Above average — CMS composite of the measures below.
A standard survey is most likely before around December 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 Litzenberg Memorial County Hospital during CMS and state inspections, most recent first.
Infection Control Failures During Wound and Catheter Care: An LPN and NAs failed to follow hand hygiene, glove change, and gown use requirements during wound care and catheter care for residents with chronic wounds and indwelling catheters. Observations showed the same gloves were used throughout wound care, contaminated gloves were used to access wipes and continue catheter care, and clean gloves were not applied before cleaning the meatus and catheter tubing. The DON confirmed the expected practices were not followed.
The facility failed to review pre-employment health screens for two staff members, maintain cleanliness in the tub and shower room, and implement Enhanced Barrier Precautions for a resident post-surgery. Staff also did not apply PPE correctly, perform hand hygiene between glove changes, or follow proper catheter care procedures, affecting resident care. Additionally, oxygen tubing was not changed as required.
The facility failed to document the provision of a baseline care plan summary to residents or their representatives within 48 hours of admission. Two residents' records lacked documentation of care plan discussions, and one newly admitted resident was not placed on required Enhanced Barrier Precautions following surgery. The facility's policy did not clearly mandate documentation of care plan meetings or the offering of a copy to residents.
A facility failed to maintain a medication error rate below 5%, with an observed rate of 10.53%, affecting three residents. An LPN administered medications with discrepancies between labels and electronic records, including incorrect timing and improper tablet splitting. The errors involved residents with conditions such as multiple sclerosis, anxiety disorder, and hypotension.
Two residents with indwelling Foley catheters experienced contamination issues during care. One resident's catheter bag was placed on the floor during dressing, while another's catheter tubing touched the floor while seated in a wheelchair. Both actions were confirmed as inappropriate by facility staff.
A resident identified as malnourished did not consistently receive the prescribed amount of Glucerna supplement due to inconsistent documentation and administration practices. Despite a physician's order for 8 ounces twice daily, records showed varying amounts were given, and staff interviews revealed confusion in charting methods. This inconsistency affected the resident's nutritional support.
Infection Control Failures During Wound and Catheter Care
Penalty
Summary
The facility failed to ensure proper infection prevention practices during wound care for one resident with bilateral ankle pressure wounds. The resident was admitted with open wounds to both ankles, had a Braden Scale score of 15, and the MDS showed moderate cognitive impairment, dependence for multiple activities of daily living, and two Stage 3 ulcers present on admission. During observed wound care, the LPN performed hand hygiene and donned a gown and gloves, but then removed the old dressing from one ankle, cleansed the wound, applied Alginate AG and a dressing, repositioned the resident, and repeated the process on the other ankle without performing hand hygiene or changing gloves between tasks. The LPN kept the same gloves on throughout the entire wound care and did not date or initial the dressing. The LPN later confirmed hand hygiene and glove changes should have occurred throughout the dressing change, and the DON agreed. The facility also failed to follow infection control practices during catheter care for the same resident. The resident had an indwelling catheter, a diagnosis related to bladder dysfunction, and was observed with slightly cloudy urine. During catheter care, the NA performed hand hygiene, donned gloves and a gown, emptied the drainage bag, then removed the gown and gloves and performed hand hygiene before continuing care without a gown. The NA assisted the resident into position, removed the brief, and used contaminated gloves to repeatedly access the wipes container while cleansing the groin, urethral meatus, peri-area, catheter tubing, and buttock. The NA continued using the same gloves while applying a new brief and assisting the resident to dress and get up for breakfast. The NA confirmed a gown should have been worn, hand hygiene and glove changes should have occurred more often, and contaminated gloves should not have been used to access the wipes container; the DON also confirmed these expectations. A similar failure occurred during catheter care for another resident with an indwelling Foley catheter related to BPH. The resident’s MDS showed an indwelling catheter and intact cognition, and the care plan required enhanced barrier precautions for staff. During observation, the NA donned a gown and gloves, gathered wipes, assisted the resident to stand, removed clothing and the brief, and used one wipe and the original gloves to perform perineal care, then continued with the same wipe and gloves to clean the meatus and catheter tubing. The NA did not remove contaminated gloves, perform hand hygiene, or don clean gloves before cleaning the meatus and tubing, and did not retract the foreskin to clean and inspect the meatus. The DON confirmed the expectation that contaminated gloves should be removed, hand hygiene performed, and clean gloves applied before cleaning the meatus and catheter tubing. The resident’s urinalysis was positive for a UTI, and an order for ertapenem was started for treatment.
Infection Control and Staff Screening Deficiencies
Penalty
Summary
The facility failed to ensure that pre-employment health history screens were reviewed for two out of three staff members, which could potentially affect all residents. The records for a housekeeper and a laundry aide showed that their medical history questionnaires were incomplete, lacking necessary signatures and dates. This oversight was confirmed by the Social Services Director, who stated that these forms should be reviewed and signed before the first day of employment. The facility's policy requires a health assessment before employment begins, but this was not adhered to in these cases. The facility also failed to maintain the tub and shower room in a clean and sanitary manner, which could impact all residents. Observations revealed grime, discolored grout, and soap scum buildup in the tub room. The cleaning process was inadequate, as the shower chair's safety harness was not fully submerged in disinfectant, and the staff member responsible for cleaning was unsure of the correct water temperature for disinfection. This lack of proper cleaning procedures poses a risk of infection. Additionally, the facility did not implement Enhanced Barrier Precautions (EBP) for a resident who required them after surgery. The resident was admitted following a surgical repair of a fractured femur, but EBP was not applied until several days later. The Director of Nurses admitted forgetting the requirement for new surgical patients to be on EBP. Furthermore, staff failed to apply Personal Protective Equipment (PPE) correctly, perform hand hygiene between glove changes, and follow proper catheter care procedures, affecting the care of two residents. Oxygen tubing was also not changed as required, with outdated labels observed on the equipment.
Deficiencies in Baseline Care Plan Documentation and Implementation
Penalty
Summary
The facility failed to ensure that the medical records contained documentation that a written summary of the baseline care plan was provided to the resident or their representative within 48 hours of admission. For two residents, there was no documentation of any discussion of the care plan with the resident or their representative, nor was there any record of a care conference note or any other note indicating that a baseline care plan review meeting occurred. The Director of Nursing Services (DNS) confirmed that while they review the baseline care plan with the resident on the day of admission, they do not document the discussion or the offering of a copy of the care plan. Additionally, the facility did not complete the baseline care plan with the necessary information for one newly admitted resident. This resident, who was admitted following surgery to repair a fractured femur, was not placed on Enhanced Barrier Precautions (EBP) at the time of admission, which is required for surgical wound care. Staff were observed not using EBP when assisting the resident, and the care plan was only revised to include EBP after the oversight was identified. The facility's policy on comprehensive care plans requires the development of a person-centered care plan with measurable objectives and timetables. However, the policy does not explicitly state the need to document the occurrence of the care plan meeting or the offering of a copy to the resident, which contributed to the deficiencies noted in the report.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with an observed rate of 10.53%, affecting three residents. Resident 3, admitted with multiple sclerosis, chronic respiratory failure, and hypertension, received Modafinil and Potassium Chloride incorrectly. The Modafinil administration time did not match the electronic medication administration record, and the Potassium Chloride tablet, which should not be crushed, was split and crumbled, leading to improper administration. LPN-B acknowledged the errors and was unaware of the resident's difficulty swallowing large tablets. Resident 20, diagnosed with anxiety disorder, dementia, and Parkinson's disease, was administered Quetiapine with discrepancies between the medication label and the electronic record. The as-needed order for Quetiapine had been discontinued, yet it was still administered. Resident 22, with hypotension, received Midodrine HCL with mismatched administration instructions between the medication packaging and the electronic record. LPN-B confirmed these discrepancies during interviews, highlighting the facility's failure to ensure accurate medication administration.
Contamination of Urinary Catheters During Care
Penalty
Summary
The facility failed to prevent urinary catheters from becoming contaminated during personal care and transportation for two residents. Resident 3, who was admitted with multiple sclerosis and neuromuscular dysfunction of the bladder, was observed having their Foley catheter bag placed on the bare floor while being assisted with dressing by a nurse assistant. This action was confirmed by the Director of Nursing Services (DNS) as inappropriate, as the catheter bag should not come into contact with soiled or dirty surfaces like the floor. Resident 27, admitted with kidney failure, obstructive uropathy, and a history of urinary tract infections, was observed sitting in a wheelchair with the Foley catheter tubing touching the floor. The tubing extended from the resident's pants, past the wheelchair pedal, and onto the floor before connecting to a cloth bag under the wheelchair. A Licensed Practical Nurse (LPN) confirmed that the catheter bags and tubing should not contact the floor, and the DNS reiterated that the tubing should not meet soiled surfaces.
Inconsistent Administration of Nutritional Supplement
Penalty
Summary
The facility failed to ensure that Resident 15, who was identified as malnourished, received the physician-ordered amount of Glucerna supplement. Resident 15 was a new admission with multiple diagnoses, including malnutrition, cellulitis, lymphedema, diabetes, urinary tract infection, and confusion, all of which could affect nutritional status. The resident's Mini Nutritional Assessment (MNA) scores indicated malnutrition, and the registered dietician recommended a liberalized regular diet and 8 ounces of Glucerna twice daily to meet caloric and protein needs. Despite the physician's order for 8 ounces of Glucerna twice daily, the Medication Administration Record (MAR) showed inconsistencies in the amount given. The documentation revealed that on several occasions, less than the prescribed 240 ml was administered, with some entries showing only 100 ml or 120 ml given. Additionally, there were instances where the charting was unclear, with checkmarks or percentages used instead of specific volumes, leading to confusion about the actual intake. Interviews with facility staff, including the registered dietician, LPNs, and the Director of Nursing, confirmed the inconsistency and confusion in charting the supplement intake. The staff reported different methods of documentation, which varied depending on who entered the order into the MAR. This inconsistency in documentation and administration led to the deficiency in providing the necessary nutritional support to Resident 15, who was at risk for malnutrition.
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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 Central City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Adept Nursing & Rehab Of Central City | 0.1 mi | ★★★★★ | 1 | 0 |
| Memorial Community Care | 16.2 mi | ★★★★★ | 4 | 0 |
| Westfield Quality Care Of Aurora | 16.4 mi | ★★★★★ | 1 | 0 |
| Accura Healthcare Of Fullerton | 18.1 mi | ★★★★★ | 8 | 0 |
| Midwest Covenant Home | 21.6 mi | ★★★★★ | 0 | 0 |
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