Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Citizens Care Center during CMS and state inspections, most recent first.
A resident with an order for morning Tylenol Extra Strength 500 mg for pain reported pain at a level of 8/10 and received the medication, but staff did not document any follow-up assessment to determine the effectiveness of that dose. Later the same day, the physician ordered Tylenol Extra Strength 500 mg every 8 hours for pain, and the first dose under this new order was associated with a documented pain level of 0. Review of the MAR and staff interviews, including with the DON, confirmed there was no evidence that nursing staff reassessed the resident’s pain after the initial morning administration.
A resident's wishes regarding life-sustaining treatment were not timely updated or clearly documented, despite the resident expressing a desire for CPR and being alert and oriented. Staff failed to complete a timely capacity evaluation after changes in the resident's condition, resulting in discrepancies and unclear documentation about the resident's code status and decision-making authority.
A resident exhibited increased confusion and tearfulness, which was documented by both nursing and social work staff. However, there was no evidence that the provider was notified of this change in mental status, as required. Nursing leadership confirmed that the notification did not occur or was not documented.
A resident's TAR indicated that heel protector boots were applied as ordered, but progress notes from multiple staff and the physician documented that the boots were missing and unavailable for several days. The DON confirmed discrepancies between the TAR and progress notes, showing that the resident's care was not accurately documented.
The facility failed to maintain water temperatures within an acceptable range, with multiple rooms showing elevated temperatures. The Director of Maintenance confirmed the issue was due to the boiler system, but could not provide documentation of temperature checks. The Administrator admitted that water temperatures in resident rooms were not being monitored, leading to the deficiency.
A facility failed to ensure proper follow-up and care for residents, including a missed urology appointment for a resident with a Foley catheter, improper positioning and timing of enteral nutrition, and incorrect oxygen administration. Additionally, pain management orders were not transcribed, leading to unclear medication administration. These deficiencies were observed in several residents, highlighting lapses in adherence to physician orders and care protocols.
A resident was not assisted out of bed for four out of five days and was not dressed in their own clothing, instead wearing a soiled hospital gown. Staff interviews revealed the resident preferred the gown, but the GNA did not inform the nurse about the resident's prolonged bed stay. The Unit Manager stated that residents typically get out of bed after breakfast unless they refuse, in which case the nurse should be notified.
A facility failed to issue a bed hold notice to a resident or their representative during a hospitalization. The deficiency was identified during a recertification survey when a surveyor found no documentation of the notice in the medical record. The DON confirmed the absence of such documentation.
A facility failed to follow the care plan for a resident with a suprapubic catheter, missing a required urology follow-up. The resident, with Multiple Sclerosis and Benign Prostatic Hyperplasia, did not receive a urology consultation within six months as planned. The DON acknowledged the oversight, attributing it to the physician's inability to accommodate the resident on a stretcher.
An LPN failed to ensure a resident consumed their medication before leaving the room, placing a protein supplement on the bedside table without instructions. The MAR audit showed discrepancies in medication administration times, not adhering to the standard practice of administering within an hour of the scheduled time.
The facility did not conduct annual performance reviews for its GNAs as required. During a survey, it was found that no evaluations were completed for the years 2022 and 2023 for four GNAs. The DON admitted to being behind on evaluations, and a staff educator stated that conducting evaluations was not part of her role. This issue was discussed with the administrative team during the survey exit conference.
A facility failed to timely address a pharmacy recommendation for a resident prescribed PRN lorazepam. The pharmacist's MRR highlighted the need for a stop date or documented rationale for extending the PRN order, but the physician did not respond, and the order remained active without necessary documentation. The issue was identified during a review, and the PRN lorazepam was eventually discontinued after a delay.
A resident prescribed Zyprexa was not monitored for side effects, as required by an existing order. The MAR and TAR lacked documentation of monitoring, despite staff acknowledging the need to report and document behavioral changes. This deficiency was identified during a survey, highlighting a lapse in the facility's monitoring process.
Surveyors found deficiencies in medication management and storage, including an unattended and unlocked medication cart with Baclofen, expired medications, and improperly stored supplies. Temperature logs for biologicals and supplements were inconsistently recorded, and expired items were found in medication rooms. Staff acknowledged these issues, indicating lapses in the facility's practices.
The facility failed to document and maintain accurate inventory sheets for residents' personal effects and ensure the accuracy of medical orders. Two residents' inventory sheets lacked signatures and dates, and staff were uncertain about a resident's denture status. Additionally, a discrepancy was found between a medical order and a wound consult for a resident with a pressure ulcer, with the order directing care on the wrong side of the body.
The facility failed to document that four GNAs completed the required 12 hours of annual clinical training for 2022 and 2023. The DON could not provide evidence of training completion during a survey, and the staff educator indicated that staff education was not her primary role. This issue was discussed with the administrative team during the survey exit conference.
Failure to Document Follow-Up Pain Assessment After PRN Analgesic Administration
Penalty
Summary
Facility staff failed to provide appropriate follow-up assessment for a resident who reported serious pain after receiving pain medication. Clinical record review showed that the resident had an existing order for Tylenol Extra Strength 500 mg to be administered in the morning for pain. On 12/30/25, the resident reported pain rated 8 out of 10 and was given the ordered Tylenol at approximately 9:00 AM. However, there was no documented evidence that nursing staff returned to reassess the resident’s pain level or evaluate the effectiveness of the medication after administration. Further review of the clinical record showed that later that same day, at 5:00 PM, the physician added a new order for Tylenol Extra Strength 500 mg, one tablet every 8 hours, for the diagnosis of pain. The resident received the first dose under this new order at 6:02 PM and had a documented pain level of 0 afterward. During an interview, the DON was shown the December 2025 MAR, including the documented pain level of 8 on 12/30/25 and the absence of a follow-up pain assessment. After reviewing the concern with the unit manager, the DON confirmed they could not find evidence that a nurse had followed up on the effectiveness of the morning pain medication dose.
Failure to Timely Update and Document Resident's Life-Sustaining Treatment Preferences
Penalty
Summary
The facility failed to update and accurately document a resident's wishes regarding life-sustaining treatment and did not assess the resident's decision-making capacity in a timely manner. The resident, who was their own responsible party, had a Maryland MOLST form indicating a DNR (Do Not Resuscitate) order, but subsequent documentation by staff indicated the resident expressed a desire to attempt CPR and was alert and oriented at that time. Despite this, the MOLST was not updated to reflect the resident's clarified wishes, and there were discrepancies between the resident's expressed preferences and the orders documented in the medical record. Further review revealed that after the resident experienced changes in condition and was transferred to and from the hospital, staff expressed discomfort discussing code status and requested a re-evaluation of the resident's capacity. However, no timely capacity evaluation was completed, and the medical records remained unclear about who the decision maker was during this period. Both the DON and the social worker confirmed these discrepancies and the lack of timely assessment, resulting in unclear and inconsistent documentation of the resident's life-sustaining treatment preferences.
Failure to Notify Provider of Resident's Change in Mental Status
Penalty
Summary
The facility failed to ensure timely notification to a physician regarding a resident's change in condition. Specifically, a resident was observed by a registered nurse to be tearful and experiencing increased confusion, which was also documented by a social worker. Despite these documented changes in the resident's mental status, there was no evidence in the medical record that the provider was notified of the change. Interviews with the Assistant Director of Nursing and the Director of Nursing confirmed that such changes should be communicated to the provider and documented, but no such documentation or notification was found for this incident.
Inaccurate Documentation of Resident's Treatment Administration Record for Heel Protector Boots
Penalty
Summary
The facility failed to ensure accurate documentation of a resident's Treatment Administration Records (TAR) regarding the use of heel protector boots. During the investigation, it was found that although the resident's TAR indicated that the boots were applied during all shifts from 5/14/25 to 5/18/25, progress notes from multiple staff members documented that the boots were missing and could not be located. Staff notes included reports from both nursing staff and the attending physician, who noted the resident's requests for the boots and the need to order replacements, indicating the boots were not available as required by the physician's order. The discrepancy was confirmed during a review of the records with the Director of Nursing, who acknowledged that the TAR documentation did not match the progress notes. The resident had an active order for heel protector boots to be worn at all times except during bathing, but the documentation failed to accurately reflect the resident's actual care and the absence of the boots during the specified period.
Failure to Maintain Safe Water Temperatures
Penalty
Summary
The facility failed to ensure that water temperatures remained within an acceptable range, as observed during a survey of the Harbor View Unit. On multiple occasions, water temperatures in resident rooms were found to be significantly above the recommended levels, with temperatures ranging from 120 degrees Fahrenheit to as high as 137.5 degrees Fahrenheit. The Director of Maintenance (DOM) was notified and confirmed the elevated temperatures, attributing the issue to the facility's boiler system, which had been powered down for the use of the chiller. However, the DOM could not provide documentation of water temperature checks during this process. Residents in the affected rooms, including two specific residents, were interviewed, and while they did not report any burns or issues, the elevated temperatures posed a potential risk. Further observations revealed that water temperatures in several other rooms were also above the acceptable range. The surveyor and the DOM conducted dual observations, confirming the elevated temperatures. During an interview, the Administrator and the DOM admitted that water temperatures in resident rooms were not being monitored, as they had assumed the temperatures were being taken at the boiler. This oversight led to the deficiency, as the facility failed to ensure a safe environment free from accident hazards related to water temperature.
Multiple Deficiencies in Resident Care and Treatment
Penalty
Summary
The facility failed to ensure that a resident followed up with a urologist for the management of a Foley catheter. Resident #18, who was admitted with multiple sclerosis and benign prostatic hyperplasia, had an indwelling catheter and was recommended to follow up with a urologist within six months. However, the follow-up did not occur as the resident missed an appointment due to the physician's inability to accommodate the resident via a stretcher. The Director of Nursing acknowledged the need for arrangements to be made for the follow-up. Resident #59 experienced multiple deficiencies in care. The resident was observed with a dark red dried substance on the left earlobe, which was not addressed until brought to the attention of an LPN. A physician's order to apply bacitracin to the left ear every morning and evening was not followed. Additionally, the resident was not properly positioned for enteral nutrition, with the head of the bed not elevated to the required 35-degree angle, risking aspiration. The enteral nutrition was also not administered during the ordered times, and medications were given outside the prescribed time frame. Resident #33 was observed receiving 3L of oxygen via nasal cannula, contrary to the physician's order of 2L. The LPN was unaware of the discrepancy and had not assessed the oxygen concentrator. Similarly, resident #100 was on 4.5 liters of oxygen instead of the ordered 2 liters. Furthermore, resident #1 had a physician order for pain management using a pain scale that was not transcribed or processed, leading to a lack of clarity in administering Tylenol and Tramadol for pain relief.
Failure to Uphold Resident Dignity and Personal Preferences
Penalty
Summary
The facility staff failed to uphold the resident's right to be treated with respect and dignity by not getting a resident out of bed for four out of five days and not dressing the resident in their own clothing. This deficiency was observed in one resident during the survey. On multiple occasions, the resident was found in bed wearing a soiled hospital gown, with uncombed hair, and the blinds closed. Interviews with staff revealed that the resident preferred to wear a hospital gown while in bed, and the Geriatric Nursing Assistant (GNA) assigned to the resident did not get them out of bed on several days. The GNA was also unable to confirm if the assigned nurse was informed about the resident not being dressed in their clothing and not getting out of bed for several days. The Unit Manager described the typical routine for residents, which includes getting out of bed after breakfast, but noted that if a resident refuses, the nurse should be informed.
Failure to Issue Bed Hold Notice
Penalty
Summary
The facility failed to issue a bed hold notice to a resident or their representative during a hospitalization event. This deficiency was identified during the facility's recertification survey. The surveyor reviewed the medical record and found a nursing progress note indicating that the resident was transferred to the hospital. However, there was no documentation in the medical record to show that the facility had issued the required bed hold notice. The surveyor requested documentation from the Director of Nursing (DON) to confirm whether the bed hold notice had been provided. During an interview, the DON admitted that the facility did not have any documentation to prove that the bed hold policy was communicated to the resident or their representative.
Failure to Follow Care Plan for Resident with Catheter
Penalty
Summary
The facility failed to adhere to the care plan for a resident with a foley catheter, specifically in managing follow-up urology consultations. The resident, who has a history of Multiple Sclerosis and Benign Prostatic Hyperplasia, was admitted with an indwelling suprapubic catheter due to a neurogenic bladder. The care plan, which was last revised in August 2022, included a requirement for urology consults as ordered. However, the facility did not ensure that the resident received a follow-up urology consultation within six months after the last one in April 2022. During an interview, the Director of Nursing (DON) acknowledged the lapse in following the care plan, citing the physician's inability to accommodate the resident on a stretcher as a reason for the missed consultation. This oversight was identified during a survey, which reviewed the medical records and included interviews with facility staff. The deficiency was discussed with the administration team at the time of the survey's exit.
Failure to Ensure Medication Consumption Before Leaving Resident's Room
Penalty
Summary
The nursing staff failed to meet professional standards of care by not ensuring that medication was consumed prior to leaving the resident's room. This deficiency was observed when an LPN administered medications to a resident and placed a dark amber colored liquid in a small cup on the resident's bedside table without ensuring the resident consumed it. The LPN left the room without providing any directions to the resident regarding the medication. A GNA later identified the liquid as a protein supplement. The LPN confirmed that the standard practice is to ensure the resident completes the medication before leaving the room. A review of the Medical Administration Record (MAR) audit for the resident showed that several medications, including Tylenol, Potassium Chloride, Lasix, and Prostat, were scheduled for administration at specific times. The MAR audit revealed discrepancies in the documentation times, with the Lasix documented at 11:29 AM and the other medications at 11:34 AM, despite the standard practice of administering medications within an hour before and after the due time.
Failure to Conduct Annual Performance Reviews for GNAs
Penalty
Summary
The facility failed to conduct annual performance reviews for geriatric nursing assistants (GNAs) based on their hire dates, as required. This deficiency was identified during a survey when the surveyor reviewed the human resource and staff education files. The surveyor requested records for seven staff members, including four GNAs, and found no evidence of completed performance evaluations for the years 2022 and 2023 for these GNAs. During interviews, the Director of Nursing (DON) admitted to being behind on completing the evaluations and acknowledged the need for improvement. Additionally, a staff educator mentioned that conducting performance evaluations was not part of her primary or secondary roles. The facility was unable to provide completed performance reviews for the GNAs in question, and this issue was discussed with the administrative team during the survey exit conference.
Failure to Address Pharmacy Recommendation for PRN Lorazepam
Penalty
Summary
The facility failed to address a pharmacy recommendation in a timely manner for a resident who was prescribed PRN lorazepam. The pharmacist conducted a medication regimen review (MRR) and issued a letter to the physician on 3/8/24, highlighting the need for a stop date for the PRN psychotropic drug, as required by policy. The letter suggested a 14-day stop date or, if extended, required the prescriber to document the rationale and indicate the duration for the PRN order. However, the physician did not respond to the letter by checking any of the provided options (agree, disagree, or other), nor was there any documentation in the medical record indicating that the PRN lorazepam order was discontinued or adjusted. The deficiency was identified during a record review and interviews with facility staff. The Nurse Manager confirmed the absence of documentation regarding the discontinuation of the PRN lorazepam order, which was initially prescribed on 2/21/24. The Director of Nursing later provided documentation that the PRN lorazepam was discontinued on 5/6/24, indicating a delay in addressing the pharmacist's recommendation. This oversight affected the resident's medication management, as the necessary actions to comply with the facility's policies and procedures were not taken promptly.
Failure to Monitor Psychotropic Medication Side Effects
Penalty
Summary
The facility staff failed to monitor a resident for side effects of psychotropic medication, specifically Zyprexa, which was prescribed at different dosages over time. The medication administration record (MAR) and treatment administration record (TAR) for the resident did not contain documentation verifying that the resident was being monitored for side effects. This deficiency was identified during a survey when the records were reviewed, revealing a lack of documentation for monitoring side effects despite an existing order to do so. Interviews with facility staff, including an LPN and the Director of Nursing (DON), highlighted a gap in the monitoring process. The LPN indicated that changes in behavior would be reported and documented, but there was no evidence of such documentation in the resident's records. The DON confirmed that there should have been an order for staff to document side effects, yet the records showed no such documentation. This oversight was evident for one of the two medical records reviewed during the survey.
Medication Management and Storage Deficiencies
Penalty
Summary
The facility failed to ensure proper medication management and storage, as observed by surveyors. On one occasion, a medication cart on the Bay Lane Unit was left unattended and unlocked, with a Baclofen medication blister packet and scissors left on the work surface. This incident was acknowledged by a registered nurse who admitted to leaving the cart unlocked while searching for tube feeding supplies. Additionally, the surveyor found that expired medications and improperly stored medical supplies were present in the medication storage rooms. The temperature logs for refrigerators storing biologicals and supplements were not consistently recorded, indicating a lack of adherence to proper storage protocols. Further observations revealed multiple deficiencies in the treatment cart and medication room on Harbor View and Bay Lane. Opened and exposed medical supplies, expired medications, and biologicals were found, along with a lack of daily temperature checks for refrigerated items. Interviews with nursing staff and management confirmed these findings, with admissions that maintenance and nursing staff were responsible for checking refrigerator temperatures and ensuring supplies were up to date. The presence of expired and improperly stored items, along with the failure to maintain accurate temperature logs, highlights significant lapses in the facility's medication management practices.
Deficiencies in Documentation and Medical Order Accuracy
Penalty
Summary
The facility failed to properly document and maintain inventory sheets for residents' personal effects, as well as ensure the accuracy of medical orders. During the recertification survey, it was found that inventory sheets for two residents lacked signatures and dates, making it unclear when the inventory was conducted. Specifically, one resident reported broken dentures, but the inventory sheet did not list any dentures, and staff were uncertain about the resident's denture status upon admission. The Director of Nursing confirmed that staff are responsible for updating and documenting items on the inventory form. Additionally, the facility failed to ensure the accuracy of a medical order for wound care. A discrepancy was found between the medical order and the wound consult for a resident with a pressure ulcer. The medical order directed wound care on the right ischium, while the wound consult indicated the wound was on the left ischium. The Director of Nursing confirmed the inconsistency after reviewing the medical record with the surveyor.
Deficiency in GNA Training Documentation
Penalty
Summary
The facility failed to ensure that four geriatric nursing assistants (GNAs) received and completed the required 12 hours of clinical training annually. This deficiency was identified during a survey when the director of nursing (DON) was unable to provide documentation proving that the GNAs completed the necessary training for the years 2022 and 2023. The surveyor requested human resources and staff education records for seven employees, including four GNAs, one licensed practical nurse (LPN), and two registered nurses (RNs). However, the records provided did not include evidence of the GNAs' training completion. During an interview, the staff educator, identified as staff #9, stated that staff education was not her primary or secondary role, although she occasionally assisted with teaching and scheduling clinical in-services. She also did not conduct annual performance evaluations for the GNAs. This lack of documentation and oversight was discussed with the facility's administrative team during the survey exit conference.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Havre De Grace
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Lorien Bulle Rock | 4.3 mi | — | 0 | 0 |
| Sterling Care Riverside | 9.4 mi | — | 0 | 0 |
| Lorien Nsg & Rehab Ctr Belair | 10.7 mi | — | 9 | 0 |
| Autumn Lake Healthcare At Calvert Manor | 12.3 mi | — | 2 | 0 |
| Laurelwood Healthcare Center | 14.2 mi | — | 16 | 0 |
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