Citizens Memorial Healthcare Facility

Inspectors wroteBased on interview and record review, the facility failed to ensure all residents were treated with dignity and respect when one staff (Nurse Practitioner (NP)) spoke disrespectfully and in a loud tone when interacting with one resident (Resident #1) in a selected sample of 14 residents. The facility census was 94. The Administrator was notified by the Director of Nursing (DON) and Social Service Director (SSD) on 09/23/25 of the incident regarding the resident and the NP. The NP was removed from the facility that day and the facility completed in-servicing of all staff by 09/25/25. The non-compliance was corrected on 09/25/25. Review of the facility's policy titled Patient Rights and Responsibilities, last revised November 2026, showed the following: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an environment as free of accident hazards as possible when staff failed to check the temperature of soup prior to serving and failed to ensure the resident was in an appropriate upright position prior to meal service for one resident (Resident #44) resulting in a burn from the hot liquid. The facility census was 95. Review of the facility policy titled, Event Reporting, approved 10/2025, showed the following:-The incident reporting system will be used to report possible errors, untoward events, and near misses to management, risk manager/administration;-To promptly document information relative to possible errors, untoward events, and near misses;-Definition of event is an occurrence that ideally should not have happened to a patient/resident, client, visitor, or other, whether or not an injury resulted; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store and prepare food in accordance with professional standards of practice and protect all food from possible contamination when the facility staff failed to date stored food in the refrigerator and freezer; failed to discard prepared food after the use by date; and failed to follow proper hygiene practices when two staff failed to wear beard nets. The facility's census was 95. Based on observation, interview, and record review, the facility failed to store and prepare food in accordance with professional standards of practice and protect all food from possible contamination when the facility staff failed to date stored food in the refrigerator and freezer; failed to discard prepared food after the use by date; and failed to follow proper hygiene practices when two staff failed to wear beard nets. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to have a process in place to ensure food was served at a palatable temperature to all residents when food was below the optimal holding temperature before leaving the kitchen and was not routinely temped by all kitchen staff. This resulted in complaints regarding cold food from seven residents (Resident #55, #39, #72, #11, #83, #61, and #52.) The facility census was 95. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish and maintain a complete infection control program when staff failed to use Enhanced Barrier Precautions (EBP - an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs - microorganism that has developed resistance to one or more classes of antibiotics, making infections caused by it more difficult to treat) in nursing homes) during personal cares for one resident (Residents #5) who had a catheter (thin tube that remains in the bladder for continuous urine drainage, often held in place by a small balloon and connected to a collection bag) and when the staff failed to complete proper hand hygiene during personal cares for two residents (Resident #5 and #57) and during wound care for one resident (Resident # 12). The facility census was 95. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care per standards of practice when staff failed to ensure complete weekly skin assessments and wound assessments were completed and document for two residents (Resident #12 and Resident #84) with pressure ulcers (localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device). The facility census was 95. Review of the facility policy titled Pressure Ulcer/Wound Assessment and Treatment, dated May 2025, showed the following: [...]

Inspectors wroteBased on observation, interview, and record review, the facility staff failed to ensure residents who were incontinent of bladder received appropriate treatment and services to prevent and treat urinary tract infections when staff failed to notify the physician of and provide treatment for suspected urinary tract infections (UTI) for one resident (Resident #36). The facility also failed to ensure proper catheter (a thin, flexible tube inserted into the body to drain fluid) care when staff failed to keep the catheter tubing below bladder level and failed to keep the catheter bag off the floor for one resident (Resident #7). The facility census was 95.1. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure an effective pain management system was in place when staff failed to accurately assess and document pain levels, failed to document follow-up after a change in pain medication, and failed to update the care plan related to pain for one resident (Resident #80) resulting in the resident having continued pain that affected his/her desire to get out of bed. The facility's census was 95. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide dialysis (the cleaning of the blood with a machine due to the kidneys not working) services per professional standards of practice when the facility failed to obtain an order for dialysis and routine assessment and monitoring of the dialysis site, failed to document ongoing communication with the dialysis center, and failed to provide a lunch meal timely for one resident (Resident #3) who received dialysis. The facility census was 95. [...]

Inspectors wroteBased on observation, interview, and record review, facility failed to ensure the facility maintained a medication administer error rate of less than 5% when staff failed to administer the correct insulin dosage to one resident (Resident #42) and failed to prime the insulin pen prior to use for two resident (Residents #42 and #72), resulting in two error out of 26 opportunities (a medication error rate of 7.69%). The facility census was 95. Review of the facility policy Medication Errors and Near Misses, dated 04/25, showed the following:-A medication error was defined as a preventable event that may cause or lead to inappropriate medication use or patient harm;-Example of medication errors would include wrong dose and omission of ordered medication. [...]

Inspectors wroteBased on observation, interview, and record review, facility failed to ensure all residents were free from significant medication errors when staff failed to administer the correct insulin dosage to one resident (Resident #42) and failed to prime the insulin pen prior to use for two resident (Residents #42 and #72). The facility census was 95. Review of the facility policy Medication Errors and Near Misses, dated 04/25, showed the following:-A medication error was defined as a preventable event that may cause or lead to inappropriate medication use or patient harm;-Example of medication errors would include wrong dose and omission of ordered medication. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care for pressure ulcers per standards of practice when staff failed to follow-up regarding an intervention of an appropriately sized bed and when staff failed to follow-up with the physician in a timely manner regarding a wound culture for one resident (Resident #1) and when facility staff failed to utilize appropriate hand hygiene prior to and during pressure ulcer wound care for one resident (Resident #2). The facility census was 83. 1. Review of the facility policy titled, “Pressure Ulcer/Wound Assessment and Treatment”, revised June 2025, showed: -Nursing personnel will continually strive to maintain the skin integrity, tone, turgor, and circulation to prevent skin breakdown, injury, and infection; -Purpose to provide a consistent effective method or treatment for pressure ulcers/wounds; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care to all residents with a urinary catheter (a sterile tube inserted into the bladder to drain urine) in a manner that prevented possible infection when staff failed to follow proper infection controls practices, including proper handwashing, during wound and catheter care for one resident (Resident #2) with a history of urinary tract infections (UTIs). The facility census was 83. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure establish an accurate system of administration of narcotic pain medications when staff failed to accurately document administration of narcotic pain medications and administer them within the parameters of physicians' orders for two residents (Resident #1 and Resident #2). Ten residents were sampled out of a facility census of 100. Review of the facility's policy titled Medication Administration and Documentation, revised 06/2024, showed the following: -The facility maintains a standard procedure for admission of drugs by licensed personnel with a physician's order; -Purpose of the policy was to outline correct procedure for documentation of bedside medication administration utilizing the Medication Administration Record (MAR) in the Patient Care System (PCS). [...]

Inspectors wroteBased on interview and record review, the facility failed to provide care per standards of practice when staff failed to accurately and consistently monitor and document weights for three residents (Resident #37, #73, and #56). The facility census was 103. Record review of the facility's policy titled, Patient Weights. dated April 2022, showed the following: -In long-term care setting, weights will be done on admission, monthly, and as needed or ordered; -Upon admission to long-term care facility, an initial weight will be obtained; -Wheelchair weights: balance scales, patient may be rolled upon platform by placing scale side flaps down, receive weight, weight empty wheelchair, and subtract weight of chair from total weight of resident; -Document the weight in the electronic medical record. Review of the facility's policy titled, Documentation, dated December 2020, showed the following: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide and accurately care plan one resident's reasonable accommodation of need for one resident (Resident # 48) who was unable to access the call light system. The facility census was 103. Review of the facility policy, titled General Physical Environment, dated June 2019, showed the following: -The facility considers the purpose of an equipped and functional environment to ensure adequate care and safety of residents, employees, and visitors; -The nurses' call system registers calls to the nurses' station from each resident's bed, toilet room, bathtub, and shower. Review of the facility policy, titled Nursing Safety, dated March 2021, showed the following: -The facility considered the purpose of nursing safety to ensure safety for the residents, employees, and visitors; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a catheter (a flexible tube inserted through a narrow opening into a body cavity, particularly the bladder, for removing fluid) was only inserted when needed and with physician orders for catheter insertion and management when staff place a catheter for one resident (Resident #56) without physician orders. The facility census was 103. Review of the facility's policy titled, Catheter Care, dated August 2022, showed the following information: -Urinary catheterization is to facilitate urinary drainage when medically necessary; -Urinary catheters should be placed only under the direction of a physician order; -Indwelling catheters should be removed as early as possible to help prevent catheter-associated urinary tract infections; -Obtain physician order for removal. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure all residents received dialysis services per professional standards, when staff failed to have written physicians' orders related receiving dialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly), failed to document monitoring the resident as care planned, and the failed to mark dialysis on the Minimum Data Set (MDS - a federally mandated comprehensive assessment completed by facility) for one resident (Resident #62). The facility census was 103. Review of the facility's policy titled, Patient Weights, dated April 2022, showed the following: -In long-term care setting, weights will be done on admission, monthly, and as needed or ordered; -Upon admission to long-term care facility, an initial weight will be obtained. [...]

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure staff followed acceptable standards of practice for infection control at all times when staff failed to perform hand hygiene during a medication pass and failed to dispose of potentially contaminated medication for one resident (Resident #16) of two residents observed during medication pass. The facility census was 103. Review of a facility policy entitled Hand Hygiene, reviewed 07/21, showed the following: -Hand hygiene is the single-most effective method of reducing the transmission of microorganisms in a healthcare setting. The term hand hygiene replaced hand washing to reflect the acceptance of waterless hand cleaning agents such as alcohol based hand rubs (ABHR). Hand hygiene education is provided during orientation and annually; [...]

Inspectors wroteBased on interview and record review, the facility failed to notify all residents' families of changes in condition or an event that would require a change in plan of care when staff did not notify one resident's (Resident #1) family when the resident left the building out of an alarmed exit door in the early morning hours while it dark outside without staff knowing. The facility census was 93. Review of the facility's policy Changes in Resident Condition Notification Guidelines, dated 12/2022, showed the following: -Physicians, residents, hospice when applicable, and families will be notified in a timely manner of changes in clinical conditions and environmental changes affecting the resident; -Purpose to provide timely communication of condition and environmental changes to care providers, residents, and families; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adequate supervision to prevent possible accidents when staff failed to monitor the whereabouts a resident and respond to a door alarm timely when one resident (Resident #1), assessed as a high elopement risk, exited the building without staff's awareness. Staff found the resident in a wheelchair, outside at the west entrance of the front parking lot, approximately 65 feet from the C hall's alarmed exit door. The facility census was 93. Review of the facility policy Elopement Risk Assessment of Long Term Care Resident, dated 05/2022, showed the following: -The facility will evaluate and document elopement risk of residents and initiate safety interventions as needed and as appropriate; [...]

Inspectors wroteBased on interview and record review, the facility failed to address and provide feedback regarding concerns expressed by multiple residents attending the monthly resident council meetings. The facility census was 89. Record review of the Facility's Resident Council Policy, dated January 2019, showed the following: -A Residents Council meeting may be held on a monthly basis to include the residents, activity director, and supervisory staff; -Purpose to promote the residents' right to organize; -The Activity Director (AD) or designee shall assist in scheduling and organizing a monthly Resident Council Meeting; -The AD shall assist in notifying department supervisors in advance of the meetings; -The AD will follow up with the department supervisors concerning problems expressed by the residents during the meeting; [...]

Inspectors wroteBased on observation,interview, and record review, the facility failed to ensure food was served at an appetizing temperature to all residents. The census was 89. Record review of the facility's policy titled, Temperatures and Reheating Foods, dated 07/2010 and approved 07/2020, showed the following: -Fresh, frozen or canned fruits and vegetables should be cooked and have a holding temperatures of 140 degrees F; -Cooked meat should have a holding temperatures of 140 degrees F or higher. 1. Record review of the Resident Council Meeting Minutes showed the following: -In January 2021, ten residents attended the meeting. The residents said the food was not hot, the meals were cold when served in the dining room and in their rooms; -In February 2021, nine residents attended the meeting. The residents said their meals were cold when served. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper hand hygiene practices were utilized during food service, and failed to handle tableware, food, and ice in a manner to prevent possible cross contamination. The facility census was 89. Record review of the facility's policy, titled Safe Food Handling and Preparation, review dated July 2020, showed direction to staff for the following: -Prevent cross contamination and avoid conditions which might cause food borne illness; -Keep hands clean. Dirty hands spread infections; -Keep fingers and hands out of food; -Grasp glasses and bowls by the bottoms and grasp cups by handles. 1. Observations on 4/12/21, starting at 11:35 A.M., of meal service showed the following: -Dietary Aide (DA) D held a resident's used cup containing a pink liquid over the clean ice bin and scooped ice into the cup. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent potential accidents by not assuring a call light was in reach at all times for one visually impaired resident (Resident #41) with a history of falling and on fall precautions. The facility census was 89. Record review of the facility's policy titled Fall Program, review date July 2020, showed direction for staff to complete the following: -Identify residents fall risk factors; -Implement fall prevention/management interventions; -Provide resident fall prevention education. Record review of the facility's policy titled Falling Leaf Guidelines, review date April 2020, showed the following: -The program identifies residents at high risk for falls and require increased observation and intervention; -Residents in the program will be visually identified by a Falling Leaf tag on their doorway. 1. [...]