing (DON) to confirm whether the bed hold notice had been provided. During an interview, the DON admitted that the facility did not have any documentation to prove that the bed hold policy was communicated to the resident or their representative.
Failure to Follow Care Plan for Resident with Catheter
Penalty
Summary
The facility failed to adhere to the care plan for a resident with a foley catheter, specifically in managing follow-up urology consultations. The resident, who has a history of Multiple Sclerosis and Benign Prostatic Hyperplasia, was admitted with an indwelling suprapubic catheter due to a neurogenic bladder. The care plan, which was last revised in August 2022, included a requirement for urology consults as ordered. However, the facility did not ensure that the resident received a follow-up urology consultation within six months after the last one in April 2022. During an interview, the Director of Nursing (DON) acknowledged the lapse in following the care plan, citing the physician's inability to accommodate the resident on a stretcher as a reason for the missed consultation. This oversight was identified during a survey, which reviewed the medical records and included interviews with facility staff. The deficiency was discussed with the administration team at the time of the survey's exit.
Failure to Ensure Medication Consumption Before Leaving Resident's Room
Penalty
Summary
The nursing staff failed to meet professional standards of care by not ensuring that medication was consumed prior to leaving the resident's room. This deficiency was observed when an LPN administered medications to a resident and placed a dark amber colored liquid in a small cup on the resident's bedside table without ensuring the resident consumed it. The LPN left the room without providing any directions to the resident regarding the medication. A GNA later identified the liquid as a protein supplement. The LPN confirmed that the standard practice is to ensure the resident completes the medication before leaving the room. A review of the Medical Administration Record (MAR) audit for the resident showed that several medications, including Tylenol, Potassium Chloride, Lasix, and Prostat, were scheduled for administration at specific times. The MAR audit revealed discrepancies in the documentation times, with the Lasix documented at 11:29 AM and the other medications at 11:34 AM, despite the standard practice of administering medications within an hour before and after the due time.
Failure to Conduct Annual Performance Reviews for GNAs
Penalty
Summary
The facility failed to conduct annual performance reviews for geriatric nursing assistants (GNAs) based on their hire dates, as required. This deficiency was identified during a survey when the surveyor reviewed the human resource and staff education files. The surveyor requested records for seven staff members, including four GNAs, and found no evidence of completed performance evaluations for the years 2022 and 2023 for these GNAs. During interviews, the Director of Nursing (DON) admitted to being behind on completing the evaluations and acknowledged the need for improvement. Additionally, a staff educator mentioned that conducting performance evaluations was not part of her primary or secondary roles. The facility was unable to provide completed performance reviews for the GNAs in question, and this issue was discussed with the administrative team during the survey exit conference.
Failure to Address Pharmacy Recommendation for PRN Lorazepam
Penalty
Summary
The facility failed to address a pharmacy recommendation in a timely manner for a resident who was prescribed PRN lorazepam. The pharmacist conducted a medication regimen review (MRR) and issued a letter to the physician on 3/8/24, highlighting the need for a stop date for the PRN psychotropic drug, as required by policy. The letter suggested a 14-day stop date or, if extended, required the prescriber to document the rationale and indicate the duration for the PRN order. However, the physician did not respond to the letter by checking any of the provided options (agree, disagree, or other), nor was there any documentation in the medical record indicating that the PRN lorazepam order was discontinued or adjusted. The deficiency was identified during a record review and interviews with facility staff. The Nurse Manager confirmed the absence of documentation regarding the discontinuation of the PRN lorazepam order, which was initially prescribed on 2/21/24. The Director of Nursing later provided documentation that the PRN lorazepam was discontinued on 5/6/24, indicating a delay in addressing the pharmacist's recommendation. This oversight affected the resident's medication management, as the necessary actions to comply with the facility's policies and procedures were not taken promptly.
Failure to Monitor Psychotropic Medication Side Effects
Penalty
Summary
The facility staff failed to monitor a resident for side effects of psychotropic medication, specifically Zyprexa, which was prescribed at different dosages over time. The medication administration record (MAR) and treatment administration record (TAR) for the resident did not contain documentation verifying that the resident was being monitored for side effects. This deficiency was identified during a survey when the records were reviewed, revealing a lack of documentation for monitoring side effects despite an existing order to do so. Interviews with facility staff, including an LPN and the Director of Nursing (DON), highlighted a gap in the monitoring process. The LPN indicated that changes in behavior would be reported and documented, but there was no evidence of such documentation in the resident's records. The DON confirmed that there should have been an order for staff to document side effects, yet the records showed no such documentation. This oversight was evident for one of the two medical records reviewed during the survey.
Medication Management and Storage Deficiencies
Penalty
Summary
The facility failed to ensure proper medication management and storage, as observed by surveyors. On one occasion, a medication cart on the Bay Lane Unit was left unattended and unlocked, with a Baclofen medication blister packet and scissors left on the work surface. This incident was acknowledged by a registered nurse who admitted to leaving the cart unlocked while searching for tube feeding supplies. Additionally, the surveyor found that expired medications and improperly stored medical supplies were present in the medication storage rooms. The temperature logs for refrigerators storing biologicals and supplements were not consistently recorded, indicating a lack of adherence to proper storage protocols. Further observations revealed multiple deficiencies in the treatment cart and medication room on Harbor View and Bay Lane. Opened and exposed medical supplies, expired medications, and biologicals were found, along with a lack of daily temperature checks for refrigerated items. Interviews with nursing staff and management confirmed these findings, with admissions that maintenance and nursing staff were responsible for checking refrigerator temperatures and ensuring supplies were up to date. The presence of expired and improperly stored items, along with the failure to maintain accurate temperature logs, highlights significant lapses in the facility's medication management practices.
Deficiencies in Documentation and Medical Order Accuracy
Penalty
Summary
The facility failed to properly document and maintain inventory sheets for residents' personal effects, as well as ensure the accuracy of medical orders. During the recertification survey, it was found that inventory sheets for two residents lacked signatures and dates, making it unclear when the inventory was conducted. Specifically, one resident reported broken dentures, but the inventory sheet did not list any dentures, and staff were uncertain about the resident's denture status upon admission. The Director of Nursing confirmed that staff are responsible for updating and documenting items on the inventory form. Additionally, the facility failed to ensure the accuracy of a medical order for wound care. A discrepancy was found between the medical order and the wound consult for a resident with a pressure ulcer. The medical order directed wound care on the right ischium, while the wound consult indicated the wound was on the left ischium. The Director of Nursing confirmed the inconsistency after reviewing the medical record with the surveyor.
Deficiency in GNA Training Documentation
Penalty
Summary
The facility failed to ensure that four geriatric nursing assistants (GNAs) received and completed the required 12 hours of clinical training annually. This deficiency was identified during a survey when the director of nursing (DON) was unable to provide documentation proving that the GNAs completed the necessary training for the years 2022 and 2023. The surveyor requested human resources and staff education records for seven employees, including four GNAs, one licensed practical nurse (LPN), and two registered nurses (RNs). However, the records provided did not include evidence of the GNAs' training completion. During an interview, the staff educator, identified as staff #9, stated that staff education was not her primary or secondary role, although she occasionally assisted with teaching and scheduling clinical in-services. She also did not conduct annual performance evaluations for the GNAs. This lack of documentation and oversight was discussed with the facility's administrative team during the survey exit conference.
Latest citations in Maryland
The facility did not ensure that its Infection Preventionist (IP) met required qualifications for managing the Infection Prevention and Control Program. The DON reported serving as the IP but acknowledged lacking the specialized infection control training required for the role, and confirmed that no other staff member was currently qualified. Records showed that the previously qualified IP left several months earlier, and the Administrator and DON confirmed they were still seeking a replacement, leaving the infection control program without a properly trained leader.
Staff failed to consistently secure medications and medical supplies across three units, including an oxygen tank left on the floor behind a resident’s bed without a supporting device, a treatment cart with Collagenase Santyl cream left on top while two residents in power wheelchairs passed by, an unattended and unlocked treatment cart at a nursing station, and another treatment cart with Diclofenac gel and dressings left on top, indicating repeated lapses in maintaining locked and secure storage for drugs, biologicals, and related supplies.
The facility failed to provide sufficient dietitian coverage and timely nutritional assessments for several residents with significant dietary needs. A resident admitted for diabetic management with a high A1C was placed on a regular diet instead of the recommended carb-controlled diet and had only one weight taken in the first two weeks, with no dietitian review of the record. Another resident with prior significant weight loss had no documented dietitian follow-up despite continued weight loss, and a resident admitted with severe protein-calorie malnutrition experienced further significant weight loss without any dietitian assessment. The dietitian reported working limited hours and prioritizing certain high-risk cases, resulting in delayed or missed evaluations for new admissions and residents with ongoing nutritional concerns.
The facility failed to maintain adequate linen and incontinence supplies and did not keep resident care areas in good repair, resulting in delays and alterations in incontinence care and substandard environmental conditions. Staff reported that towels and washcloths were used instead of wipes and then discarded due to heavy soiling, and that linen deliveries to units were late, leaving residents waiting for care. Observations showed very limited numbers of clean washcloths and other linens on units and in the laundry, with no stock of disposable wipes or backup washcloth supply despite repeated reports to housekeeping. Additional observations revealed recliner chairs blocking a dining-area handwashing sink and kitchenette, multiple resident and shared bathrooms with unfinished spackle, chipped paint, musty odors, black substances near showers, missing threshold molding, exposed cracks and nails, and eroded, rusted baseboard heaters. Hallway handrails on both units were worn, chipped, and splintered, and a shower room contained fecal odors, dried brown stains on the toilet, and deteriorated fixtures, all contributing to a failure to provide a safe, clean, and homelike environment.
Facility staff did not thoroughly investigate two separate abuse allegations involving a resident and an injury of unknown origin involving another resident. In both cases, investigations focused on the directly affected resident and included staff interviews, but there were no interviews of other residents on the unit or documented assessments of those residents for signs of abuse or injuries of unknown origin, including residents unable to communicate due to cognitive status.
Two residents who were dependent on staff for oral care, including one with a tracheostomy, were observed with thick, white or milky substances coating their mouths and teeth, indicating inadequate oral hygiene. One resident communicated that staff did not brush their teeth and that staff "need to." In another case, despite oral care supplies being present in the room, the resident’s mouth and teeth remained unclean on multiple observations, with a thick milky substance caking the teeth and stringing between them when the resident tried to open their mouth. These findings showed that staff did not consistently provide oral care to residents who relied on them for this ADL.
Staff failed to maintain complete and accurate medical records for multiple residents, including missing and inconsistent documentation of wound care, delayed pain assessment after discovery of an injury of unknown origin in a cognitively impaired resident, and inaccurate recording of a PPD test result that was documented as negative despite no evidence the injection was administered and no supporting nurse’s note. Residents reported not receiving certain treatments, while MAR entries either lacked signatures for completion or contained conflicting information about whether care was provided.
Surveyors found that the facility failed to consistently implement and communicate correct transmission-based precautions and PPE use. One resident with a Foley catheter related to wounds had no precaution signage posted, while another resident in a double room had a contact precautions sign at the door, yet the NP entered without PPE and the GNA provided high-contact care wearing only gloves. Staff in that room stated the resident was not on contact precautions and later reversed the sign to show no PPE requirement. Therapy staff reported they rely solely on posted signs to determine PPE, and surveyors identified broader issues with inaccurate signage and staff awareness of which residents required contact precautions.
Surveyors found that MDS assessments were inaccurately coded for two residents. In one case, a resident sustained a femoral neck fracture after a fall, but the subsequent significant change MDS did not code the fall as a major injury and failed to capture prn Tylenol use documented on the MAR within the look-back period. In the other case, a quarterly MDS indicated opioid use for a resident, but the MAR for the same period showed no prescribed opioid, indicating incorrect coding of high-risk drug classes.
A resident who had recently been admitted and experienced a fall received multiple doses of the narcotic analgesic Tramadol, but the facility failed to accurately document all administered doses on the Medication Administration Record (MAR). Review showed only one Tramadol dose recorded on the MAR, while the Controlled Drug Receipt/Record/Disposition Form on the med cart reflected three doses given over two days. In interview, the DON stated staff are expected to document narcotic administration on the MAR and confirmed that two administered doses were not recorded there, resulting in an incomplete and inaccurate medical record.
Unqualified Infection Preventionist Overseeing Infection Control Program
Penalty
Summary
The facility failed to ensure that its designated Infection Preventionist (IP) met the mandatory qualifications for overseeing the Infection Prevention and Control Program. During an interview on 3/24/26 at 10:00 AM, the DON confirmed that she/he was serving as the facility’s IP but had not completed the specialized training in infection control required for the position. The DON further stated that no other staff member currently met the qualifications to serve as IP. Record review showed that the previously qualified IP left the facility in October 2025, and as of the survey date, the position remained unfilled by a qualified individual. At 1:30 PM on the same day, the Administrator and DON confirmed they were still in the process of finding a qualified IP for the facility, leaving the Infection Prevention and Control Program without a properly trained and qualified leader. No specific residents, medical histories, or clinical conditions were described in relation to this deficiency.
Unsecured Medications, Treatment Carts, and Oxygen Equipment
Penalty
Summary
Facility staff failed to ensure that drugs, biologicals, and related medical supplies were securely stored and properly maintained on multiple units. On one unit, an oxygen tank assigned to a resident was observed sitting on the floor behind the resident’s bed without any supporting device. On another unit, a treatment cart was observed with a tube of Collagenase Santyl cream labeled for a specific resident left on top of the cart, while residents in power wheelchairs passed by and staff were present at the nursing station. These observations showed that medications and oxygen equipment were not consistently secured as required. Further observations on additional units revealed an unattended and unlocked treatment cart at a nursing station, and on a separate occasion, a treatment cart with Diclofenac gel labeled for a resident left on top along with multiple packs of dressings. These incidents occurred across three units and on more than one date, demonstrating repeated failures to keep medications and treatment supplies in locked compartments or otherwise secured from unauthorized access.
Insufficient Dietitian Coverage and Delayed Nutritional Assessments
Penalty
Summary
The deficiency involves the facility’s failure to employ sufficient food and nutrition staff, including adequate dietitian coverage, to ensure timely assessment and appropriate diets for residents with significant nutritional and diabetic needs. A resident admitted over two weeks earlier with multiple comorbidities and an A1C of 11.5% had a hospital discharge recommendation for a carbohydrate-controlled diet, but was placed on a regular diet at admission with no acknowledgment of the recommended diet until one week later, when the resident requested larger portions. As of the survey date, the dietitian had not yet seen or reviewed this resident’s medical record, and the resident reported not having seen a dietitian and being very frustrated with the meals. During the first two weeks after admission, only one weight was obtained for this resident, despite physician notes stating the resident’s weight was “stable.” Further review of other residents showed additional failures in timely dietitian assessment and follow-up. One resident, readmitted in January and previously seen by the dietitian in September for a 6.4 lb weight loss over 30 days, had no documented follow-up despite continued weight loss totaling 22 lbs since the last dietitian review. Another resident admitted at the end of February with severe protein-calorie malnutrition had not been seen by the dietitian after about a month in the facility, despite a documented 14 lb (7%) weight loss over two weeks. The dietitian reported working only 12 hours per week at the facility and stated that she must prioritize which residents to see, focusing first on residents with tube feedings and those identified in risk meetings, resulting in delayed or absent assessments for new admissions and residents with ongoing weight loss and malnutrition diagnoses.
Linen Shortages and Poor Environmental Maintenance Compromise Resident Care and Comfort
Penalty
Summary
The deficiency involves the facility’s failure to maintain an adequate supply of clean linens and appropriate incontinence wipes, resulting in delays and alterations in residents’ incontinence care, as well as the use of towels and washcloths in place of disposable wipes. During the initial tour, the surveyor observed that the linen supply on one nursing unit hallway was low. Complaint reviews included concerns about delays in incontinence care and bed linens not being changed regularly, with residents left without clean bedding. A complainant reported that there was not enough clean linen available for residents. Staff interviews confirmed that towels, sheets, and washcloths were being used to wipe residents for incontinence care due to the absence of wipes, and that many of these linens were being thrown away when soiled. Staff also reported a shortage of linen, that linen deliveries to the units were late, and that residents who preferred to get up before breakfast had to wait for care when linen was delayed. Further observations showed that the clean supply room contained no disposable wipes or cloths for incontinence care, and a resident reported that staff did not use wipes, that the resident had to purchase their own, and that heavily soiled towels or washcloths were discarded. A tour of all nursing unit linen carts and closets revealed only six clean washcloths and limited supplies of towels, gowns, and bed linens. In the laundry room, only three washcloths were present, and the laundry assistant stated that there were only three washcloths available for each nursing unit that morning, that the facility was short on linen supply, and that these concerns had been repeatedly reported to the Director of Housekeeping over the preceding month and again that morning. The laundry assistant confirmed there was no additional laundry in process. The DON stated that wipe squares should be used for incontinence care, but no such wipes were found in the clean medical supply room, and no backup supply of washcloths was present in the emergency linen supply. The Director of Housekeeping confirmed there was no backup supply of washcloths. The deficiency also includes environmental and maintenance issues affecting resident bathrooms, handrails, and common areas. In the main dining area, a recliner chair was observed positioned directly in front of the handwashing sink, and two recliner chairs were stored in front of the nutrition area kitchenette. Multiple resident bathrooms and shared bathrooms were repeatedly observed over several days with unfinished spackle on walls that needed resurfacing and painting, chipped paint around sinks, uneven boards nailed to walls under sinks that appeared to partially cover holes, musty odors, black substances between shower bases and walls, missing threshold transition molding exposing cracks, missing tiles, and a nail, as well as eroded and chipped paint on baseboard heaters with exposed dark brown metal and rust-like material. Hallway handrails on both nursing units were observed to be worn, with chips, splintering, holes, and areas where the wood finish had worn off. A shower room was observed with a foul fecal odor, dried brown stains on the back of the toilet seat and in the toilet bowl, and a baseboard heater with eroded, chipped paint and rust-like material, along with chipped paint on the handrail. These conditions were acknowledged by the Director of Maintenance and other leadership, and some areas were noted to be in the process of renovation, but the observed deficiencies remained present during the survey period. Overall, the facility did not maintain a safe, clean, comfortable, and homelike environment in good repair across both nursing units and the dining area. The lack of adequate linen and incontinence supplies, combined with the poor condition of resident bathrooms, handrails, and certain common areas, constituted the basis for the cited deficiency. The observations and staff and resident reports consistently described shortages of essential hygiene supplies, delayed care related to linen availability, and multiple unresolved environmental and maintenance issues in resident care areas and shared spaces.
Failure to Thoroughly Investigate Abuse Allegations and Injuries of Unknown Origin
Penalty
Summary
Facility staff failed to thoroughly investigate allegations of potential abuse involving one resident and an injury of unknown origin involving another resident. For one resident, there were two separate allegations of abuse occurring on different days in early February. The facility’s investigation packets included interviews with staff who cared for or were scheduled to work with this resident on the days of the alleged incidents, and the investigations focused solely on this resident. However, there were no interviews conducted with other residents on the unit to inquire about abusive or neglectful treatment by the staff who were working during the times of the allegations. The surveyors noted that, although the allegations were not validated, there was no documentation that other residents were interviewed, if able, or assessed for signs or symptoms of injury. In a separate incident, another resident was identified on March 4 with a new bruise on the right eye, documented as a change in condition at 4:09 AM. This resident had a BIMS score of 99, indicating the resident was unable to complete an interview and therefore could not report how the injury occurred. The facility’s investigation identified a potential cause of the injury but did not reach a definitive resolution. Additionally, there were no interviews of other residents on the unit regarding possible abuse, nor were there documented assessments of other residents for injuries of unknown origin, particularly for those unable to speak for themselves, as in this resident’s case.
Failure to Provide Oral Care to Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide oral care to residents who were dependent on staff for activities of daily living, specifically oral hygiene. One resident with a tracheostomy was observed with a thick, sticky white substance in the mouth and was noted to intermittently chew on nearby bedding. This resident made good eye contact and, when asked if staff brushed their teeth, shook their head no and mouthed that staff “need to.” According to the resident’s Minimum Data Set (MDS) dated 2/11/26, the resident was dependent on staff for oral care. Another resident, also dependent on staff for oral care per the 3/11/26 MDS, was observed sitting propped up in bed and able to respond with smiles. During the initial observation, the inside of this resident’s lips and upper and lower teeth had a thick, clear, white milky substance visible when the resident tried to open their mouth to smile. Oral care supplies were present in the nightstand, but the resident’s mouth and teeth were not clean. On a subsequent observation with the DON, NHA, and Corporate VP of clinical services, the same resident again had a thick, clear, milky substance between the lips and caking the teeth, which would string between the teeth when the resident attempted to open their mouth, demonstrating a lack of consistent oral care for residents dependent on staff for this ADL.
Incomplete and Inaccurate Medical Record Documentation for Treatments and Assessments
Penalty
Summary
Facility staff failed to maintain complete and accurate medical records and documentation for multiple residents. For one resident with wound care needs, review of the MAR showed that wound care and related treatments were signed as completed on the dates initially reported, despite the resident’s ongoing complaints that wound dressings were not being changed. When additional dates were reviewed, there were missing staff signatures for wound care on two specific dates, as well as three instances where application of A&D ointment to the resident’s feet was not signed off out of 24 days reviewed. Another resident with severe cognitive impairment, as evidenced by a BIMS score of 00, was found to have an injury of unknown origin (a bruise on the left hand). Documentation showed that a change in condition was initiated late in the morning, but a formal pain evaluation was not initiated and completed until that night, and the resident was unable to explain how the injury occurred or verbalize pain using a standard pain scale. For a third resident, documentation related to the admission PPD test was inconsistent and incomplete. The MAR contained an entry indicating “9” for the administration date, meaning “see nurse’s note,” but there was no corresponding nurse’s note. Despite the absence of a signed administration of the PPD injection, staff documented the PPD result as “negative” on the scheduled read date. The resident reported never receiving the PPD injection, and the DON confirmed that the facility had been out of PPD solution at the time, so the test would not have been administered. These findings demonstrate failures in accurate documentation of treatments and assessments, including wound care, pain assessment, and TB screening, as well as missing or incomplete supporting notes in the medical record.
Failure to Implement and Communicate Correct Transmission-Based Precautions
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to inconsistent and incorrect implementation of transmission-based precautions and PPE use. During a complaint investigation focused on residents on transmission-based precautions, one resident with a visible Foley catheter was observed in the room with physical therapy, but there were no signs posted indicating any need for PPE, despite the resident being a new admission with a Foley catheter placed related to wounds. In another double-occupancy room, a contact precautions sign was posted at the doorway, but the nurse practitioner was in the room on a personal phone with no PPE, and the assigned GNA was repositioning the resident in bed while wearing only gloves. When questioned, the NP, RN, and GNA all stated that the resident in the room was not on contact precautions, and the GNA reported that signs were hanging at all doors and that this particular resident’s sign was “just wrong.” The surveyor observed the GNA later return to the room and turn the sign around to indicate no PPE requirement. Subsequent interviews revealed that therapy staff relied on posted signage to determine PPE use and that if the sign was wrong, the PPE used would be wrong. Overall, surveyors found problems with signage accuracy and staff awareness of which residents required contact precautions, as well as observed failures to follow appropriate PPE use for residents who should have been on contact precautions.
Inaccurate MDS Coding for Falls, Pain Management, and High-Risk Medications
Penalty
Summary
Facility staff failed to ensure Minimum Data Set (MDS) assessments were accurately coded for two residents reviewed during a complaint survey. For one resident, a facility-reported incident showed that the resident was found seated on the floor beside the bed and was diagnosed with a non-displaced femoral neck impaction fracture of the left hip following an x-ray. Despite this fall with a major injury, the subsequent significant change MDS dated 11/4/25 did not code the fall with major injury in Section J1900C. Review of the resident’s Medication Administration Records for October and November 2025 showed administration of Tylenol on 10/31/25 at 9:30 PM, which fell within the 5-day look-back period for the MDS, but Section J0100 (prn pain) of the same significant change MDS did not capture the use of Tylenol. For another resident, review of a quarterly MDS with an assessment reference date of 10/15/25 showed that Section N0415 (High-Risk Drug Classes) documented the use of an opioid medication. However, review of the resident’s October 2025 Medication Administration Record did not show that the resident had been prescribed an opioid during that period. In both cases, MDS staff later confirmed that these were errors in MDS coding, demonstrating that the assessments did not accurately reflect the residents’ clinical status and medication use as documented in their medical records.
Incomplete Documentation of Narcotic Administration on MAR
Penalty
Summary
The facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for one resident receiving narcotic medication. The resident, admitted in March 2026, had a fall on 3/6/26 and was sent to the hospital on 3/9/26. Review of the March 2026 Medication Administration Record (MAR) showed documentation of a single 25 mg dose of Tramadol administered on 3/8/26 at 9:23 AM. However, review of the resident’s Controlled Drug Receipt/Record/Disposition Form, kept on the nurse’s medication cart and not in the medical record, showed that Tramadol 25 mg was administered three times between 3/8/26 and 3/9/26: at 11:00 AM and 9:00 PM on 3/8/26, and at 9:00 AM on 3/9/26. In interview, the DON stated that staff are expected to document narcotic administration on the MAR and confirmed that only one of the three Tramadol doses reflected on the controlled drug record was documented on the resident’s MAR. This discrepancy between the controlled substance record and the MAR, with missing documentation of two administered doses of Tramadol on the official medical record, constituted the failure to maintain a complete and accurate medical record for the resident.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
