Citadel at Saint Benedict

In the surveyor’s words

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

• Actual harm, isolatedF689Jan 22, 2025

  Based on interview and record review, the facility failed to develop and implement individualized plan of care interventions to reduce the risk of injury from falls. This failure affects two of four residents (R1, R2) reviewed for falls. These failures resulted in R1 being left unsupervised in the dining room and was later observed on the floor with an abrasion to the head. R1 was sent to the hospital and diagnosed with three compression fractures of the thoracic spine. These failures also resulted in R2 rolling out of bed, landing on R2's buttocks on the floor, and was subsequently diagnosed with a left comminuted hip fracture. […]

• Actual harm, isolatedF600Jun 30, 2024

  Based on observation, interview and record review, the facility failed to protect a residents' right to be free from verbal, physical and mental abuse by an employee. This failure affected one (R1) of four residents in the sample reviewed for abuse. This failure resulted in R1 feeling unhappy, fearful, and not wanting to have her daughter leave her alone at the facility. Findings include: R1's diagnosis includes: Anemia, unspecified, Hypothyroidism, unspecified, Type 2 diabetes mellitus without complications Hyperlipidemia, unspecified, Essential (primary) hypertension Athscl heart disease of native coronary artery w/o Cardiomyopathy, unspecified Acute respiratory failure with hypoxia, Gastritis osteoarthritis, unspecified site Muscle weakness (generalized). […]

• Actual harm, isolatedF689Jun 30, 2024

  Based on interview and record review, the facility failed to safely transfer a resident (R1) using a mechanical lift and failed to follow the facility procedure for use of a mechanical lift for one (R1) of four residents. The facility failure to follow the mechanical lift transfer safety guidelines resulted in injury to R1 who sustained bruises during a one-person staff transfer. Findings include: R1's diagnosis includes: Anemia, unspecified, Hypothyroidism, unspecified, Type 2 diabetes mellitus without complications Hyperlipidemia, unspecified, Essential (primary) hypertension Athscl heart disease of native coronary artery w/o Cardiomyopathy, unspecified Acute respiratory failure with hypoxia, Gastritis osteoarthritis, unspecified site Muscle weakness (generalized). […]

• Actual harm, isolatedF690May 16, 2024

  Based on interview and record review the facility failed to monitor and assess for signs of urinary catheter obstruction and monitor urine output for one (R21) of one resident reviewed for urinary tract infections on the sample list of 37. This failure resulted in R21's emergent hospitalization and diagnosis of severe sepsis and acute kidney injury. Findings include: R21 is a [AGE] year-old female admitted to the facility on [DATE] with diagnosis including but not limited to Metabolic Encephalopathy; Alzheimer's Disease; Age related Osteoporosis; Anemia; and Peripheral Vascular Disease. […]

• Actual harm, isolatedF686Mar 5, 2021

  Based on observation, interview, and record review, the failed to follow its policy to assess, identify, treat, and monitor resident who is at risk for developing pressure ulcer resulting in Deep Tissue Injury (DTI) . This deficiency affects two (R4, R55) of three residents in a sample of 18 reviewed for pressure ulcer/wound care management. Findings include: On 3/3/21 at 10:06am V14 Wound Care Coordinator (WCC) stated that R55 has left buttocks moisture associated skin disorder (MASD), she classified it as skin irritation/excoriation in wound report. Treatment ordered was Mupirocin 2% ointment and Calcium Silver Alginate. V14 turned R55 to his left side to provide wound care on sacral area. V14 stated right buttocks has skin dry, peeling skin, no redness, and skin intact. […]