Citizens Care Center

In the surveyor’s words

From the most serious findings on record at Citizens Care Center, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF641Jan 29, 2026

  Based 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. The findings include: The Minimum Data Set (MDS) is a comprehensive, federally mandated assessment tool used to evaluate a resident's functional, cognitive, and health status to create individualized care plans, monitor quality of care, and support reimbursement for Medicare and Medicaid certified facilities. 1) On 01/21/2026 at 3:07 PM, a review of Resident #3's physician order dated 12/14/2025 for siderails: 2 1/4 padded bed rails for seizure precautions. […]

• No harm, potential for more than minimal, patternF700Jan 29, 2026

  Based 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. The findings include:Bed rails are adjustable bars attached to beds. While they can aid mobility and safety, they can also act as a restraint, preventing exit, and pose an entrapment risk if incorrectly installed. […]

• No harm, potential for more than minimal, patternF684May 7, 2024

  Based 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 Findings include: 1. […]

• No harm, potential for more than minimal, patternF689May 7, 2024

  Based 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. Findings include: 1. On 4/30/24 at 10:39 AM the surveyor made observations of water temperatures in resident rooms located on the Harbor View Unit. Bathroom temperatures for the following rooms were observed: Room# 148 had a temperature of 122 degrees Fahrenheit (F) Room # 149 had a temperature of 122 degrees F Observations were made on the same date at 11:05 AM of the water temperatures of the sink located inside the resident rooms as follows: Room # 149 sink temperature was 120 degrees… […]

• No harm, potential for more than minimal, isolatedF604Jan 29, 2026

  Based 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. The findings include:1) On 01/20/2026 at 10:02 AM, during initial tour and observation, an alarm activated when Resident #4 got out of bed. At 10:07 AM, Resident #4 was observed standing in the doorway, appearing anxious due to the alarm's sound. The resident commented to staff (unknown) at the nearby medication cart, Don't you get tired of that sound, to which the staff member replied, Sometimes. […]