Citadel At Saint Benedict

Based on observation, interviews and record reviews, the facility failed to follow policy related to use of three-compartment sink; failed to maintain normal range of chemical concentration in the sanitizer buckets; and failed to properly label and date leftover foods in the refrigerator. These deficiencies potentially affect the 86 residents receiving foods in the kitchen. Findings include: Per census report, facility has 88 residents currently residing in the facility. Two residents are currently on NPO (nothing by mouth). On 05/27/25 at 9:55 AM during initial brief tour in the kitchen, the following leftover food items placed in a bowl covered with plastic, unlabeled, were observed stored in the walk-in refrigerator: drained pineapple - dated 05/21; apple sauce - dated 05/24; dried peas - undated; peaches - dated 05/21; cream of mushroom - dated 05/21. There was also a sandwich with lettuce and tomato unlabeled and undated, which was observed inside reach - in cooler. Subsequently, red sanitizer buckets were also checked. V4 (Account Manager Food Services) stated that red buckets…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide appropriate and sufficient supervision for a cognitively impaired resident (R45) with a history of falls, reviewed out of a sample of 39 residents. This failure resulted in R45 falling from her wheelchair and hitting her face against the floor, resulting in an injury of abrasions to her forehead. The facility also failed to properly assess R45 for injury and failed to send her to the hospital for evaluation after the incident. Findings include: R45 is a [AGE] year-old cognitively impaired female resident, with medical diagnosis including but not limited to dementia; cognitive communication deficit; unsteadiness on feet; abnormal posture; pain in left hip; and spinal stenosis, cervical region. R45's high risk for falls care plan, dated 05/06/2025, does not address constant close supervision, based oh her history of falls. R45's Fall Risk Assessment, dated 05/26/2055 indicates no falls in the past three months. Per R45's electronic…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review the facility failed to administer medications per physician's orders for two of five (R24, R61) residents observed during the medication pass in the final sample of 26. There were 29 opportunities with 4 errors resulting in a 13.79% medication error rate. Findings include: R24 is a [AGE] year-old admitted to the facility on [DATE] with diagnosis including but not limited to Heart Failure; Gastro-Esophageal Reflux Disease Without Esophagitis; Hereditary And Idiopathic Neuropathy; Hypertensive Heart Disease With Heart Failure; Personal History Of Covid-19; Presence Of Intraocular Lens; Ocular Hypertension, Right Eye; Nonexudative Age-Related Macular Degeneration, Bilateral; Personal History Of Other Malignant Neoplasm Of Rectum, Rectosigmoid Junction, And Anus; Polyneuropathy; Unspecified Atrial Fibrillation; Anemia In Neoplastic Disease; Essential (Primary) Hypertension; and Major Depressive Disorder. R61 is a [AGE] year-old admitted to the facility on [DATE]…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review the facility failed to administer pain medication as ordered by the physician for one of one resident (R2) reviewed for pain management. Findings include: R2's physician order sheet dated 12/27/24 shows orders for acetaminophen (Pain Relief/Antipyretic) tablet 325mg (milligrams) give 2 tablets by mouth every six hours as needed for pain, fever. Norco (Pain Relief) oral tablet 5-325mg, give one tablet by mouth every 8 hours as needed for pain. On 1/17/25 at 12:30pm ,V3, Registered Nurse (RN) said R2 was moving around in bed when R2 had a fall from R2's bed on 12/27/24 around 3:30pm. V3 said he did not recall the nurse reporting to him that R2 was admitted with a pubis ramus fracture. V3 said R2 did not have pain upon assessment. V3 said he did not administer pain medications to R2. R2's pain level summary denotes in-part on 12/27/24 at 8:07am R2's pain level was 5, on 12/27/24 at 3:46pm R2's pain level was 4, on 12/27/24 at 9:35pm R2's pain level was 4, at 9:36pm R2's pain level was 1 and at 9:37pm R2's pain level was 4. R2's medication…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure a resident was free from abuse for 1 of 3 residents (R3) reviewed for abuse in the sample of 6. Findings include: R3's Facesheet dated 1/4/24 showed she had diagnoses to include, but not limited to: metabolic encephalopathy; lack of coordination; abnormalities of gait and mobility; repeated falls; spinal stenosis; unspecified adrenocorticoid insufficiency; congestive heart failure; chronic kidney disease (stage 3A), major depressive disorder; anxiety; and a history of falling. R3's facility assessment dated [DATE] showed she was cognitively intact. R3's Skilled Nursing Evaluation dated 12/15/24 showed she was alert and oriented to person, place, and time; communicated verbally; speech was clear; and was able to understand and be understood. R3's Care Plan initiated 10/21/24 showed, R3 is at risk of possible abuse/neglect related a history of abuse. The interventions included, but were not limited to: Provide me with…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure a medication error rate of less than 5 percent (%). A medication pass observation on 05/13/2024 revealed 26 medication administration errors out of 31 opportunities, resulting in an 83.87% medication error rate. Findings include: Medication pass observation conducted on 05/13/2024 with V5 and V13 (Agency Registered Nurses) to 3 residents (R6, R7, R33) with the following observations: R7: On 05/13/24 11:28 AM, entered R7's room and observed a small clear plastic medication cup on top of the bedside table that was near the foot of bed which contained nine pills within. When asked whose medications were on the table, R7 stated those are my morning meds. She added that the nurse brought them earlier this morning, but she does not recall her name of nurse or the exact time the pills were left but knows it was before breakfast. R7 then said she knows the nurses are not supposed to leave her medications and she would prefer if the nurse stayed, but they are busy and trust her (R7) enough to take them by…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure that medical staff were properly trained to administer prescribed medications according to physician's orders and residents were free from significant medication errors. Three (R6, R7, R34) residents in the sampled medication pass of four residents (R6, R7, R33 and R34) experienced medication administration errors by the medication nurse. Findings include: R34: On 05/13/24 at 10:45 AM, observed R34 sitting in her wheelchair next to the bed with a bedside tray table in front of her. Also observed a clear, plastic medicine cup in front of resident on the bedside table that contained six pills within the cup. R34 said that her nurse had just left them a few minutes ago but she could not recall the nurse's name. She also said that she had already taken a few pills and needs to take the rest of her morning medications. When asked what these morning medications were, R34 said one is for my stomach, two are water pills, and I believe the one green pill is my iron pill. R34 could not remember what the two pink…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based in interview and record review, the facility failed to follow the abuse policy by not notifying the abuse coordinator with allegation of employee-to-resident abuse. This failure affected one (R1) of three reviewed for reporting abuse. Findings include: On 1-30-24 at 12:45 PM, V1 said when there is an allegation of abuse, the staff is expected to report the allegation of abuse to the abuse coordinator immediately. V1 said R1's nurse did not report the allegation of employee-to-resident abuse to her. V1 said she will send a state reportable, suspend staff pending investigation, begin investigation, and in-service staff on reporting abuse allegation. On 1-30-24 at 12:10 PM, V2 (Director of Nursing) said all staff are expected to notify Administrator and Director of Nursing immediately about any allegation of employee-to-resident abuse. V2 said the facility can begin the process of the abuse investigation. V2 said she was not made aware of the employee-to-resident allegation of abuse until told by surveyor. On 1-30-24 at 12:03 PM, V5 (Registered Nurse) said R1 is alert, confused,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.