Citizens Care Center
Inspection Findings
F-Tag F0578
F 0578
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.
Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
Event ID:
Facility ID:
If continuation sheet
Printed: 04/13/2026 Form Approved OMB No. 0938-0391
Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
B. Wing
A. Building
(X3) DATE SURVEY COMPLETED
11/07/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Citizens Care Center
415 South Market Street Havre DE Grace, MD 21078
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F-Tag F0580
F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
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.
Event ID:
Facility ID:
If continuation sheet
Printed: 04/13/2026 Form Approved OMB No. 0938-0391
Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
B. Wing
A. Building
(X3) DATE SURVEY COMPLETED
11/07/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Citizens Care Center
415 South Market Street Havre DE Grace, MD 21078
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F-Tag F0842
F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
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.
Event ID:
Facility ID:
If continuation sheet
CITIZENS CARE CENTER in HAVRE DE GRACE, MD inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in HAVRE DE GRACE, MD, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from CITIZENS CARE CENTER or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.