Below average — CMS composite of the measures below.
The next survey window likely opens around November 2026
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 Memorial Healthcare Facility during CMS and state inspections, most recent first.
A resident with a history of intracerebral hemorrhage and anxiety, care planned to receive calm, reassuring communication, approached an NP at the nurses' station with concerns about blood pressure medication. During this interaction, the resident and NP engaged in a heated argument, with both raising their voices, and multiple staff heard loud yelling. A CMT observed the NP yelling at the resident while a nurse and charge nurse at the desk did not intervene, despite facility policy requiring respect and dignity for residents. The SSD, DON, and other staff confirmed that the NP became loud and matched the resident's tone, and the resident later reported feeling that the NP was not listening or understanding their concerns.
A resident with cerebral palsy, COPD, and upper-extremity impairment was burned when hot soup was served without a temperature check and while the resident was in bed rather than in an appropriate upright position. A DCT delivered the tray, asked twice if a CNA should help the resident sit up, then handed over the soup; the bowl slipped and spilled onto the resident’s shoulder, arm, and neck, causing redness and a blistered burn. Kitchen observation also showed soup being microwaved and placed in a warmer without being temped, and a later bowl measured 183.4 degrees F.
Surveyors found repeated food storage and preparation failures, including salad, cottage cheese, raw hamburger, tomatoes, and prepared ice cream containers that were not labeled or dated, along with food kept past the use-by date in the cooks fridge and freezer. Staff gave inconsistent answers about who was responsible for dating food and discarding expired items. Surveyors also observed two dietary staff with facial hair not wearing beard nets, including one staff member seen multiple times wearing only a surgical mask.
Food Served at Improper Temperatures: Surveyors found that kitchen staff did not consistently check or maintain food temperatures before and during serve out. Observations showed soup placed in a warmer without temping and plated items served below hot-holding temperatures, while multiple residents reported receiving cold meals in the dining room or in their rooms. Staff gave inconsistent accounts of who was responsible for temping food, and the DON was unaware of the complaints.
Staff failed to follow infection control practices during resident care, including EBP and hand hygiene. For a resident with a Foley catheter, CNAs did not wear gowns and used the same gloved hands for catheter-related contact, brief care, turning, and peri care without hand hygiene. For another resident, a CNA performed perineal care, then dressed the resident and handled oxygen and transfer equipment without removing gloves or washing hands. During wound care for a resident with pressure ulcers, an RN changed gloves twice without hand hygiene.
Incomplete Skin and Wound Assessments for Residents With Pressure Injuries: The facility failed to complete and document required weekly skin and wound assessments for two residents with pressure injuries. One resident developed a DTI and stage 1 ankle injuries related to an air cast, but weekly skin and wound documentation stopped for weeks. Another resident had stage III pressure injuries to both heels and the sacrum, yet assessments were missing, incomplete, and not documented as required. Interviews with the DON, RN, LPN, physician, and Administrator confirmed that weekly assessments were expected but were missed after the wound nurse left.
A resident with urinary symptoms had a UA and culture showing significant growth, but staff did not document physician notification or timely antibiotic treatment, and the resident reported burning and pain while waiting for treatment. Another resident with an indwelling catheter had repeated observations of the catheter bag touching the floor and urine remaining in the tubing, with the tubing routed improperly and the bag placed on the bed or under a wheelchair.
Pain Assessment, Documentation, and Care Plan Failures: A resident with chronic left hip pain, low back pain, and arthritis had repeated pain screenings documented as no pain, while the resident reported daily pain that limited getting out of bed and sitting up. Staff did not accurately document pain levels, did not document follow-up after a change in pain medication that led to PRN tramadol, and did not update the pain care plan to include the new medication or resident-specific pain interventions.
Failure to Coordinate Dialysis Care, Site Monitoring, and Timely Meals: A resident with ESRD who received dialysis three times weekly did not have an order for dialysis or dialysis site assessment, lacked documented monitoring of the dialysis site, and had no documented dialysis communication forms returned from the dialysis center. Staff also failed to provide a timely lunch before dialysis appointments, and interviews showed the resident often received the meal only when the van was ready rather than before leaving for treatment.
The facility exceeded the allowed medication error rate when an LPN made two insulin administration errors during observed med passes. For one resident with diabetes, the LPN misread the insulin orders, gave 13 units instead of the ordered 10 units, and did not prime the Novolog FlexPen. For another resident with diabetes, the LPN administered 16 units of Novolog without priming the pen. The DON and physician stated staff were expected to follow the insulin orders and prime the pen before use.
Insulin Dosing and Priming Errors: An LPN administered the wrong insulin dose to one resident after misreading the order and gave 13 units instead of the ordered 10 units, while also failing to prime the Novolog FlexPen. The same LPN also failed to prime the pen before giving insulin to another resident. Both residents had diabetes and were receiving Novolog, and the DON and physician stated staff were expected to follow the order, prime the pen, and give the correct dose.
Staff failed to provide proper pressure ulcer care and prevention for two residents, including not addressing a resident's need for an appropriately sized bed, delaying follow-up with a physician regarding a wound culture, and not performing proper hand hygiene during wound care. These actions led to worsening wounds, infection, and inadequate infection control practices.
Surveyors found that appropriate care was not consistently provided for residents who were continent or incontinent of bowel and bladder, including improper catheter care and insufficient measures to prevent UTIs. These deficiencies were observed during the survey and were linked to failures in following established protocols.
The facility failed to accurately document and administer narcotic pain medications for two residents, leading to a deficiency in pharmaceutical services. A resident reported not receiving pain medications during the night as documented by an LPN, while another resident's medication administration did not align with physician's orders. Staff interviews revealed a lack of adherence to medication administration policies, and the DON and Administrator acknowledged the errors.
NP Engages in Loud, Disrespectful Argument With Resident Over Medication
Penalty
Summary
The deficiency involves a failure to ensure a resident was treated with dignity and respect when a Nurse Practitioner (NP) engaged in a loud, disrespectful interaction with the resident at the nurses' station. The facility's policy on Patient Rights and Responsibilities, last revised in November 2026, states that personnel will be oriented and instructed in observing patient rights, including the right to dignity and respect and to be treated with consideration, recognizing each resident's individuality. Resident #1, admitted on 05/21/20 with a diagnosis including nontraumatic intracerebral hemorrhage and anxiety, had a care plan directing staff to allow ample time to absorb and respond to information, provide a calm therapeutic environment, and use a calm, reassuring approach with explanations and reassurance. According to the resident, during an encounter a few months prior, the resident was upset about blood pressure medication and went to the nurses' desk to speak with the NP. The resident reported that he/she and the NP "got into it" and yelled at each other. CMT B, who was in the medication room next to the nurses' desk, heard yelling, looked out, and observed the resident and NP in a heated argument about the resident's medication, with both the NP and the resident yelling. CMT B stated that staff should not yell or raise their voice to residents and noted that a nurse and a charge nurse were present at the desk during the yelling and did not attempt to intervene. CMT C reported hearing loudness from the area and later being told that the NP and resident had been loud with each other. The Social Services Director (SSD) and the Director of Nursing (DON) both described hearing loud voices and observing or being informed that the NP and resident were loud with each other. The SSD stated the resident later reported feeling that the NP was not listening or understanding what the resident was trying to say. The DON reported hearing loud voices from her office, exiting to find the resident yelling at the NP, and observing the NP at the nurses' station facing the nurse on duty while they appeared to disagree over an order requested by the resident. The DON and other staff, including CNAs and RNs, indicated that staff yelling at residents is inappropriate and not respectful or dignified. The Director of Clinical and the Administrator both reported being informed that the NP had become loud with the resident and that the NP had matched the resident's tone during the interaction.
Hot Soup Served Without Temperature Check and Resident Not Properly Positioned
Penalty
Summary
The facility failed to maintain an environment as free of accident hazards as possible when staff served hot soup to a resident without checking its temperature and without ensuring the resident was in an appropriate upright position before meal service. Resident #44 had cerebral palsy, COPD, and insomnia, was cognitively intact, had impairment on both sides of the upper extremities, required set-up/clean-up assistance with eating, and used an electric wheelchair. The resident’s care plan indicated the resident could feed himself/herself with assistance for set-up and clean-up. On the day of the incident, a DCT delivered the resident’s dinner tray with hot soup while the resident was in bed. The DCT asked twice whether a CNA should assist the resident to sit up, but the resident declined and asked for the soup. The DCT handed the resident the bowl of soup and reached for a spoon, at which point the soup slipped and spilled onto the resident’s left shoulder, arm, and neck area. The resident reported that he/she was sitting up in bed when the tray arrived, picked up the bowl with the right hand, and was trying to get a better hold with the left hand when the soup spilled. Staff later documented that the resident had a reddened area and a blister on the left shoulder, and the resident described a sore and bandage on the left shoulder during observation. The medical record and staff interviews showed the burn was treated as a partial thickness burn. The nurse documented that hot soup had spilled over the resident’s left shoulder extending down the upper arm to the elbow, with a blister forming where most of the soup landed. The DCT stated he/she was not trained to obtain temperatures on food. Observation of kitchen preparation showed soup being microwaved and placed in a warmer without temperature checks, and later a bowl of soup was observed at 183.4 degrees F after being carried from the kitchen. Staff interviews indicated cooks were expected to check temperatures of food heated in the microwave before serving, but this was not done before the soup was served to the resident.
Food Storage and Beard Net Compliance Failures
Penalty
Summary
The facility failed to store and prepare food in accordance with professional standards of practice and to protect food from possible contamination. Observations showed multiple food items in the refrigerator and freezer that were not labeled or dated, including salad, cottage cheese, raw hamburger, sliced tomatoes, and prepared ice cream containers. Several prepared food items were also found with a made date of 12/14/25 and a use-by date of 12/17/25, yet they remained in the freezer on 12/19/25. The facility policies required opened products and prepared foods to be covered, labeled, dated, and kept no more than three days, and staff interviews showed inconsistent understanding about who was responsible for dating food and discarding food past the use-by date. The report also documented that food was not consistently discarded after the use-by date. In the cooks fridge and salad bar/resident freezer, surveyors repeatedly observed unlabeled and undated food items over several days, including containers of salad, cottage cheese, and raw hamburger. In the cooks freezer, multiple 8-ounce containers of ice cream remained stored beyond the use-by date, and four containers with an orange substance were labeled with a name but had no date. Staff interviews indicated that some employees believed the person preparing the food was responsible for dating it, while others stated all staff were responsible for labeling and removing expired food. The facility also failed to follow hygiene practices related to facial hair. The Nutritional Services policy stated that beards and goatees were not permitted and that daily shaving was required, while the FDA Food Code required beard restraints when facial hair was present. Surveyors observed two dietary staff with facial hair not wearing beard nets, and one staff member was observed multiple times wearing a black surgical mask without a beard net. Interviews confirmed that staff and leadership expected beard nets or other facial hair controls to be used in the kitchen, but the observed practice did not match those expectations.
Food Served at Improper Temperatures
Penalty
Summary
The facility failed to ensure food was served at a palatable temperature and did not have a process in place to make sure food was consistently held and served at the proper temperature. The facility policy required hot foods to be held at 140 degrees Fahrenheit or above and food service personnel to use thermometers to monitor food temperatures, but survey observations showed that soup was placed in a warmer without the temperature being checked and that plated foods on the steam table were served at temperatures below the expected hot-holding range, including French fries at 114 degrees Fahrenheit and cooked carrots at 130 degrees Fahrenheit. Multiple cognitively intact residents and residents with moderate cognitive impairment reported receiving cold food, including breakfast items, meals served in the dining room, and meals delivered to rooms. One resident said food was cold in the room, another said a waffle was cold, another said food was cold in the dining room, and another said staff had to reheat food because it was cold when served. Staff interviews showed inconsistent practices: one dietary aide said cooks were responsible for checking temperatures, another said cold food should be replaced with a fresh tray, and the dietary director stated cooks were responsible for temping food after preparation, before serving, and during serve out, while also stating they were unaware of the complaints.
Infection Control Failures During Personal Care and Wound Care
Penalty
Summary
The facility failed to establish and maintain a complete infection control program when staff did not follow Enhanced Barrier Precautions and hand hygiene requirements during resident care. The report states that the facility policy required gown and glove use during high-contact care for residents with indwelling medical devices or wounds, and required hand hygiene before and after resident contact, after glove removal, and when moving between contaminated and clean tasks. The facility census was 95. For one resident with a Foley catheter, the care plan directed staff to use EBP. During observed personal care, two CNAs entered the room, washed their hands, and donned gloves, but did not don gowns. One CNA touched the Foley catheter bag with a gloved hand, placed it on the bed, and then used the same hand to touch the resident while turning him/her. The CNAs then removed a soiled brief, touched the resident’s hair with gloved hands without hand hygiene, cleaned the peri area with the same gloves, and exited the room after collecting trash without performing hand hygiene. Staff interviews confirmed they knew residents with Foley catheters were on EBP and that gowns and gloves were expected, but they forgot to wear gowns during the care. For another resident, who was severely cognitively impaired, dependent for toileting and personal hygiene, and incontinent of bowel and bladder, a CNA removed the damp brief, performed perineal care, and then, without removing gloves or performing hand hygiene, retrieved pants from the closet, dressed the resident, turned off the oxygen concentrator, applied a gait belt, and assisted the resident to transfer. The CNA later acknowledged not washing hands and reapplying gloves after perineal care. During wound care for a third resident with pressure ulcers and ordered daily dressing changes, the RN and LPN washed hands and donned gowns and gloves, but the RN doffed gloves and donned new gloves twice without completing hand hygiene during the glove changes. The RN stated he/she forgot to wash hands when changing gloves.
Incomplete Skin and Wound Assessments for Residents With Pressure Injuries
Penalty
Summary
The facility failed to provide care per standards of practice when weekly skin assessments and wound assessments were not completed and documented for residents with pressure injuries. The report identified two residents with pressure ulcers and documented that staff did not consistently complete the required assessments, did not document wound measurements and descriptions as required, and did not maintain the weekly skin and wound assessment records over extended periods. One resident was admitted with a right tibia fracture and later developed a deep tissue injury to the right lateral ankle and a stage 1 pressure injury to the right medial ankle related to an air cast. Nursing documentation showed the new skin concerns were identified and treatment orders were started, and wound assessments were recorded on 10/09/25, 10/15/25, and 10/23/25. After that, the record showed no nursing notes related to the wounds from 10/10/25 through 12/15/25, no wound assessments from 10/23/25 through 12/15/25, and no weekly skin assessments from 11/06/25 through 12/15/25. A later wound assessment documented the right lateral ankle pressure injury and a new stage 2 pressure injury to the left heel. The second resident was admitted with limited mobility and was at risk for impaired skin integrity. Physician orders were in place for treatment of pressure injuries to the sacrum and both heels, and nursing notes documented family education about the wounds. Weekly skin assessments and wound assessments were incomplete, with missing descriptions and sizes for some areas, and the record showed no wound assessment completion on 11/05/25. The DON stated staff did not complete weekly skin assessments from 11/05/25 through 12/16/25, did not complete a wound assessment on 11/05/25, and there were no wound assessments from 10/27/25 through 12/16/25. Interviews with nursing staff and leadership confirmed that charge nurses were expected to complete weekly skin and wound assessments, but assessments were missed after the wound nurse left.
Failure to Treat Suspected UTI and Maintain Proper Catheter Care
Penalty
Summary
Staff failed to ensure appropriate treatment and services were provided for a resident with urinary symptoms and suspected UTI. The resident had a history of occasional urinary incontinence, limited mobility, and was assessed as cognitively intact with partial to moderate assistance needed for toileting and bathing. An infection screening assessment documented acute mental status change, functional decline in hygiene and toilet use, general illness, and urinary pain/frequency, with criteria met for further evaluation. A UA and urine culture were obtained, and the culture later showed greater than 100,000 CFU/mL of both Escherichia coli and Klebsiella pneumoniae. The medical record did not show notification of the physician regarding the urine culture results. A nurse later documented that the resident continued to have tenderness in the lower abdomen and peri area when voiding, tenderness with palpation, and tenderness in the kidney area, and passed this information to the night nurse for continued monitoring and physician notification. The DON reviewed the results and stated the resident had a UTI and should have had documentation of provider notification and an antibiotic order, but no provider message, progress note, or antibiotic was found in the record at that time. The resident stated he/she had burning with urination a couple weeks earlier and said it took two weeks to get an antibiotic, during which time he/she had pain and discomfort. Staff also failed to provide proper catheter care for a resident with an indwelling urinary catheter related to neurogenic bladder and urinary retention. The resident had diagnoses including renal failure and neurogenic bladder, and was dependent on staff for toileting. Observations showed the catheter bag touching the floor under the wheelchair and beside the bed, urine remaining in the tubing, and the tubing routed over an incontinence brief with a loose anchor device on the abdomen. At another observation, staff transferred the resident and placed the catheter bag on the bed, then later attached the bag under the wheelchair where it again touched the floor. The DON, physician, and Administrator all stated the catheter bag should not touch the floor.
Pain Assessment, Documentation, and Care Plan Failures
Penalty
Summary
The facility failed to ensure an effective pain management system was in place for one resident with chronic pain. Resident #80 had diagnoses including diabetes and pneumonia, and the record showed chronic pain concerns related to left hip pain, low back pain, and arthritis involving multiple joints. The resident’s physician orders included scheduled baclofen, Tylenol, gabapentin, and duloxetine, and the care plan identified a potential for pain with weekly pain assessments and a pain plan review every 90 days. The record showed staff did not accurately document the resident’s pain. Multiple pain assessment interviews dated in November and December documented that the resident had no pain in the last five days, rarely or not at all experienced pain, and rarely or not at all had trouble sleeping or limitations in daily activities because of pain. However, during interviews the resident stated he/she had daily left hip pain ranging from 2 to 5 on a 1 to 10 scale, said the pain made it difficult to get out of bed and stay up in a chair, and reported telling nursing staff about the pain without feeling that it was taken seriously. Staff interviews also indicated that CNAs and CMTs were expected to report pain to the nurse, and the nurse was expected to assess pain and administer medication if needed. The facility also failed to document follow-up after a change in pain medication and failed to update the care plan to reflect the resident’s pain concerns. After the DON contacted the resident’s sister about pain control concerns, the pharmacist recommended tramadol and the physician was contacted, but the nurses’ notes did not include other documentation related to the resident’s chronic pain. The care plan was not updated to reflect the pain concerns or the request for new medication, and the current pain plan did not include the PRN tramadol order. The DON, MDS Coordinator, physician, and Administrator all stated they expected pain to be assessed, reassessed after interventions, documented, and reflected in an individualized care plan with resident-specific goals and interventions.
Failure to Coordinate Dialysis Care, Site Monitoring, and Timely Meals
Penalty
Summary
The facility failed to provide dialysis services per professional standards of practice for a resident with ESRD who received dialysis every Monday, Wednesday, and Friday. The resident’s record showed diagnoses including anemia, heart failure, and hypertension, and the MDS indicated moderately impaired cognitive skills and that the resident received dialysis. The care plan addressed transportation to dialysis and dressing changes at the dialysis center, but it did not include communication forms to and from the dialysis center, monitoring of the dialysis site, or meal provisions on dialysis days. The physician order sheet did not contain an order for dialysis or for assessment of the dialysis site. The medical record also lacked documentation of dialysis communication forms from the dialysis center since 11/01/25, and staff did not document follow-up contact with the dialysis center after each dialysis visit. During interviews, staff stated the resident had a dialysis packet, that the dialysis center changed the dressing at appointments, and that nurses should check the dialysis site for discoloration, drainage, discomfort, infection, pain, or swelling, but these assessments were not documented. The DON stated there was no order for staff to monitor the dialysis site and no order for dialysis treatments, while the MDS/Care Plan Coordinator stated the communication forms inform staff how the resident did at the appointment and that none of the forms were uploaded in the computer. The facility also failed to provide the resident a timely lunch meal before dialysis appointments. The resident stated staff did not deliver lunch in time before the appointment and that the meal arrived when the van was ready, while the resident wanted food before dialysis so the procedure would not make him/her sick. Staff interviews confirmed the resident required an early meal on dialysis days, with kitchen staff stating lunch should be delivered no later than 11:30 A.M. and the Dietary Director stating the resident needed the tray by 11:00 A.M. on Monday, Wednesday, and Friday. The DON and Administrator both stated staff were expected to communicate with dietary staff to provide an early lunch tray before scheduled dialysis appointments.
Insulin Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to maintain a medication administration error rate of less than 5% when two medication errors were identified out of 26 opportunities, resulting in a 7.69% error rate. The deficiency involved insulin administration for two residents with diabetes mellitus, both of whom had active orders for Novolog FlexPen. Facility policy defined medication errors to include wrong dose and omission of ordered medication, and the facility did not provide a policy for sliding scale insulin or priming insulin pens. For one resident, the physician's orders included Novolog FlexPen 10 units subcutaneously three times a day with meals and a separate order to see protocol for insulin before meals and at bedtime. During observation, an LPN reviewed the insulin orders on the computer, noted two insulin orders for the noon dose, checked the resident's blood sugar at 130 mg/dL, dialed up 13 units of Novolog, did not prime the pen, and administered the insulin. The LPN later stated the order was read incorrectly and that the sliding scale level for a blood sugar of 130 mg/dL would not have required extra units. The progress note documented that staff administered 13 units per sliding scale insulin and scheduled insulin, although the resident was only to receive 10 units scheduled insulin and no SSI. For the second resident, the physician's order was for Novolog FlexPen 16 units subcutaneously three times a day with meals. During observation, the same LPN dialed up 16 units, did not prime the pen, and administered the insulin. The LPN later stated the pen was not primed by wasting two to three units before administration. The DON stated staff were to read and follow the physician's order, prime the insulin flex pen before administration, and double check orders when additional insulin was ordered per sliding scale. The physician stated staff were expected to prime the insulin pen prior to use and administer the correct amount of insulin.
Insulin Dosing and Priming Errors
Penalty
Summary
The facility failed to ensure residents were free from significant medication errors when insulin was administered incorrectly and insulin pens were not primed before use. The report states the facility did not provide a policy for sliding scale insulin that was not included in physician orders, and it also did not provide a policy regarding priming insulin pens. The manufacturer instructions for the Novolog FlexPen required priming before administration by dialing to two units and confirming a drop of insulin at the needle tip. Resident #42 had diabetes mellitus and was receiving insulin. The resident’s orders included Novolog FlexPen with a note to see protocol and an order for 10 units subcutaneously three times a day with meals. During observation, an LPN reviewed the insulin orders on the computer, noted two insulin orders for the noon dose, checked the resident’s blood sugar at 130 mg/dL, dialed up 13 units of Novolog, did not prime the pen, and administered the insulin in the resident’s abdomen. The LPN later stated the orders were read incorrectly and that the sliding scale level for a blood sugar of 130 mg/dL would not have required extra units. The progress note documented that staff administered 13 units per sliding scale insulin and the scheduled insulin, when the resident was only to receive 10 units scheduled and no SSI. Resident #72 also had diabetes mellitus and was receiving Novolog FlexPen 16 units subcutaneously three times a day with meals. During observation, the same LPN dialed up 16 units, did not prime the pen, and administered the insulin in the resident’s right arm. The LPN later stated the pen was not primed by wasting two to three units before administration. The DON stated nurses were to read and follow the physician’s order, prime the insulin flex pen before use, and double check orders when additional sliding scale insulin was to be given. The physician stated staff were expected to prime the insulin pen prior to use and administer the correct amount of insulin.
Failure to Provide Proper Pressure Ulcer Care and Infection Control
Penalty
Summary
Facility staff failed to provide appropriate care and prevention for pressure ulcers, resulting in deficiencies in both the management of existing wounds and the prevention of new ulcers. For one resident with a history of peripheral vascular disease, diabetes, and prior toe amputation, staff did not adequately address the need for an appropriately sized bed, despite repeated reports from the resident, CNAs, and therapy staff that the resident was too tall for the bed and frequently slid down, causing the toes to press against the foot board. Multiple interventions, such as wedges and heel protectors, were attempted but were ineffective, and documentation shows that the resident's need for a longer bed was not addressed in a timely manner. The resident developed a pressure ulcer on the right great toe, which worsened over time and eventually became infected with MRSA, leading to hospitalization and amputation. Additionally, staff failed to follow up with the physician in a timely manner regarding a wound culture for the same resident. After a wound culture was obtained due to signs of infection and stalled healing, preliminary results indicating a staph infection were available, but there was a delay in notifying the physician and initiating appropriate antibiotic therapy. Documentation gaps were noted, including missing records of daily dressing changes and unclear communication between nursing staff and the nurse practitioner regarding the wound culture results and subsequent care. For another resident with a history of chronic pressure ulcers and osteomyelitis, staff failed to utilize appropriate hand hygiene prior to and during pressure ulcer wound care. Facility policy requires hand hygiene before and after patient contact, before donning gloves, and after glove removal, but observations revealed that these protocols were not consistently followed. This lapse in infection control practices further contributed to the facility's failure to provide care in accordance with professional standards and facility policy.
Deficient Bowel/Bladder and Catheter Care Leading to UTI Risk
Penalty
Summary
The report identifies a deficiency related to the provision of care for residents who are continent or incontinent of bowel and bladder, as well as the management of catheter care and the prevention of urinary tract infections (UTIs). Surveyors found that appropriate care was not consistently provided to residents in these areas. Specific failures included inadequate attention to the needs of residents with continence or incontinence issues, improper catheter care, and insufficient measures to prevent UTIs. These lapses were observed during the survey and were directly related to the facility's failure to follow established protocols for continence care, catheter management, and infection prevention.
Inaccurate Documentation and Administration of Narcotic Pain Medications
Penalty
Summary
The facility failed to ensure the accurate administration and documentation of narcotic pain medications for two residents, leading to a deficiency in pharmaceutical services. Resident #1, who was cognitively intact and had a history of chronic pain, reported not receiving pain medications during the night as documented by LPN A. Despite the resident's statement that they had not requested or received pain medication during the night, LPN A documented the administration of oxycodone on multiple occasions. This discrepancy was noted by other staff members, who reported the issue to the Director of Nursing (DON), but the medication pass was deemed normal by the DON. Resident #2, who had moderate cognitive impairment and a history of chronic pain, was documented by LPN A as receiving hydrocodone at times that did not align with the physician's orders. The resident's MAR and Controlled Drug Record showed inconsistencies in the timing of medication administration, with doses given more frequently than prescribed. LPN A admitted to preparing medications in advance and sometimes forgetting to adjust the administration time, leading to further discrepancies in documentation. Interviews with various staff members, including CMTs and RNs, revealed a lack of adherence to the facility's medication administration policy, which requires verification of the right patient, medication, dose, time, and route. The DON and Administrator acknowledged the documentation errors and the failure to administer medications as prescribed. The Director of Pharmacy Services confirmed that PRN pain medication orders should not be liberalized, emphasizing the need for strict adherence to physician's orders.
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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 Bolivar
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Parkview Health Care Facility | 0.7 mi | ★★★★★ | 0 | 0 |
| Big Spring Care Center For Rehab And Healthcare | 14.7 mi | ★★★★★ | 3 | 0 |
| Northwood Hills Care Center | 15.5 mi | ★★★★★ | 0 | 0 |
| Colonial Springs Healthcare Center | 17.9 mi | ★★★★★ | 7 | 0 |
| Buffalo Prairie Center For Rehab And Healthcare | 18 mi | ★★★★★ | 17 | 1 |
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