The Citadel at Saint Anne Place

In the surveyor’s words

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

• Immediate jeopardy, isolatedF684Jan 25, 2021

  Based on interview and record review, the facility failed to provide the necessary care and services for a resident with unrelieved knee pain and swelling, which resulted in a delay in treatment of [REDACTED]. This applies to 1 of 3 residents (R1) reviewed for quality of care in the sample of 9. This failure resulted in an Immediate Jeopardy. The Immediate Jeopardy began on January 11, 2021 when R1 began complaining of right knee pain. The Immediate Jeopardy was identified on January 19, 2021. V1 (Administrator) was informed of the Immediate Jeopardy on January 25, 2021. […]

• Actual harm, isolatedF684Nov 25, 2025

  Based on interview and record review the facility failed ensure a thorough assessment was performed for a resident sustaining a fall and failed to identify an acute fracture prior to sustaining a second fall. This failure resulted in R3 sustaining a fall with x-ray results showing a right hip impacted subcapital fracture of right femoral neck without staff identifying and reporting her injury and sustaining a 2nd fall approximately two days later delaying emergency care and services. This applies to 1 of 3 residents (R3) reviewed for quality of care in the sample size 18. […]

• Actual harm, isolatedF684Jul 8, 2025

  Based on observation, interview, and record review the facility failed to assess, document, notify the provider, and monitor an injury of unknown origin for 1 of 3 residents (R1) reviewed for quality of care in the sample of 5. This failure resulted in R1 exhibiting signs of an injury (bruising, pain with movement of left arm) for three days before the facility notified the provider and obtained an order for an X-ray. R1's X-ray showed a non-displaced fracture of her left humerus (upper arm). The findings include: On 7/3/25 at 11:01 AM, R1 was seated in a padded, reclining wheelchair. R1 had a sling to her left arm. V5 (Unit Manager) explained to R1 that we needed to look at her arm. V5 unhooked R1's sling, removed her left arm from the sling, and exposed the skin to R1's upper arm. […]

• Actual harm, isolatedF686Jun 5, 2025

  4. R117's face sheet documents she was admitted to the facility on [DATE] with multiple diagnoses including the presence of a stage 3 pressure ulcer to the left buttock, a stage 4 pressure ulcer to the left lower back, stage 3 pressure ulcer to the sacral region, and stage 3 pressure ulcers to the right upper back and left lower back. On 6/4/25 at 10:25 AM, R117 was lying in her bed with an air mattress, and she was positioned onto her right side with pillows. The skin evaluation forms were requested and reviewed and show the first pressure ulcer assessments were completed on 5/8/25. On 6/5/25 at 9:24 AM, V10 RN, said when a resident is admitted with pressure injuries it is the responsibility of the admitting nurse to perform wound assessments and document them in the wound sheets. […]

• Actual harm, isolatedF689Jun 5, 2025

  Based on observation, interview and record review the facility failed to assist a resident at risk for falls with reaching his urinal (R58), and safely transferring a resident with a mechanical lift (R23 and R2). This failure resulted in R58 falling and obtaining a fractured hip and wrist requiring surgery and hospital stay. The applies to three of eleven residents reviewed for safety in the sample of 59. The findings include: 1. The facility face sheet shows R58 was admitted to the facility with diagnoses to include adult failure to thrive, Type 2 Diabetes Mellitus, chronic kidney disease and low back pain. R58's facility assessment dated [DATE] shows he has no cognitive impairment and required maximum assist from staff for standing and toileting. […]