The Citadel at Saint Joseph Village

In the surveyor’s words

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

• Immediate jeopardy, isolatedF686Jan 17, 2023

  I. Based on observation, interview, and record review, the facility failed to document wound assessments for a resident (R1), failed to notify a physician of a resident's worsening pressure wound (R1), failed to obtain new treatment orders for a resident's pressure wound (R1), failed to identify signs of infection for a resident's pressure wound (R1), failed to provide wound care in a manner to prevent infection for a resident (R1), failed to identify three pressure wounds for a resident caused by a medical device (R4). These failures contributed to R1's pressure wound advancing from a Stage 2 to an unstageable wound that became infected and required hospitalization , surgical debridement, and placement of a wound vac (negative pressure wound therapy). […]

• Actual harm, isolatedF689Sep 2, 2025

  Based 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. […]

• Actual harm, isolatedF689Mar 18, 2025

  Based 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. The findings include: 1. R1's Face Sheet dated March 17, 2025 shows she was admitted to the facility with diagnoses including fibromyalgia, morbid obesity, spinal stenosis, cervical spine fusion, major depressive disorder, repeated falls, and pain. R1's Care Plan dated August 16, 2019 shows R1 is requiring almost total care by staff. Assist of two people for all transfers. […]

• Actual harm, isolatedF694Dec 11, 2024

  Based 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. The findings include: R2's Current Minimum Data Set on 12/11/2024 shows, R2 is cognitively intact. On 12/11/24 at10:17AM, R2 pulled up her pant leg to reveal a CVC-Central Venous Catheter in her left upper thigh that had a blue colored locking cap labeled 3.6 milliliters and a red colored locking cap labeled 3.5 milliliters. The clear lumens of the red capped and blue capped catheter had dark red blood in the tubing. […]

• Actual harm, isolatedF689Sep 13, 2024

  Based 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. The findings include: On 9/10/24 at 10:05 AM, R1 was in wheelchair, being pushed to her room by a family member. There was dried blood and 6 stables on the top of R1's head, in her hairline. There was dried blood and scabbing along the staple line. The surveyor asked R1 if her head was sore and how it happened. R1 said her head hurt real bad when it first happened, but it was starting to get a little better. […]