Citizens Care Center

Inspectors wroteBased on clinical record review and staff interview it was determined that the facility staff failed to code the resident's status accurately on the Minimum Data Set (MDS) assessment. This was evident for 7 (#3, #4, #6, #123, #12, #34, #50) of 13 residents reviewed for MDS accuracy during the recertification/complaint survey.

Inspectors wroteBased on clinical record review, observation, and interviews with the facility staff it was determined the facility failed to properly assess a resident for bedrails as evidenced by: not assessing a resident for entrapment risk, reviewing risks and benefits with the resident/representative, or obtaining informed consent prior to installation. This was evident for 5 Residents (# 34, # 50, #3, #4, and #6) of 5 residents observed having siderails in use during the facility's recertification/complaint survey.

Inspectors wroteBased on observation, record review, and interview, it was determined the facility failed to maintain a restraint-free environment as evidenced by ensuring least restrictive measures were attempted prior to utilizing restraints. This was identified for 2 (Resident #4 and #6) of 2 residents reviewed for restraints during the recertification/complaint survey.

Inspectors wroteBased on record review and interviews, the facility failed to develop and implement a person-centered care plan to meet and address the residents' medical and physical needs. This was evident for 2 (Resident #2 and Resident #125) of 40 care plans reviewed during the recertification/complaint survey process. Findings Included:A care plan is a tool used to summarize the resident's healthcare needs, treatments, and care goals. This tool is to be developed within 7 days after completion of the comprehensive assessment (MDS) and prepared by an interdisciplinary team.1) On 01/20/2026 at 09:18 AM, the surveyor observed Resident #2 receiving oxygen (O2) with no date observed on the O2 tubing to indicate when the O2 tubing was last changed. [...]

Inspectors wroteBased on record review and interviews, it was determined that the facility failed to provide documented evidence that the residents' care plans were reviewed and revised by an interdisciplinary team to address the resident's medical and physical needs after a change in health status. This was evident for 1 (Resident #2) of 40 care plans reviewed during the recertification/complaint survey process. Findings Included:A care plan is a tool used to summarize the resident's healthcare needs, treatments, and care goals. This tool is to be developed within 7 days after completion of the comprehensive assessment (MDS) and prepared by an interdisciplinary team. [...]

Inspectors wroteBased on resident interview, staff interview, and clinical record review it was determined that the facility staff failed to ensure that the resident had the opportunity to participate in an activity program and failed to provide documentation of participation in desired activity. This was found to be evident for 1(Resident # 34) of 5 residents reviewed for activity during the recertification/complaint survey.

Inspectors wroteBased on record review and interview, it was determined the facility failed to ensure that a resident received treatment and care in accordance to professional standards of practice, as evidenced by failing to: 1) properly manage a bowel regimen that led to persistent constipation, and 2) appropriately assess, evaluate, and modify interventions for a newly developed pressure ulcer. This was evident for 1 (Resident #123) of 8 residents that were reviewed during the recertification/complaint survey.

Inspectors wroteBased on surveyor observation, review of the medical record, and interview with facility staff it was determined the facility staff failed to provide necessary respiratory care services for residents by failing to change out an empty humidifier bottle, failing to maintain nasal cannula in a sanitary manner, and failing to administer oxygen as prescribed. This was evident for 3 (#138, #125, #3) out of 6 residents reviewed for Respiratory Care during the recertification/complaint survey. The Findings Include:1) On 01/21/2026 at 9:43 AM, a surveyor's observation revealed that Resident #125 had oxygen at bedside. The oxygen tubing was observed laying on top of the oxygen concentrator and not stored in a sanitary environment. It was also observed that the attached humidifier was dated 01/13/2026. [...]

Inspectors wroteBased clinical record review and staff interview it was determined that the facility staff failed to ensure a resident reporting serious pain received a follow up assessment after receiving treatment for the pain to ensure effectiveness of the treatment. This was evident for one (Resident #46) out of three residents reviewed pain during the recertification/complaint survey.

Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to ensure a resident's blood sugar was properly monitored. This was evident for one (Resident #5) out of five residents reviewed for the unnecessary medication review task during the recertification/complaint survey.

Inspectors wroteBased on clinical record review, resident interview, and staff interview, it was determined that facility staff failed to ensure a resident received routine dental services. This was evident for one (Resident #5) out of three residents reviewed for dental services during the recertification/complaint survey.

Inspectors wroteBased on the investigation of complaints, medical record review, and staff interviews, it was determined that the facility failed to update residents' (and/or responsible parties') wishes related to life-sustaining treatment and assess residents' capacity to make decisions in a timely manner. This failure was evident for one (Resident #8) of the eight residents whose care was reviewed during this complaint survey.

Inspectors wroteBased on the investigation of complaints, medical record review, and interviews with facility staff, it was determined that the facility failed to ensure that changes in residents' condition were notified to the physician in a timely manner. This failure was evident for one (Resident #8) of the eight residents whose care was reviewed during this complaint survey.

Inspectors wroteBased on an investigation of intakes, reviewing medical records, and interviewing facility staff, it was determined that the facility failed to ensure that a resident's Treatment Administration Records (TAR) were correctly documented. This was evident for one (Resident #8) of eight residents reviewed for care during this complaint survey.

Inspectors wroteBased on medical record review and interviews with facility staff it was determined the facility failed to: (1) to ensure that a resident followed up with the Urologist for management of the foley catheter; (2) transcribe physician pain scale orders for resident #1. (3) follow a treatment order as ordered by the physician for resident #59. (4) follow physician orders as evidenced by a resident not being properly positioned to receive enteral nutrition, enteral nutrition not being administered during the ordered times, medications were not administered the times ordered, and the ordered amount of oxygen was not delivered for several days. This deficient practice was evident in 5, (Resident #1 # 18, #33, #59, #100) of 38 resident records reviewed during the Survey

Inspectors wroteBased on observations and interviews with facility staff it was determined the facility failed to ensure that water temperatures remained within acceptable range. This was found to be evident during 11 room observations made of the Harbor View Unit and 2 residents (#31,#32) during the facility's survey.

Inspectors wroteBased on observations and interviews it was determined that the facility staff failed to get a resident out of bed for four out of five days and failed to dress the resident in his/her own clothing. This deficient practice was evident in 1(#59) of 2 residents observed for dignity during the survey.

Inspectors wroteBased on record review and interview it was determined that the facility failed to issue the bed hold notice. This was evident for 1 out of 1 resident (#109) reviewed for hospitalization during the facility's recertification survey.

Inspectors wroteBased on a review of the medical record and interviews with the facility staff it was determined the facility failed to follow the resident care plan for the management of a resident with a foley catheter. This was found to be evident for 1 (Resident # 18) of 39 residents reviewed during the facility's survey.

Inspectors wroteBased on observations, staff interviews, and record review, it was determined that the nursing staff failed to meet professional standards of care by not ensuring that medication was consumed prior to leaving the resident room. This was evident for 1 (Resident #89) of 4 residents observed for professional standards.

Inspectors wroteBased on interviews and record review the facility failed to demonstrate that annual performance reviews were conducted for geriatric nursing assistants (GNAs)annually based on the employee's hire date. This was determined and evidenced to be true for 4 out of 4 GNAs, (GNA #40, 41,42, and 44) during the review of facility human resource and staff education files while performing the staffing facility task during the survey.

Inspectors wroteBased on record review and interview with facility staff, it was determined that the facility failed to address a pharmacy recommendation in a timely manner. This was evident for 1 (Resident #3) of 5 residents reviewed for unnecessary medications.

Inspectors wroteBased on medical record review and interviews it was determined that the facility staff failed to monitor a resident for side effects who was prescribed psychotropic medication. This deficient practice was evident for 1 (#33) of 2 medical records reviewed for side effects of medications during the Survey.

Inspectors wroteBased on observation and interview of facility staff it was determined the facility failed to ensure a medication was not left unattended and failed to: (1) ensure a medication cart was locked evident for one medication cart observed : (2) discard expired medications, properly store medical supplies, and check the refrigerator temperatures for biologicals and supplements. This deficient practice was evident in 2 out of 2 medication storage rooms assessed during the survey.

Inspectors wroteBased on record review, interview and observation it was determined the facility failed to: 1.) date and sign inventory sheets for resident personal effects, and 2.) failed to ensure accuracy of a medical order. This was evident for 2 out of 2 resident's inventory sheets (#39, #42) reviewed and 1 out of 3 residents reviewed for pressure ulcers during the facility's recertification survey.

Inspectors wroteBased on interviews and record review the facility failed to ensure that four geriatric nursing received and completed a total of 12-hours of clinical training annually. This was determined and evidenced to be true for four out of four GNAs, (GNA #40, 41,42, and 44) human resource and staff education files reviewed during the survey.

Inspectors wroteBased on medical record review and interview it was determined the facility staff failed to review and revise the care plan for Resident (#4) to reflect accurate and current interventions. This was evident for 1 of 1 residents reviewed for care plans during the survey process and 1 of 49 residents reviewed during the annual survey process.

Inspectors wroteBased on observation, reviews of a medical record and staff interview, it was determined the facility staff failed to follow a physician's order and apply had splints to a resident daily, to take steps to address skin discolorations on a resident's legs, to address and notify the physician of results of an abnormal blood sugar level. This was evident for 3 (Resident #3, #52, and #77) of 49 residents reviewed during an annual recertification survey.

Inspectors wroteBased on reviews of administrative records and staff interview, it was determined that the nursing administrative staff failed to 1) conduct a yearly performance review on the entire nursing assistant staff for the year of 2018, and 2) ensure that all geriatric nursing assistant (GNA) staff completed a minimum of 12 hours of education per year.

Inspectors wroteBased on dining observation and interview, it was determined the facility staff failed to provide Residents (#6 and #103) with the most dignified existence with dining. This was evident for 2 of 9 residents observed for dining in the first-floor dining room.

Inspectors wroteBased on medical record review and interview it was determined the facility staff failed to provide showers to Resident (#4). This was evident for 1 of 49 reviewed for choices during the annual survey process.

Inspectors wroteBased on medical record review and interview it was determined the facility staff failed to ensure an advance directive was in place for Resident (#33). This was evident for 1 of 6 residents selected for review of advance directives and 1 of 49 residents selected for review during the annual survey process.

Inspectors wroteBased on observation, medical record review and interview it was determined the facility staff failed to provide thorough grooming and personal hygiene services for (Resident #75). This is evident for 1 of 3 residents selected for review for ADL care and 1 of 49 reviewed during the annual survey process.

Inspectors wroteBased on clinical record review, observation and staff interview it was determined the facility staff failed to ensure Resident (#75) was being turned and repositioned as ordered. This was true for 1 out of 49 residents selected to be reviewed for pressure ulcers. A nursing care plan is a formal process that includes correctly identifying existing needs, as well as recognizing potential needs or risks. Care plans also provide a means of communication among nurses, their patients, and other healthcare providers to achieve health care outcomes. Without the nursing care planning process, quality and consistency in patient care would be lost. Pressure ulcers are injuries to skin and underlying tissue resulting from prolonged pressure on the skin. Pressure ulcers most often develop on skin that covers bony areas of the body, such as the heels, ankles, hips and tailbone. [...]

Inspectors wroteBased on medical record review, observation and interview, it was determined the facility staff failed to provide Resident (#53) with the physician ordered nutritional services and failed to document the amount of supplement consumed. This was evident of 1 of 4 residents selected for review of nutrition during the annual survey process and 1 of 49 residents selected for review during the annual survey process.

Inspectors wroteBased on medical record review and interview, it was determined the facility staff failed to conduct AIMs testing on Residents (#74). This was evident for 1 of 49 resident selected for review during the survey process.

Inspectors wroteBased on resident interview, reviews of a medical record, and staff interview, it was determined that the facility staff failed to take steps to obtain dental services for a resident. This was evident for 1 (Resident #112) of 3 residents reviewed for dental services during an annual recertification survey.

Inspectors wroteBased on observation of medication pass, it was determined the facility staff failed to administer medications without using bare hand contact. This was evident for 1 of 5 residents observed for medication observation and 2 out of 37 opportunities.