Citizens Care Center
CITIZENS CARE CENTER in HAVRE DE GRACE, MD — inspection on January 29, 2026.
Found 1 citation. 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
Provide safe, appropriate pain management for a resident who requires such services.
Based clinical record review and staff interview it was determined that the facility staff failed to ensure a resident reporting serious pain received a follow up assessment after receiving treatment for the pain to ensure effectiveness of the treatment.
This was evident for one (Resident #46) out of three residents reviewed pain during the recertification/complaint survey.The findings include: A review of a facility reported incident (#2704171) was conducted on 1/20/26. A review of the resident's clinical record on the same day revealed that Resident #46 was ordered Tylenol extra strength 500 mg to be administered in the morning for pain.
The resident reported pain on 12/30/25 that was rated as 8 out 10.
The resident was administered the medication at approximately 9:00 AM but there was no evidence that staff went back to see if it was effective.
The resident's physician added a medication order at 5:00 PM on the same day for Tylenol extra strength 500 mg one tablet every 8 hours for the diagnosis of pain.
The resident received their first dose at 6:02 PM and had a pain level of 0 as a result.
The Director of Nursing (DON) was interviewed on 1/23/26 at 3:40 PM.
This surveyor informed her of the facility reported incident that prompted a review of pain levels and the administration of pain medication during the month of December 2025.
She was then shown the Medication Administration Record (MAR) for December 2025 and the lack of a documented follow up to the pain level of 8 on 12/30/25.
She said she would investigate.
The DON returned to the conference room where the survey team was working on 1/23/26 at 4:45 PM.
She informed this surveyor that she investigated the concern and was aided by the unit manager.
They could not find evidence that a nurse followed up on the effectiveness of the pain medication.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.
For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
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