Citizens Care Center
CITIZENS CARE CENTER in HAVRE DE GRACE, MD — inspection on November 7, 2025.
Found 3 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
later than Staff #4's notes.
The DON agreed that the facility should have obtained a Full Code MOLST for Resident #8 and then subsequently revised it to DNR.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
11/07/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Citizens Care Center
415 South Market Street Havre DE Grace, MD 21078
SUMMARY STATEMENT OF DEFICIENCIES
Based 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.The findings include: As part of the investigation into complaint #361874, the surveyor reviewed Resident #8's medical records on 11/05/25 at 8:30 AM.
The review revealed the following: -Staff #11 (Registered Nurse) documented in a progress note on 5/12/25 at 12:38 PM that Resident #8 was tearful with increased confusion.-Staff #4 (Social Worker) recorded Resident #8's confusion on 5/12/25 at 1:26 PM in a progress note, stating: [Resident's name] was tearful during our exchange.
Unable to provide year, month stating ‘I'm confused.'However, there was no documentation indicating that Resident #8's change in mental status was notified to the provider.In an interview with the Assistant Director of Nursing (ADON) on 11/05/25 at 12:09 PM, she confirmed that a resident's change in mental status should be considered a change in condition, which must be documented in the electronic medical record system and communicated to the provider.On 11/05/25 at 2:32 PM, the Director of Nursing (DON) verified that there was no documentation to support that Resident #8's change in mental status had been notified to the provider.
She validated the concern.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
11/07/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Citizens Care Center
415 South Market Street Havre DE Grace, MD 21078
SUMMARY STATEMENT OF DEFICIENCIES
Based 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.The findings include:During the investigation of complaint #361874, on 11/05/25 at 8:30 AM, it was noted that Staff #8 ( Licensed Practical Nurse) wrote a progress note on 5/14/25 at 7:14 PM as returned from hospital without boots.Further review of Resident #8's progress notes revealed that multiple staff documentation about the resident's boots, which could not be found.
Specifically: A note dated 5/15/25 by Staff #4 wrote, Resident #8 reported that he/she don't know where his/her blue boots were he/she was supposed to wear them.
The nurse clarified that there were no boots. A note dated 5/16/25 by Staff #4 wrote, Resident asked for his/her blue boots.
Nursing to follow up. A note dated 5/17/25 by Staff #9 (Registered Nurse) wrote that they were unable to find protector boots during the evening shift, and they were still missing. A note dated 5/18/25 by the attending Physician documented 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.The review of Resident #8's TAR for May 2025, on 11/05/25 at 10:30 AM, revealed that the resident had an order of Heel protector boots on at all times, remove for bathing every shift for heel protection from 4/24/25 to 5/27/25.
However, the TAR documentation for all shifts from 5/14/25 to 5/18/25 indicated that the boots were applied.
During an interview with the Director of Nursing (DON) on 11/06/25 at 12:19 PM, the surveyor reviewed Resident #8's TAR and progress notes with the DON.
She validated that there were discrepancies regarding Resident #8's boots: progress notes documented they were missed, but the TAR documented they were applied.
Facility ID: