Citizens Care Center: DNR Documentation Failure - MD
A November 2025 complaint inspection found that the facility failed to first obtain a Full Code MOLST, the standardized Maryland medical order form that documents a patient's resuscitation wishes, before revising Resident 8's status to DNR. The sequence matters because the Full Code document establishes the baseline, the starting point from which any change to a DNR must be made. Without it, there is no documented record that the resident or their representative ever formally authorized full resuscitation measures before agreeing to forgo them.
The Director of Nursing acknowledged the error directly to inspectors. The facility should have obtained the Full Code MOLST first, she agreed, and then revised it to DNR. It hadn't.
The inspection also noted a discrepancy in staff documentation. Notes entered by Staff 4 were recorded later than they should have been, a finding that compounded the paperwork problem rather than clarifying it.
CMS classified the violation under F0578, which covers a resident's right to self-determination, including the right to formulate advance directives and have those directives followed. The level of harm was rated as minimal harm or potential for actual harm, and the number of residents affected was listed as few.
The MOLST form, which stands for Medical Orders for Life-Sustaining Treatment, carries the weight of a physician's order in Maryland. It travels with a patient across care settings and is meant to ensure that a person's end-of-life wishes are honored in an emergency, when there may be no time to consult family or review a chart. A gap in that documentation is not merely an administrative inconvenience. In a crisis, a missing or out-of-sequence form can mean the difference between a resuscitation attempt and none, regardless of what the resident actually wanted.
Citizens Care Center is a 120-bed facility. The November 7 inspection was triggered by a complaint, not a routine survey cycle.
The Director of Nursing's acknowledgment that the facility should have done it differently did not appear in the report alongside any explanation of how or when the error was discovered, or whether Resident 8's actual wishes had been accurately captured despite the missing paperwork. The inspection record does not say.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Citizens Care Center from 2025-11-07 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 4, 2026 · Our methodology
CITIZENS CARE CENTER in HAVRE DE GRACE, MD was cited for violations during a health inspection on November 7, 2025.
The sequence matters because the Full Code document establishes the baseline, the starting point from which any change to a DNR must be made.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.