Citadel at Casa Scalabrini

In the surveyor’s words

From the most serious findings on record at Citadel at Casa Scalabrini, in the surveyor’s own words.

• Actual harm, isolatedF689Mar 21, 2025

  Based on interview and record review, the facility failed to ensure that therapy recommendations for hands-on transfers were followed to prevent a resident from falling. This failure resulted in R132 falling and sustaining a fracture of the left fibula. This applies to 1 of 1 resident (R132) reviewed for accidents in the sample of 35. Findings include: R132's electronic medical record showed R132 is an [AGE] year old admitted to the facility on [DATE] with medical diagnoses that include cerebral infarction, repeated falls, malignant neoplasm of endometrium and uterus, unilateral primary osteoarthritis of the left knee, aphasia, and apraxia following cerebral infarction. […]

• Actual harm, isolatedF689Jun 1, 2021

  Based on interview and record review, the facility failed to provide the safe transfer of a resident using a sit-to-stand mechanical lift. This resulted in R1 sustaining a left wrist (distal radial) fracture. This applies to 1 of 3 residents (R1) reviewed for transfer with a mechanical lift in the sample of 3. This past noncompliance occurred from 5/18/2021 to 5/26/2021 Findings include: R1's EMR (Electronic Medical Record) shows R1 was admitted to the facility on [DATE]. R1 has multiple diagnoses including history of stroke, [CONDITION(S)], heart failure, hypertension, [CONDITION(S)], diabetes mellitus type 2, arthritis, [CONDITION(S)], and depression. R1's fall assessment dated [DATE] shows R1 was assessed to be at high risk for falls. […]

• No harm, potential for more than minimal, widespreadF812Mar 21, 2025

  Based on observation, interview and record review, the facility failed to follow sanitary practices in the facility kitchen. This applies to 172 residents that received foods prepared in the facility kitchen. Findings include: Facility's CMS (Centers for Medicare and Medicaid Services) Form 671 dated March 18, 2025 showed that the facility census was 176 residents. Facility provided information that there were 4 residents on NPO (nothing by mouth) status. On March 18, 2025 at 9:11 AM, during initial tour of the kitchen in the presence of V5 (Dietary Manager) the following observations were made: In the dry storage area, 2 dented cans at the seams were stored on horizontal shelving along with other cans. […]

• No harm, potential for more than minimal, widespreadF880Mar 21, 2025

  Based on observation, interview, and record review, the facility failed to follow their Water Management Plan for Legionella. The facility also failed to follow their policy for EBP (Enhance Barrier Precautions). This applies to all 176 residents residing in the facility. Findings include: 1. The facility's Long-Term Care Facility Application for Medicare and Medicaid dated March 18, 2025, showed the facility's census was 176 residents. On March 19, 2025, at 10:31 AM, V15 (Maintenance Director) said for the facility's Water Management Plan for Legionella, V15 tests the facility's water temperature in resident rooms and shower rooms. V15 continued to say the water temperatures in the kitchen and laundry are tested daily. […]

• No harm, potential for more than minimal, widespreadF921Jan 5, 2024

  Based on observation, interview and record review, the facility failed to remove lint from the facility's clothes dryers. This has the potential to affect all residents residing in the facility, staff, and visitors. Findings include: The facility's 1/2/24 Centers for Medicare and Medicaid Services Form 671 form showed a resident census of 156 residents. On 1/4/24 at 9:46am, all the facility's five dryers were observed not in use and with lint in the lint basket/catchers. The baskets all had lint on the sides and bottom of the baskets, and the lint in each basket was about 1/2 inch thick. On 1/04/24 at 9:46am, V9 (Laundry Staff) said that she did not remember if she had cleaned out the dryers today or not. […]