Citizens Care Center
Inspection Findings
F-Tag F0697
F 0697
Provide safe, appropriate pain management for a resident who requires such services.
Level of Harm - Minimal harm or potential for actual harm
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.
Residents Affected - Few
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.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99) Previous Versions Obsolete
Facility ID:
If continuation sheet
Event ID:
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.