The Citadel at Saint Joseph Village

Inspectors wroteBased on interview and record review, the facility failed to initiate a home health referral upon a residents (R1) discharge from the facility. This applies to 1 of 3 residents reviewed for discharge in the sample of 5.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident received an ordered low sodium diet. This applies to 1 of 3 residents (R1) reviewed for special dietary needs in the sample of 5.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain accurate records of controlled medications for seven (R6, R7, R8, R9, R10, R11, R12) of ten residents reviewed for medication management in the sample of 12.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the dishwasher temperature was at an appropriate temperature to sanitize dishes and silverware and failed to maintain the garbage disposal system. These failures have the potential to affect all residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 6 residents (R19, R25, R65, R85, R94, R106) were treated with dignity during mealtimes, and failed to provide assistance with facial hair grooming for 1 resident (R31). These failures apply to 7 of 7 residents reviewed for dignity in the sample of 23.

Inspectors wroteBased on observation, interview, and record review, the facility failed to administer medications at ordered times. There were 29 opportunities with 9 errors resulting in a 31% medication error rate. This applies to 4 of 6 (R31, R53, R80, R81) residents reviewed for medication pass.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prepare pureed foods to the desired consistency. This applies to 8 of 8 residents (R2, R35, R46, R48, R53, R87, R90, R91) reviewed for pureed foods in the sample of 23.

Inspectors wroteBased on interview and record review, the facility failed to provide HS (bedtime) snacks for 6 of 6 residents (R4, R8, R30, R34, R56, R80) reviewed for HS snacks in the sample of 23.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident had a wheelchair that fit and maintained body alignment and positioning needs for 1 of 1 residents (R60) reviewed for accommodation of needs in the sample of 23.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the elasticated tubular support bandages were in place for 1 of 1 residents (R60) reviewed for quality of care in the sample of 23.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident was positioned safely to prevent a fall for 1 (R4) of 4 residents reviewed for falls in the sample of 23.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure an indwelling catheter drainage bag was maintained below the level of the bladder for 1 of 3 residents (R31) reviewed for indwelling catheters in the sample of 23.

Inspectors wroteBased on observation, interview, and record review the facility failed to label open tube feeding, ensure a feeding tube dressing was intact, and check placement of a feeding tube prior to using the tube for 1 of 1 residents (R3) reviewed for enteral feeding in the sample of 23.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow professional standards when starting an intravenous (IV) antibiotic for 1 of 1 resident (R38) in the sample of 23.

Inspectors wroteBased on observation, interview, and record review the facility failed to have respiratory masks covered and stored in a manner to prevent any cross contamination for 3 of 3 residents (R3, R29, and R107) reviewed for respiratory care in the sample of 23.

Inspectors wroteBased on observation, interview, and record review, the facility failed to dispose of a residents (R90) expired insulin pen, failed to store narcotics in a manner to prevent medication diversion for a resident (R80). These failures apply to 2 of 2 medication carts reviewed for medication storage.

Inspectors wroteBased on observation, interview, and record review the facility staff failed to follow enhanced barrier precautions - EBP when providing care for a resident with a feeding tube for 1 of 3 residents (R3) reviewed for enhanced barrier precautions in the sample of 23.

Inspectors wroteBased on observation, interview, and record review the facility failed to honor resident preferences regarding menu items. This failure has the potential to affect all residents residing in the facility.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a resident (R1), with a urinary catheter in place, was dressed in a manner to prevent a resident injury, failed to ensure facility staff safely managed and positioned a resident's (R2) urinary catheter as the resident ambulated, and failed to ensure a resident (R3) was showered in a manner to prevent a resident fall. This failure resulted in R1 being sent to a local hospital after her skin was lacerated by a plastic clip connected to her urinary catheter as she was being dressed by facility staff. R1 required nine sutures to repair her laceration. These failures apply to 3 of 3 residents (R1, R2, R3) reviewed for resident safety and supervision in the sample of 3.

Inspectors wroteBased on interview and record review the facility failed to ensure residents were treated in a dignified manner for 3 of 3 residents (R1-R3) reviewed for dignity in the sample of 5.

Inspectors wroteBased on interview and record review the facility failed to provide showers to a resident that required staff assistance to shower for 1 of 3 residents (R1) reviewed for activities of daily living (ADLs) in the sample of 5.

Inspectors wroteBased on interview and record review the facility failed to follow up and obtain an ophthalmology appointment for a resident with vision loss for 1 of 3 residents (R1) reviewed for necessary care and services in the sample of 5.

Inspectors wroteBased on interview and record review the facility failed to ensure a surgical incision was cleansed per physician's order for 1 of 3 residents (R1) reviewed for physician's orders in the sample of 5.

Inspectors wroteBased on observation, interview, and record review, the facility failed to administer medications as ordered by the physician for one of six residents (R1) reviewed for medications in the sample of six.

Inspectors wroteBased on interview and record review, the facility failed to provide wound/skin treatments and failed to perform weekly skin checks. This applies to 4 of 5 (R4, R3, R1, R5) residents reviewed for improper nursing care in the sample of 6.

Inspectors wroteBased on interview and record review, the facility failed to identify and report the diversion of a resident's controlled substance. This applies to 1 of 3 residents (R5) reviewed for controlled substances in the sample of 6.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide treatments for a pressure wound. This applies to 1 of 5 residents (R2) reviewed for wound care in the sample of 6.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an accurate disposition of controlled substances, failed to have procedures in place to accurately measure controlled substances, and failed to maintain an accurate log of controlled substances. This applies to 1 of 3 residents (R5) reviewed for controlled substances in the sample of 6.

Inspectors wroteBased on interview and record review, the facility failed to safely reposition a resident in bed for one of seven residents (R1) reviewed for safety supervision in the sample of seven. This failure contributed to R1 experiencing multiple fractures which required a hospitalization. This past non compliance occurred from February 7, 2025 to March 8, 2025.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide physician ordered intervention that maintained the patency of a CVC-Central Venous Catheter for 1 of 1 resident (R2) reviewed for parental fluids in the sample of 18. This failure resulted in the occlusion of R2's catheter and the need for replacement.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure pureed Swiss steak was a smooth, uniform texture that does not require chewing for 4 of 4 residents (R2, R35, R52, R78) reviewed for pureed diets in the sample of 18.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a spatula and food processor components were washed and sanitized in a manner to prevent cross-contamination for 4 of 4 residents (R2, R35, R52, R78) reviewed for pureed diets in the sample of 18.

Inspectors wroteBased on observation, interview, and record review, the facility failed to treat a resident in a dignified manner for 1 of 18 residents (R9) reviewed for dignity in the sample of 18.

Inspectors wroteBased on observation, interview and record review the facility failed to safely transfer a resident by using a gait belt for 1 of 18 residents (R36) reviewed for safety in the sample of 18.

Inspectors wroteBased on observation, interview, and record review, the facility failed to administer medications as ordered. There were 37 opportunities with 4 errors resulting in a 10.81 % error rate. This applies to 1 of 3 residents (R2) observed in the medication pass.

Inspectors wroteBased on interview and record review the facility failed to ensure a resident received the correct insulins as ordered by an endocrinologist for 1 of 1 resident (R2) reviewed for significant medication errors in the sample of 18.

Inspectors wroteBased on observation, interview, and record review the facility failed to safely transfer a resident (R1) for 1 of 4 residents reviewed for safety in the sample of 6. This failure resulted in R1 falling, and hitting her head on the oxygen concentrator. R1's head laceration required 6 staples and 2 sutures for closure of the wound, in the emergency department.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide care to a resident with dementia in a manner to prevent escalating agitation for 1 of 3 residents (R4) reviewed for dementia in the sample of 6.

Inspectors wroteBased on interview and record review the facility failed to ensure a resident was transferred in a safe manner to prevent injury. This failure resulted in R4 sustaining a fractured femur during a transfer on [DATE]. This applies to 1 of 3 residents (R4) reviewed for falls in a sample of 4.

Inspectors wroteBased on observation, interview, and record review the facility failed to assess, treat, and document areas of skin damage to a resident's inner thigh and left knee. This applies to 1 of 3 residents (R1) reviewed for skin alterations in a sample of 4.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident's medication choice was followed for 1 of 3 residents (R1) reviewed for medications in the sample of 3.

Inspectors wroteBased on interview and record review the facility failed to treat residents in a dignified manner during care. This applies to 3 of 3 resident (R1, R2, and R3) reviewed for dignity in a sample of 3 residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to notify the physician of a new pressure wound, failed to initiate a treatment upon identification of a new pressure area, and failed to complete weekly assessments after identification of a new pressure wound. This failure resulted in R31's pressure wound deteriorating to a stage 3 before a wound treatment was initiated.

Inspectors wroteBased on observation, interview, and record review, the facility failed to treat 3 residents (R14, R60, R79) with dignity during mealtime. This applies to 3 of 3 resident's reviewed for dignity outside of the sample.

Inspectors wroteBased on interview and record review the facility failed to prepare a resident for discharge resulting in the resident exhausting his medication supply prior to his appointment with his primary physician. This applies to 1 of 3 residents (R80) reviewed for discharge in the sample of 21.

Inspectors wroteBased on observation, interview, and record review, the facility failed to perform a restorative assessment following a change in condition for a resident, failed to ensure a call light was available for a resident with a history of falls and failed to update a resident's care plan with updated fall interventions. These failures apply to 1 of 7 residents (R16) reviewed for falls in the sample of 21.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident had care orders for an indwelling catheter for 1 of 2 residents reviewed for catheters in the sample of 21.

Inspectors wroteBased on observation, interview, and record review, the facility failed to identify a resident (R57) was utilizing a BiPap (bi-level positive airway pressure) machine and failed to store a resident's BiPap mask in a sanitary manner for 1 resident (R57).

Inspectors wroteBased on observation, interview, and record review the facility failed label insulin pens with an open date and discard date. This applies to 1 of 1 resident (R70) reviewed for medications in the sample of 21 and one resident (R53) outside of the sample.

Inspectors wroteBased on observation, interview, and record review, the facility failed to wear personal protective equipment (PPE) into a COVID-19 positive resident's room. This applies to 1 of 5 residents (R8) reviewed for infection control in the sample of 21 and 1 resident (R4) outside of the sample.

Inspectors wroteBased on interview, and record review, the facility failed to ensure a resident refusing the COVID-19 vaccine did not receive it for 1 of 1 resident (R6) reviewed for immunizations in the sample of 10.

Inspectors wroteBased on interview and record review, the facility failed to ensure an employee was immediately removed from resident care pending the investigation of an allegation of missing medications for 1 of 3 residents (R1) reviewed for missing medications.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a resident was free from a significant medication error. This applies to 1 of 3 residents (R2) reviewed for medication administration in the sample of eight.