Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around November 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 Memorial Healthcare Facility during CMS and state inspections, most recent first.
A resident with a history of intracerebral hemorrhage and anxiety, care planned to receive calm, reassuring communication, approached an NP at the nurses' station with concerns about blood pressure medication. During this interaction, the resident and NP engaged in a heated argument, with both raising their voices, and multiple staff heard loud yelling. A CMT observed the NP yelling at the resident while a nurse and charge nurse at the desk did not intervene, despite facility policy requiring respect and dignity for residents. The SSD, DON, and other staff confirmed that the NP became loud and matched the resident's tone, and the resident later reported feeling that the NP was not listening or understanding their concerns.
Staff failed to provide proper pressure ulcer care and prevention for two residents, including not addressing a resident's need for an appropriately sized bed, delaying follow-up with a physician regarding a wound culture, and not performing proper hand hygiene during wound care. These actions led to worsening wounds, infection, and inadequate infection control practices.
Surveyors found that appropriate care was not consistently provided for residents who were continent or incontinent of bowel and bladder, including improper catheter care and insufficient measures to prevent UTIs. These deficiencies were observed during the survey and were linked to failures in following established protocols.
The facility failed to accurately document and administer narcotic pain medications for two residents, leading to a deficiency in pharmaceutical services. A resident reported not receiving pain medications during the night as documented by an LPN, while another resident's medication administration did not align with physician's orders. Staff interviews revealed a lack of adherence to medication administration policies, and the DON and Administrator acknowledged the errors.
NP Engages in Loud, Disrespectful Argument With Resident Over Medication
Penalty
Summary
The deficiency involves a failure to ensure a resident was treated with dignity and respect when a Nurse Practitioner (NP) engaged in a loud, disrespectful interaction with the resident at the nurses' station. The facility's policy on Patient Rights and Responsibilities, last revised in November 2026, states that personnel will be oriented and instructed in observing patient rights, including the right to dignity and respect and to be treated with consideration, recognizing each resident's individuality. Resident #1, admitted on 05/21/20 with a diagnosis including nontraumatic intracerebral hemorrhage and anxiety, had a care plan directing staff to allow ample time to absorb and respond to information, provide a calm therapeutic environment, and use a calm, reassuring approach with explanations and reassurance. According to the resident, during an encounter a few months prior, the resident was upset about blood pressure medication and went to the nurses' desk to speak with the NP. The resident reported that he/she and the NP "got into it" and yelled at each other. CMT B, who was in the medication room next to the nurses' desk, heard yelling, looked out, and observed the resident and NP in a heated argument about the resident's medication, with both the NP and the resident yelling. CMT B stated that staff should not yell or raise their voice to residents and noted that a nurse and a charge nurse were present at the desk during the yelling and did not attempt to intervene. CMT C reported hearing loudness from the area and later being told that the NP and resident had been loud with each other. The Social Services Director (SSD) and the Director of Nursing (DON) both described hearing loud voices and observing or being informed that the NP and resident were loud with each other. The SSD stated the resident later reported feeling that the NP was not listening or understanding what the resident was trying to say. The DON reported hearing loud voices from her office, exiting to find the resident yelling at the NP, and observing the NP at the nurses' station facing the nurse on duty while they appeared to disagree over an order requested by the resident. The DON and other staff, including CNAs and RNs, indicated that staff yelling at residents is inappropriate and not respectful or dignified. The Director of Clinical and the Administrator both reported being informed that the NP had become loud with the resident and that the NP had matched the resident's tone during the interaction.
Failure to Provide Proper Pressure Ulcer Care and Infection Control
Penalty
Summary
Facility staff failed to provide appropriate care and prevention for pressure ulcers, resulting in deficiencies in both the management of existing wounds and the prevention of new ulcers. For one resident with a history of peripheral vascular disease, diabetes, and prior toe amputation, staff did not adequately address the need for an appropriately sized bed, despite repeated reports from the resident, CNAs, and therapy staff that the resident was too tall for the bed and frequently slid down, causing the toes to press against the foot board. Multiple interventions, such as wedges and heel protectors, were attempted but were ineffective, and documentation shows that the resident's need for a longer bed was not addressed in a timely manner. The resident developed a pressure ulcer on the right great toe, which worsened over time and eventually became infected with MRSA, leading to hospitalization and amputation. Additionally, staff failed to follow up with the physician in a timely manner regarding a wound culture for the same resident. After a wound culture was obtained due to signs of infection and stalled healing, preliminary results indicating a staph infection were available, but there was a delay in notifying the physician and initiating appropriate antibiotic therapy. Documentation gaps were noted, including missing records of daily dressing changes and unclear communication between nursing staff and the nurse practitioner regarding the wound culture results and subsequent care. For another resident with a history of chronic pressure ulcers and osteomyelitis, staff failed to utilize appropriate hand hygiene prior to and during pressure ulcer wound care. Facility policy requires hand hygiene before and after patient contact, before donning gloves, and after glove removal, but observations revealed that these protocols were not consistently followed. This lapse in infection control practices further contributed to the facility's failure to provide care in accordance with professional standards and facility policy.
Deficient Bowel/Bladder and Catheter Care Leading to UTI Risk
Penalty
Summary
The report identifies a deficiency related to the provision of care for residents who are continent or incontinent of bowel and bladder, as well as the management of catheter care and the prevention of urinary tract infections (UTIs). Surveyors found that appropriate care was not consistently provided to residents in these areas. Specific failures included inadequate attention to the needs of residents with continence or incontinence issues, improper catheter care, and insufficient measures to prevent UTIs. These lapses were observed during the survey and were directly related to the facility's failure to follow established protocols for continence care, catheter management, and infection prevention.
Inaccurate Documentation and Administration of Narcotic Pain Medications
Penalty
Summary
The facility failed to ensure the accurate administration and documentation of narcotic pain medications for two residents, leading to a deficiency in pharmaceutical services. Resident #1, who was cognitively intact and had a history of chronic pain, reported not receiving pain medications during the night as documented by LPN A. Despite the resident's statement that they had not requested or received pain medication during the night, LPN A documented the administration of oxycodone on multiple occasions. This discrepancy was noted by other staff members, who reported the issue to the Director of Nursing (DON), but the medication pass was deemed normal by the DON. Resident #2, who had moderate cognitive impairment and a history of chronic pain, was documented by LPN A as receiving hydrocodone at times that did not align with the physician's orders. The resident's MAR and Controlled Drug Record showed inconsistencies in the timing of medication administration, with doses given more frequently than prescribed. LPN A admitted to preparing medications in advance and sometimes forgetting to adjust the administration time, leading to further discrepancies in documentation. Interviews with various staff members, including CMTs and RNs, revealed a lack of adherence to the facility's medication administration policy, which requires verification of the right patient, medication, dose, time, and route. The DON and Administrator acknowledged the documentation errors and the failure to administer medications as prescribed. The Director of Pharmacy Services confirmed that PRN pain medication orders should not be liberalized, emphasizing the need for strict adherence to physician's orders.
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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 Bolivar
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Parkview Health Care Facility | 0.7 mi | — | 0 | 0 |
| Big Spring Care Center For Rehab And Healthcare | 14.7 mi | — | 3 | 0 |
| Northwood Hills Care Center | 15.5 mi | — | 0 | 0 |
| Colonial Springs Healthcare Center | 17.9 mi | — | 7 | 0 |
| Buffalo Prairie Center For Rehab And Healthcare | 18 mi | — | 17 | 1 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.