The falsified documentation at Citizens Care Center continued for five straight days in May, with treatment records showing heel protector boots were "applied" during every shift from May 14 through May 18, according to a November complaint investigation by federal inspectors.
The boots had vanished after the resident returned from a hospital stay.
On May 14 at 7:14 PM, a licensed practical nurse documented that Resident #8 had "returned from hospital without boots." But the resident had a doctor's order requiring "heel protector boots on at all times, remove for bathing every shift for heel protection" that ran from April 24 to May 27.
The next day, staff documented that the resident "reported that he/she don't know where his/her blue boots were he/she was supposed to wear them." A nurse clarified in the progress notes that "there were no boots."
Still, the Treatment Administration Records showed boots were applied during all shifts.
On May 16, progress notes recorded that the "resident asked for his/her blue boots. Nursing to follow up." The treatment records continued to document that the boots were on the resident's feet.
By May 17, a registered nurse wrote that staff "were unable to find protector boots during the evening shift, and they were still missing." The TAR documentation that same day indicated the boots were applied.
The attending physician got involved on May 18, documenting that "the resident wants his/her boots back and that the physician was told they must be ordered: Please order the boots he/she wants."
Even then, treatment records showed the boots were applied during all shifts on May 18.
The Director of Nursing confirmed the discrepancies when interviewed by inspectors on November 6. She validated that progress notes documented the boots were missing while the Treatment Administration Records documented they were applied.
Federal inspectors found the violation during a complaint investigation that began November 5. The facility failed to maintain accurate medical records in accordance with professional standards.
Heel protector boots prevent pressure sores that can develop when residents spend extended time in bed or seated. The boots cushion the heel and distribute pressure to prevent skin breakdown that can lead to painful wounds and serious infections.
The resident's repeated requests for the blue boots, documented across multiple days by different staff members, showed they understood the medical equipment was missing. Yet nurses continued signing off on treatment they couldn't provide.
The falsified records created a gap between what actually happened to the resident and what the medical documentation claimed. Treatment Administration Records serve as the official record of whether residents receive ordered medical interventions.
When nurses sign that boots were "applied" during their shifts, those records become part of the resident's permanent medical file. The documentation is used to track compliance with physician orders and evaluate the quality of care provided.
The five-day period of false documentation ended only after the attending physician intervened and ordered replacement boots for the resident.
Citizens Care Center was cited for failing to safeguard resident-identifiable information and maintain medical records according to accepted professional standards. Inspectors classified the violation as causing minimal harm or potential for actual harm to residents.
The investigation focused on one resident among eight reviewed during the complaint survey, but revealed systematic problems with record-keeping accuracy at the facility.
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.