Below average — CMS composite of the measures below.
A standard survey is most likely before around September 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at The Citadel At Saint Anne Place during CMS and state inspections, most recent first.
A resident with no cognitive impairment reported that her personal packages were repeatedly delivered already opened, causing her concern and discomfort. Staff interviews revealed that while mail and packages for residents were supposed to be sorted at reception and delivered unopened by Life Enrichment staff, this resident’s packages were routinely held so the DON could open and inspect them in the reception area or office before delivery, with only approved items passed on. Life Enrichment staff confirmed they picked up the resident’s packages already opened and told her the DON had to review the contents first. The Administrator stated staff should not open resident mail or packages except in front of the resident with consent, and both the Administrator and DON acknowledged there was no signed permission from the resident, despite a facility policy stating that mail may not be opened without the resident’s permission.
A cognitively intact resident with an active order for a daily lidocaine 4% patch for low back pain had MARs indicating consistent administration with only a few documented refusals, yet the resident reported not receiving the patch for several consecutive days. An RN confirmed there were days when the resident did not receive the patch, including occasions when the RN did not realize the resident had gotten out of bed, while the MAR still reflected administration. The DON reported that staff did not reattempt application when the resident refused, contrary to the facility’s medication administration policy requiring medications to be administered as prescribed and in accordance with good nursing practice.
A resident with dementia, stroke, and mobility deficits was transferred from the bathroom by a CNA without required two-person assistance or a gait belt, contrary to the care plan. The resident fell to the floor, sustaining a skin tear, and required help from three staff to return to the wheelchair. Facility policy on safe lifting and movement was not followed.
Failure to assess and report fracture after resident fall: A resident with dementia, high fall risk, and repeated falls sustained a fall with right hip pain and guarding, but staff did not complete or document a thorough post-fall assessment or timely notify the NP of the injury. An x-ray later showed a right femoral neck fracture, yet the resident was not sent out and then fell again, after which hospital records confirmed the fracture with decreased ROM, pain, and an externally rotated, shortened RLE.
A facility failed to ensure timely response to call lights for 4 residents reviewed for dignity. Residents reported waiting 15 minutes to 2 hours for assistance, being left in wet briefs or incontinent while waiting, and feeling helpless or that their needs were immaterial. One resident said an IV alarm beeped for 30 minutes until the surveyor notified the nurse, and another reported sometimes trying to get to the bathroom alone after call lights went unanswered, with prior falls and ongoing fear of falling.
Failure to identify and prevent worsening pressure-related skin breakdown. A resident admitted after a serious MVC with multiple fractures was assessed as high risk for pressure sores, yet later developed a large left buttocks wound documented as MASD and described by the wound physician as having an initial pressure etiology. Staff reported the resident was largely bedbound, required total assist with movement, had poor intake, and was temporarily placed on a regular mattress after problems with the bariatric air mattress, while the wound area was not initially identified as a pressure injury.
PICC Dressing Changes Not Performed: A resident with a PICC for IV antibiotics reported that staff were not changing the dressing weekly and said they did not know how because they were not RNs. An RN stated PICC dressings should be changed weekly by an RN with an order in place, and the DON confirmed there was no order entered for weekly dressing changes and the dressing changes were not done. The resident's PICC was later discontinued after it became clogged.
Medication Administration Not Completed as Ordered: A resident reported waiting 11 hours to receive Depakote and said staff did not give the medication at the ordered times. The MAR showed no initials for Depakote, Bupropion XL, or Abilify at the scheduled times, and the DON confirmed an agency nurse was assigned to administer the resident's meds.
A resident with severe cognitive impairment and left-sided weakness developed a large bruise and pain in her left upper arm, which was observed by multiple CNAs and nurses. Despite these observations, there was no timely assessment, documentation, or provider notification, resulting in a delay of several days before an X-ray was ordered and a non-displaced humerus fracture was diagnosed. Facility policy required prompt action for such injuries, but this was not followed.
Multiple residents with existing or newly developed pressure ulcers did not receive timely wound assessments, weekly documentation, or prompt treatment interventions. Delays in identifying and treating wounds led to progression to advanced stages, and recommended nutritional support was not always provided. Staff interviews confirmed that required assessments and interventions were not consistently performed, resulting in untreated and worsening pressure ulcers.
Multiple residents experienced significant weight loss or lacked proper weight monitoring due to failures in obtaining accurate weights, identifying and reporting significant changes, and implementing RD recommendations. In several cases, missing or delayed weight documentation prevented the RD from assessing nutritional needs, and recommended interventions were not consistently put into place due to breakdowns in communication and order entry.
Three residents experienced falls and injuries due to inadequate supervision and failure to maintain a safe environment. One resident fell and fractured his hip and wrist after being unable to reach his urinal and not receiving timely assistance. Another slipped out of a mechanical lift during transfer while wearing inappropriate footwear, and a third fell and sustained a black eye and other injuries after being left unattended on the bed during a transfer. In each case, staff did not provide the required assistance or ensure accident hazards were minimized.
Staff failed to prevent cross-contamination during meal service by using the same gloved hands to handle multiple food items, touch clothing, and surfaces without changing gloves, and by not using utensils for lemon wedges. Additionally, a can opener with caked-on debris was used on consecutive days, despite being reportedly cleaned, increasing the risk of food contamination.
The facility failed to correctly transcribe physician orders and ensure accurate medication administration for four residents, resulting in incorrect medications, dosages, and extended courses of treatment. These errors included giving a resident the wrong medications, administering an antibiotic longer than prescribed, providing a lower dose of Budesonide than ordered, and continuing a prednisone taper past the intended stop date.
Six residents with dysphagia or stroke were served pureed peas that contained chunks and pieces of skin, requiring chewing to swallow. The food was not blended to a smooth consistency as required for pureed diets, and this was confirmed by both staff and surveyors during meal preparation.
Three residents experienced a lack of dignity in care, including disruptive nighttime dressing changes, long delays in call light response, dismissive staff interactions, and failure to assist a female resident with personal hygiene related to facial hair. These actions did not align with facility policies requiring respect and dignity for all residents.
A resident with multiple comorbidities, including CHF and pressure ulcers, developed two skin tears on the left arm. Staff failed to assess the wounds or obtain physician treatment orders, and there was no documentation of wound assessment or treatment in the medical record, contrary to facility policy.
A resident with obstructive sleep apnea and other respiratory conditions did not have physician orders in place for CPAP use upon admission, and the care plan lacked specific CPAP instructions. The CPAP equipment was not consistently cleaned or stored according to facility policy, with the mask left unbagged on the bedside table and no documentation of daily cleaning prior to new orders being added.
Multiple residents with significant medical needs reported long delays in staff response to call lights, with one resident experiencing a fall and injury after waiting for assistance and attempting to manage independently. Residents described frequent waits of up to an hour, and staff acknowledged limitations with the facility's outdated call light system and lack of monitoring.
A staff member provided wound care to a resident with a Stage 4 pressure ulcer while only wearing gloves, failing to use a gown as required by the facility's Enhanced Barrier Precautions policy. The infection preventionist confirmed that both gown and gloves were necessary for wound care in residents with chronic wounds.
A resident with left-sided weakness and total dependence on staff for care fell out of bed during incontinence care when only one CNA was present, despite her need for two-person assistance due to limited mobility and size. The care guide did not specify the correct staffing level for incontinence care, and the facility's policies lacked guidance on assessing assistance needs, leading to the resident sustaining a hip fracture.
The facility failed to assess and notify the wound care physician of changes in a pressure injury for a resident, leading to the deterioration of the wound. Another resident developed a stage 2 pressure ulcer due to ineffective pressure-relieving interventions for oxygen tubing. The facility did not adhere to its policy on pressure injury assessment and treatment, resulting in these deficiencies.
The facility failed to supervise and implement fall prevention for two residents at high risk for falls. A resident was left unsupervised in the bathroom, resulting in a fall and injury, while another was placed in an incorrect wheelchair, contrary to their care plan. These actions violated the facility's fall prevention policy.
A facility failed to administer a prescribed lidocaine 5% patch to a resident with osteoarthritis, resulting in unmanaged pain. The RN was unaware of the absence of the patch, and the EMAR showed it was not given on multiple occasions. The LPN confirmed the patch is ordered through the facility's pharmacy, and its absence could lead to pain. This failure deviates from the facility's medication administration policy.
The facility failed to include stop dates for PRN anti-anxiety medications for two residents. One resident had an order for Ativan without a stop date, and another had an order for Lorazepam also lacking a stop date. The facility's policy requires a 14-day stop date for PRN psychotropic medications unless specified otherwise by a physician.
The facility exceeded the acceptable medication error rate with a 7.69% error rate during a medication pass. One resident did not receive a prescribed lidocaine patch, resulting in reported pain, while another resident received diclofenac gel applied incorrectly to both knees instead of just the right knee as ordered. The facility's policies require strict adherence to physician orders.
A facility failed to dispose of an expired insulin pen and did not label an opened insulin pen with the open date for a resident. The resident's physician orders included insulin aspart and insulin glargine, which were documented in the electronic medication administration record. An LPN confirmed that insulin pens should be dated when opened, as per facility policy, but was unsure of the duration for which opened insulin remains effective.
The facility failed to follow infection control protocols, as staff did not change gloves or perform hand hygiene after providing incontinence care to residents, risking cross-contamination. Additionally, staff did not wear gowns during high-contact care activities for residents under Enhanced Barrier Precautions, contrary to facility policies.
A resident was found storing Norco pills in his room, claiming to find them in his bed due to the facility's lack of medication accountability. The LPN administering the medications was surprised when the resident took the medication in her presence, as he usually refused supervision. Facility policies on controlled substances and medication administration were not followed.
A resident with multiple health conditions, including a prosthetic heart valve, did not receive his prescribed anticoagulant medication for eight days due to a failure to enter the medication order into the system. This lapse was identified by a nurse and reported to the on-call NP, and the resident's POA was informed.
Failure to Protect Resident’s Right to Unopened Personal Mail and Packages
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident’s right to receive unopened personal mail and packages. Resident 1 (R1), who had no cognitive impairment per the facility assessment, reported that her packages had been delivered to her already opened without her consent, causing her concern and discomfort. R1 stated she did not want anyone but herself to open her packages and that she had been told the DON (V2) was opening her packages before they were delivered to her. Interviews with staff confirmed that all resident mail and packages were received at the reception area, sorted by room number, and then delivered by Life Enrichment staff, with the expectation that they remain unopened. However, staff reported that R1’s packages were held so the DON could open and inspect the contents in the reception area or in the DON’s office before delivery, and that only approved items were then sent on to R1. Life Enrichment staff stated they had picked up R1’s packages already opened and informed R1 that the DON had to go through her items first. The Administrator (V1) stated staff should not open any resident’s mail or packages and that, if needed, packages should be opened in front of the resident with the resident’s consent. Both the Administrator and DON confirmed there was no signed contract or permission from R1 authorizing staff to open her packages, and the facility’s Resident Rights policy states that the facility may not open a resident’s mail without the resident’s permission.
Failure to Accurately Administer and Document Daily Lidocaine Patch
Penalty
Summary
The deficiency involves the facility’s failure to accurately administer and document a prescribed lidocaine 4% patch for a resident with an active order to apply the patch to the lower back once daily for low back pain. The resident’s March and April Medication Administration Records (MARs) show the lidocaine patch as administered every day in March except for two documented refusals, and every day in early April except for one documented refusal. The MARs also indicate that the resident’s pain was well managed, and the resident’s Minimum Data Set reflects that the resident is cognitively intact. On observation, the resident was lying in bed with needs met and no noticeable pain. Despite the MAR documentation, the resident reported that between the end of March and the beginning of April, the lidocaine patch was not administered for a period of four days to one week, and that when this was brought to staff attention, staff responded by asking why the resident had not informed them. A registered nurse who regularly cares for the resident stated that during that time there were days when the resident refused the patch, but also at least two days when the nurse did not realize the resident had gotten out of bed and the patch was not administered at all. The nurse acknowledged that if the patch was not administered, it should not have been signed as given on the MAR. The DON stated that when the resident refused the lidocaine patch, staff did not reattempt application. The facility’s Medication Administration policy requires medications to be administered as prescribed and in accordance with good nursing principles and practices.
Failure to Safely Transfer Resident Resulting in Fall
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) transferred a resident with a history of dementia, stroke, right lower leg wound, and transient ischemic attack without following the resident's care plan, which required two staff members for all transfers and toileting. The CNA transferred the resident alone and did not use a gait belt, instructing the resident to hold onto the bathroom grab bar. During the transfer, the resident's legs gave out, resulting in a fall to the bathroom floor. The CNA was unable to prevent the fall due to the absence of a gait belt and lack of assistance. Multiple staff members responded to the incident, finding the resident on the bathroom floor, kneeling and in pain, with her legs trapped between the toilet seat and grab bar. It required three staff members to safely assist the resident back to her wheelchair. The resident sustained a small skin tear to her left arm as a result of the fall. The facility's policy on safe lifting and movement of residents requires the use of appropriate techniques and devices to ensure safety, which was not followed in this incident.
Failure to Assess and Report Fracture After Resident Fall
Penalty
Summary
The facility failed to provide a thorough assessment after a resident with Alzheimer’s disease, muscle weakness, unsteadiness on feet, repeated falls, and high fall risk sustained a fall on 10/3/25. After the fall, staff documented that the resident was found at the foot of the bed with the right hip in contact with the floor and was indicating pain to the hip, but the record shows no timely assessment of the right lower extremity, no clear documentation of the fall assessment at the time, and no documented notification of the resident’s injury until later entries were added. Staff interviews showed the RN who first responded did not document the fall because another RN said she would do it, and the agency RN stated she helped with orders and provider notification but did not assess the resident. The resident continued to show guarding of the right hip and pain, and an x-ray was obtained on 10/4/25. The x-ray report showed a right hip impacted subcapital fracture of the right femoral neck with varus deformity, but the nurse practitioner stated she was not aware of the fracture, and the director of nursing stated she did not know about the fracture until reviewing records later. The record also showed pain scores ranging from 4 to 8 during this period, but there was no documented right lower extremity assessment between the first fall and the second fall. On 10/5/25, the resident had another unwitnessed fall in the dining room and was observed lying on her right side with limited range of motion in both lower extremities and crying out when moved. She was sent to the hospital, where records noted recurrent falls, decreased right hip range of motion limited by pain, a shortened and externally rotated right lower extremity, and x-ray findings of a subcapital femoral neck fracture with varus angulation. The facility’s own fall protocol required assessment and documentation of vitals, injury, musculoskeletal function, range of motion, weight bearing, and pain, and its notification policy required changes in condition or injury to be shared and reported to the physician, but these actions were not completed as documented after the initial fall and fracture finding.
Delayed Response to Call Lights
Penalty
Summary
The facility failed to ensure residents were treated with dignity by not answering call lights in a timely manner for 4 of 4 residents reviewed for dignity. During interviews, one resident stated call lights often took 20 to 30 minutes to be answered, especially during shift change or breaks, and reported lying in wet diapers for long periods while staff sometimes turned off the light and said they would return but did not always come back. Another resident reported waiting about an hour at times, becoming incontinent while waiting, and feeling helpless, while also stating that some staff were rude and frequently turned off the call light. A third resident stated call lights had been unanswered for 15 minutes to 2 hours and reported an IV had been beeping for 30 minutes until the surveyor notified the nurse. That resident said call lights were usually needed for pain medication or repositioning and felt their concerns were immaterial when staff did not respond. A fourth resident reported that call lights sometimes were not answered at all, leading the resident to try to get to the bathroom alone, dribble in Depends, and have falls in the past. The resident also stated a bathroom call light continued to ring 15 to 20 minutes after the resident had already returned to bed. The facility Residents' Rights pamphlet stated the facility must provide services to keep residents' physical and mental health and sense of satisfaction.
Failure to Identify and Prevent Worsening Pressure-Related Skin Breakdown
Penalty
Summary
The facility failed to initially identify a pressure ulcer and implement interventions to prevent worsening for a resident who was at high risk for pressure injuries. The resident was admitted after a motor vehicle accident with multiple fractures and complications including acute hypoxia, respiratory failure, and hypokalemia, and the Braden Scale dated 11/5/25 identified the resident as high risk for pressure sores. The resident’s record later showed a left buttocks wound measuring 9.0 x 11.0 x 0.10 cm with scant serosanguineous drainage, documented by the facility as MASD, while the wound physician described the area as having an initial etiology of pressure with minimal drainage and odor present, along with irregular partial-thickness skin breakdown, erythema, maceration, and superficial denudement. Staff interviews indicated the resident required turning and repositioning, was largely bedbound, and had limited mobility and poor intake. The nurse manager stated the resident had been moved from a bariatric bed with an air mattress to a regular mattress when the room was changed, and that the air mattress had been having problems before the resident went back to the hospital. Medical records staff stated the bed and mattress required repair and replacement, and the wound care nurse stated the resident was complete assist with movement and was not moving much on his own. The DON stated the resident was non-weight bearing and that the main focus was bed mobility, while the wound doctor had debrided the buttocks area after it was identified as MASD.
PICC Dressing Changes Not Performed
Penalty
Summary
The facility failed to ensure sterile catheter dressing changes were performed for a resident with a PICC line. The resident reported that the PICC had been placed in the left upper arm on 9/16/25 because of an infection in the knee and that IV antibiotics were being given. The resident stated the staff were not changing the dressing weekly and told staff it needed to be changed weekly, but staff said they did not know how to change the dressing because they were not RNs. The resident also stated the PICC line was later removed because it became clogged. During interview, an RN stated PICC line dressings should be changed once a week and only RNs can change PICC dressings, with an order needed for when to change them. The DON stated residents with PICC lines should have weekly dressing changes and that nursing should enter the order to ensure the dressing is done. The DON confirmed the resident did not have orders entered for weekly PICC dressing changes and that the resident's dressings were not done. The resident's vascular access consent was dated 9/16/25, the October 2025 physician order sheets did not include an order for PICC dressing changes, and the MAR showed orders to discontinue the PICC line and IV antibiotics on 10/21/25 for treatment of a wound infection. The facility policy stated central venous catheter dressings are to be changed at specific intervals, at least every 5-7 days and as needed, and that the date, time, insertion site location and condition, and signature and title should be recorded.
Medication Administration Not Completed as Ordered
Penalty
Summary
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist was not met when the facility failed to administer medications as ordered for one resident. The resident stated that it took 11 hours to receive Depakote on September 20, 2025, after speaking with night shift, day shift, and swing shift staff, and reported that the medication was finally given after Bingo, after 2:00 PM. The resident stated the medication should have been given twice daily at 8:00 AM and 8:00 PM. The Ombudsman stated the resident was very upset about going the whole day without medications. Review of the Medication Administration Record showed no initials for Depakote 125 mg at 8:00 AM or 8:00 PM on September 20, 2025, and also no initials for Bupropion XL 300 mg at 8:00 AM or Abilify 2 mg at 8:00 PM. The DON confirmed that an agency nurse was assigned to administer the resident's medications on that date.
Failure to Assess, Document, and Notify Provider of Resident Injury
Penalty
Summary
The facility failed to assess, document, notify the provider, and monitor an injury of unknown origin for a resident with severe cognitive impairment and significant physical dependencies. The resident, who had a history of stroke with left-sided weakness and required total assistance for activities of daily living, was observed by staff to have a large bruise on her left upper arm. Multiple CNAs and nurses noticed the bruise, which was initially red and later turned yellow, but there was no documentation or assessment of the bruise in the medical record prior to several days after it was first observed. Staff interviews revealed that the bruise was reported to nurses, but the nurses either assumed it was old or did not take further action, and there was no immediate notification to the provider or documentation of the injury. The resident exhibited pain with movement of her left arm, which was noted by staff during care, but this pain was not promptly reported or documented. It was only after several days, when the unit manager was made aware of the bruise, that the nurse contacted the provider and an X-ray was ordered. The X-ray revealed a non-displaced fracture of the left humerus. The facility's policies required prompt assessment, documentation, and provider notification for new skin issues or injuries of unknown origin, but these procedures were not followed in this case. The investigation found that the lack of timely assessment and documentation led to a delay in diagnosing the resident's fracture. Staff interviews confirmed that the bruise and associated pain were observed and reported among staff, but not properly escalated or recorded. The provider was not notified until three days after the initial observation of the bruise and pain, resulting in a delay in obtaining appropriate medical orders and treatment for the resident's injury.
Failure to Timely Assess, Document, and Treat Pressure Ulcers
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care and prevent new ulcers from developing for multiple residents. Several residents were admitted with existing pressure ulcers at various stages, but the facility did not consistently perform timely initial wound assessments, weekly reassessments, or implement treatment interventions as required. For example, one resident was admitted with multiple stage 3 and 4 pressure ulcers, but the first documented wound assessments were not completed until several weeks after admission. Nursing staff confirmed that initial wound assessments, including measurements and wound bed descriptions, should be completed on the day of admission, but this was not done. Additionally, weekly wound assessments and documentation were not consistently performed, and treatments were not always initiated promptly upon identification of new or worsening wounds. Another resident developed a pressure wound that was not treated for 26 days after it was identified, resulting in deterioration to a stage 4 ulcer. The care plan for this resident included daily skin inspections and nutritional support, but there was no evidence that the recommended protein supplement was provided. Wound assessments were missing for several weeks, and treatment orders were delayed. The wound care nurse and DON acknowledged that floor nurses are responsible for initial wound assessments and that treatments should be started as soon as possible, but this did not occur. The wound physician noted that wounds should be identified at earlier stages and emphasized the importance of high-protein supplements and offloading for prevention and healing. A third resident with severe cognitive deficits and total dependence on staff developed multiple pressure ulcers, including stage 3 and 4 wounds, which were not identified until they had progressed to advanced stages. The facility's policy required skin assessments on admission and weekly thereafter, but documentation showed gaps in assessments and delayed identification of wounds. Another resident with a history of noncompliance and high risk for skin breakdown had a stage 4 sacral wound that was not assessed for nearly three months, and new wounds were not promptly identified or treated. Staff interviews revealed that wounds were not always discovered during routine care, and appropriate offloading devices were not consistently used, despite the resident's high risk and previous wound history.
Failure to Accurately Monitor Weights and Implement Dietitian Recommendations
Penalty
Summary
The facility failed to ensure accurate and timely weight monitoring, identification, and reporting of significant weight loss, as well as failed to implement dietitian recommendations for multiple residents. For one resident with multiple diagnoses including anemia, hypertension, and pressure ulcers, significant weight loss occurred over a short period without notification to the Registered Dietitian (RD). The RD was not informed of the weight change, and there were concerns about the accuracy of the weights recorded. The resident's care plan required regular weight monitoring and prompt reporting of significant changes, but these protocols were not followed. Another resident with severe cognitive deficits and a history of malnutrition and pressure wounds was not weighed upon readmission from the hospital, contrary to facility policy requiring daily weights for the first three days post-admission. The RD was unable to assess for significant weight loss due to missing weights, and scheduled weekly weights were not documented in the electronic record. The lack of timely and accurate weight documentation prevented the RD from making necessary nutritional assessments and interventions. Additional residents experienced similar deficiencies. One resident with Alzheimer's and a history of pressure ulcers and hip fracture had a documented 14.3% weight loss over two months, with a missing monthly weight that was not entered into the electronic health record as required. Another resident with a history of fluctuating weights and multiple diagnoses did not receive a recommended nutritional supplement because the RD's recommendation was not converted into a physician order, resulting in the intervention not being implemented. Facility policies required regular weight monitoring, reweighs for significant changes, and prompt communication of RD recommendations, but these were not consistently followed.
Failure to Prevent Accidents and Provide Adequate Supervision
Penalty
Summary
The facility failed to ensure a safe environment and adequate supervision for residents at risk for falls and accidents. One resident with diagnoses including adult failure to thrive, diabetes, chronic kidney disease, and low back pain, who required maximum assistance for standing and toileting, was left unable to reach his urinal. Despite having his call light on and waiting for staff assistance, he attempted to retrieve the urinal himself after waiting for half an hour, resulting in a fall that caused a fractured hip and wrist. The resident reported that staff perceived him as independent due to his age and cognitive status, despite his documented need for assistance. Another resident, dependent on staff for toileting and requiring a sit-to-stand mechanical lift for transfers, slipped out of the lift and fell while being transferred from bed to the bathroom. At the time of the incident, the resident was wearing house shoes instead of the required non-slip footwear, which contributed to the fall. Two staff members were present during the transfer, and the resident reported feeling her feet slip and requested the lift be raised, but the fall occurred regardless. A third resident, who required substantial assistance for dressing and transfers and was to be transferred with a gait belt and two staff, sustained a black eye after falling during a transfer. The resident was left sitting on the edge of the bed while the CNA retrieved clothes from the closet, during which time the resident reached for a shirt and fell forward, hitting his head on the lift. The incident resulted in a cut and swelling to the left eyebrow, as well as scrapes to the left knee and ankle. In each case, the facility did not provide the necessary supervision or ensure the environment was free from accident hazards, directly leading to resident injuries.
Failure to Prevent Cross-Contamination in Food Handling and Equipment
Penalty
Summary
The facility failed to handle food in a manner that prevents cross-contamination and did not maintain food preparation equipment to prevent contamination. During lunch service, a cook used gloved hands to handle multiple food items, including lemon wedges, peas, french fries, and fish, without changing gloves between tasks. The cook also touched her clothing, door handles, and food carts with the same gloves and did not change them during the entire lunch service. No utensils were provided for handling lemon wedges, and the cook used her gloved hand to place them on plates for all residents. Additionally, the facility's can opener was observed to have caked-on debris on the sharp cutting tip on two consecutive days. The dietary supervisor confirmed that the can opener had been used and cleaned, but acknowledged that the tip remained dirty and posed a risk of cross-contamination. The supervisor also stated that food should not be touched with potentially contaminated gloved hands and that utensils should be used for items like lemon wedges. The facility's policy requires all food service equipment and utensils to be sanitized according to guidelines and mandates safe food handling practices.
Medication Transcription and Administration Errors
Penalty
Summary
The facility failed to provide proper pharmaceutical services by not correctly transcribing physician orders and not ensuring the correct medications and dosages were administered to residents. One resident with multiple diagnoses, including cerebral infarction and dementia, was given incorrect medications such as cetirizine, gabapentin, quetiapine, and memantine, which was discovered by another RN as the nurse was leaving the room. Another resident with liver cell carcinoma and other chronic conditions received an antibiotic for 12 days instead of the prescribed 5 days because the medication stop date was not entered by the nurse. A third resident with a history of chronic bowel disease and repeated falls was prescribed Budesonide 9mg daily, but only received 3mg due to a pharmacy dispensing error that was not caught by staff. Additionally, a resident with urinary tract infection and other chronic illnesses was given a prednisone taper beyond the intended stop date because the order was not entered correctly, resulting in the medication being continued until the error was discovered. These incidents were identified through interviews and record reviews, and all occurred within a three-month period.
Failure to Provide Properly Pureed Food for Residents with Swallowing Difficulties
Penalty
Summary
The facility failed to provide pureed peas in a smooth consistency for six residents who required pureed diets due to diagnoses such as difficulty swallowing and stroke. During meal preparation, the cook completed the pureeing process for peas, but visible chunks and pieces of skin remained, requiring chewing to swallow. Both the surveyor and the dietary supervisor confirmed the peas were not smooth, and the dietary supervisor acknowledged that peas are difficult to puree but should be blended until smooth. The pureed peas were only reprocessed after the deficiency was identified by staff. All six affected residents had documented medical conditions necessitating pureed diets, including difficulty swallowing and stroke. The facility's own protocol required altered consistency diets to manage aspiration risks, but the initial preparation of the peas did not meet these requirements, as the food was not adequately pureed before being served.
Failure to Maintain Resident Dignity and Timely Care
Penalty
Summary
The facility failed to ensure that residents dependent on staff for care were treated in a dignified manner, as evidenced by multiple incidents involving three residents. One resident, who was cognitively intact and required assistance with transfers and toileting, reported that her dressing changes were routinely performed in the middle of the night, disrupting her sleep. She expressed that only her pain medication was needed at those hours, and that dressing changes should be done before bedtime. Despite raising these concerns in a care conference, the issue persisted, and she also experienced significant delays in call light response, sometimes waiting up to 50 minutes for assistance with toileting, resulting in incontinence and distress. Another resident, who required assistance with activities of daily living, reported that her call light was not answered in a timely manner, often taking an hour or more. On one occasion, staff walked past her room while her call light was on and told her they could not help, leaving her feeling ignored and devalued. The DON acknowledged that this response was inappropriate and that staff should have communicated with the resident about when assistance would be provided. A third resident, who was dependent on staff for personal hygiene, was observed to have visible patches of facial hair, which her daughter stated would have been distressing to her. The resident had an electric razor in her room, but staff had not assisted her with shaving, possibly due to her refusal of showers. The DON agreed that this was a dignity issue and that staff should have addressed her facial hair between showers if needed. Facility policies reviewed emphasized the importance of treating residents with dignity and respect at all times.
Failure to Assess and Obtain Treatment Orders for Resident's Skin Tears
Penalty
Summary
A deficiency occurred when the facility failed to assess and obtain treatment orders for a resident who developed two skin tears on the left arm. The resident, who had diagnoses including congestive heart failure, severe protein-calorie malnutrition, and pressure ulcers, was observed with two dressings on the left arm. The resident reported waiting for dressing changes and was unsure of the exact circumstances of the injury. Review of the resident's medical record showed no physician orders for treatment of the skin tears and no documented assessment of the wounds. Interviews with nursing staff revealed that standard protocol involves cleaning, assessing, and dressing the wound, followed by notifying the physician and obtaining treatment orders, which are then entered into the resident's treatment record. However, in this case, the registered nurse was unaware of the condition of the wounds under the dressings and confirmed there were no orders or assessments documented. The Director of Nursing also confirmed that such wounds should be tracked and treated according to facility policy, which was not done in this instance.
Failure to Ensure Orders and Proper Care for CPAP Equipment
Penalty
Summary
The facility failed to ensure that a resident with a history of pulmonary embolism, obstructive sleep apnea, and other respiratory conditions had appropriate physician orders in place for the use of a CPAP machine upon admission. Review of the resident's records showed that there were no CPAP orders documented from the time of admission until several weeks later, despite the resident's need for this respiratory support. Additionally, the care plan did not include specific CPAP settings or instructions for CPAP care, and there was no evidence that the CPAP was being properly cared for during this period. Observations revealed that the CPAP equipment was not consistently stored in a sanitary manner, with the mask left unbagged on the bedside table. The resident reported that staff typically left the CPAP on the table and only recently began placing it in a bag. The facility's policy required daily cleaning and proper storage of CPAP equipment, but there was no documentation or evidence that these procedures were followed prior to the addition of new treatment orders. The DON confirmed that orders should be entered upon admission and that staff are expected to follow facility policy for cleaning and storage.
Delayed Call Light Response for Multiple Residents
Penalty
Summary
The facility failed to respond to residents' call lights in a timely manner, as evidenced by multiple resident accounts and staff interview. One resident, admitted with adult failure to thrive, Type 2 Diabetes Mellitus, chronic kidney disease, and low back pain, required maximum assistance for standing and toileting. This resident reported activating the call light for help reaching a urinal, but after waiting for half an hour without response, attempted to manage independently, resulting in a fall and self-reported hip injury. The resident stated that staff perceived him as independent due to his cognitive status, despite his physical needs. Another resident with Bell's Palsy, atrial fibrillation, and left-side paralysis, who was cognitively intact, reported that call lights often took a long time to be answered, including an instance where she waited an hour to be changed. A third resident with muscle weakness, COPD, and diabetes, also cognitively intact, described frequent delays in call light response, sometimes waiting up to an hour, and recounted being ignored by staff who walked past while her call light was on. The Director of Nursing acknowledged the facility's outdated call light system and lack of monitoring capability, and no facility policy regarding call lights was provided.
Failure to Use Required PPE During Wound Care Under Enhanced Barrier Precautions
Penalty
Summary
A staff member failed to follow the facility's Enhanced Barrier Precautions policy while providing wound care to a resident with a Stage 4 pressure ulcer. The resident, who had been admitted with this diagnosis, was on Enhanced Barrier Precautions as indicated by signage on her door, which required the use of both a gown and gloves during wound care. During an observed wound care procedure, the staff member wore only gloves and did not don a gown as required. The facility's infection preventionist confirmed that both gown and gloves should have been used for residents with chronic wounds under Enhanced Barrier Precautions, in accordance with the facility's policy last approved in May 2024.
Failure to Provide Adequate Supervision During Incontinence Care Resulting in Resident Fall
Penalty
Summary
A deficiency occurred when a resident, who was totally dependent on staff for care due to left-sided weakness from a stroke and was described as a larger individual, fell out of bed during incontinence care. The resident required significant assistance for bed mobility and incontinence care, as she was unable to support herself or roll independently. Despite this, only one CNA was present during the provision of incontinence care, and the resident rolled out of bed, landing on her knees and later being diagnosed with a left femoral neck fracture. Interviews with staff revealed that the determination of whether one or two CNAs were needed for incontinence care was based on the resident's size and bed mobility, but this information was not clearly communicated or documented in the care guide. The CNA providing care at the time of the incident was not informed that two staff members were required for this resident, and the care guide only indicated the need for one staff member for bed mobility, not specifically for incontinence care. Multiple staff members, including the LPN, unit manager, and other CNAs, stated that two staff should have been present due to the resident's condition and inability to support herself. The facility's policies on urinary incontinence did not address the assessment of the level of staff assistance required for incontinence care. As a result, there was a lack of clear guidance and communication regarding the appropriate staffing needed to safely provide care for residents with significant mobility limitations, directly contributing to the resident's fall and subsequent injury.
Failure to Prevent and Manage Pressure Injuries
Penalty
Summary
The facility failed to properly assess and notify the wound care physician of changes in a pressure injury for a resident, R100, and did not implement pressure-relieving interventions to prevent the development of a new pressure injury. R100, who had a history of type I diabetes mellitus and a hip fracture, was found to have a stage 1 pressure ulcer on his right heel, which later deteriorated to an unstageable pressure injury. Despite recommendations from a vascular surgery appointment to follow up with a wound care doctor, no appointments were set up, and the wound care nurse was not informed of the wound's deterioration. Another resident, R95, developed a stage 2 pressure ulcer behind his right ear due to the continuous use of oxygen tubing. The facility's interventions, such as using ear protectors, were ineffective as they frequently fell off or slid around, and staff did not perform daily checks behind the ears of residents on oxygen. The lack of effective pressure-relieving interventions and inadequate monitoring contributed to the development of the pressure injury. The facility's policy on pressure injury assessment and treatment, revised in July 2024, emphasizes the need for pressure-relieving devices to be observed for effectiveness and interventions to be changed or implemented to prevent pressure injuries. However, the facility failed to adhere to these guidelines, resulting in the deterioration of R100's pressure injury and the development of a new pressure injury for R95.
Inadequate Supervision and Fall Prevention for High-Risk Residents
Penalty
Summary
The facility failed to ensure adequate supervision and fall prevention interventions for two residents at high risk for falls. Resident R114, who was admitted after a fall resulting in a humerus fracture, was left unsupervised in the bathroom despite being on the falling star program, which indicates a high risk for falls. This lack of supervision led to R114 falling from the toilet, resulting in a skin tear and a head injury, necessitating a transfer to the emergency room. The CNA responsible for R114 admitted to leaving her alone due to a busy morning and not being familiar with her needs, which was against the facility's fall prevention policy. Resident R4, with a history of falls and high anxiety, was observed in a high reclining wheelchair despite the care plan specifying a low reclining wheelchair to prevent falls. This discrepancy was noted after R4 had previously fallen from a higher wheelchair, and the intervention was to use a lower one. The Restorative Nurse confirmed that R4 should only be in the low reclining wheelchair, but it was unclear why she was placed in a different one. The facility's fall policy requires daily reviews of falls to identify additional interventions, but this was not effectively implemented for R4.
Failure to Administer Prescribed Medication
Penalty
Summary
The facility failed to provide a medication as ordered for a resident, identified as R33, who was admitted with diagnoses including osteoarthritis, repeated falls, and anxiety disorder. The physician's orders for August 2024 included a prescription for a lidocaine 5% patch to be applied to R33's lower back in the morning and removed at bedtime. However, observations on August 6, 2024, revealed that the Registered Nurse (RN) did not have the lidocaine patch for R33 and was unaware of the reason for its absence. The resident reported experiencing pain rated at 4-5/10 due to arthritis. The Electronic Medication Administration Record (EMAR) indicated that the lidocaine patch was not administered on August 1, 2, and 6, 2024. A Licensed Practical Nurse (LPN) confirmed that the patch is ordered through the facility's pharmacy and acknowledged that its absence could result in the resident experiencing pain. The facility's policy on administering medications, revised in December 2021, mandates that medications be administered safely, timely, and as prescribed. The failure to provide the lidocaine patch as ordered represents a deviation from this policy, resulting in the resident potentially experiencing unmanaged pain.
Failure to Include Stop Dates for PRN Anti-Anxiety Medications
Penalty
Summary
The facility failed to ensure that as-needed anti-anxiety medications had a stop date for two residents reviewed for psychotropic medications. Resident R4 had a physician order for Ativan 0.5 mg to be taken twice daily as needed, with a start date but no stop date. The Assistant Director of Nursing acknowledged that PRN anti-anxiety medication should have a stop date 14 days after it was ordered. Similarly, Resident R95 had an active order for Lorazepam 2 MG/ML to be taken every 2 hours as needed for anxiety/agitation, also lacking a stop date. The facility's policy on psychotropic medications, last revised in November 2022, states that PRN psychotropic medications should have a stop date of 14 days unless otherwise specified by a physician.
Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to administer medications as ordered, resulting in a medication error rate of 7.69%, which exceeds the acceptable threshold of 5%. This deficiency was observed during a medication pass involving two residents. The first resident, identified as R33, was admitted with diagnoses including osteoarthritis, repeated falls, and anxiety disorder. The physician's order for R33 included the application of a lidocaine 5% patch to the lower back in the morning and removal at bedtime. However, on the morning of August 6, 2024, the RN administering medications did not have the lidocaine patch for R33 and was unaware of the reason for its absence. Consequently, R33 reported experiencing pain rated at 4-5 out of 10. The second resident, identified as R110, was admitted with diagnoses including osteoarthritis, chronic kidney disease, edema, weakness, and a history of falling. The physician's order for R110 specified the application of diclofenac sodium 1% gel to the right knee twice daily. During the medication pass, the RN applied the gel to both the right and left knees, contrary to the physician's order. The LPN later confirmed that physician orders should be followed precisely and that any changes requested by residents should be communicated to the nurse practitioner for a new order. The facility's policies on administering medications and handling medication errors emphasize adherence to physician orders and define medication errors as deviations from these orders.
Medication Storage and Labeling Deficiency
Penalty
Summary
The facility failed to properly manage medication storage and labeling for a resident, identified as R99, leading to a deficiency. Specifically, an expired insulin pen was not disposed of, and an opened insulin pen was not labeled with the date it was opened. The physician orders for R99 included insulin aspart sliding scale and insulin glargine pen at bedtime, which were documented in the electronic medication administration record. During an observation, it was noted that the insulin aspart pen was opened and dated, but the insulin glargine pen was opened without a date. A Licensed Practical Nurse (LPN) acknowledged that insulin pens should be dated upon opening to ensure effectiveness and admitted uncertainty about the duration for which opened insulin remains effective. The facility's policy mandates recording the open date on multi-dose containers, and another policy specifies that opened insulin pens are good for 28 days at room temperature.
Infection Control Deficiency: PPE and Hand Hygiene Failures
Penalty
Summary
The facility failed to adhere to proper infection prevention and control protocols, specifically in the use of personal protective equipment (PPE) and hand hygiene practices. On multiple occasions, staff members did not change gloves or perform hand hygiene after providing incontinence care to residents, which could lead to cross-contamination. For instance, a Certified Nursing Assistant (CNA) did not change gloves or perform hand hygiene after wiping a resident's buttocks and then handling clean items. Similarly, during incontinence care for another resident, two CNAs did not wear gowns as required by Enhanced Barrier Precautions (EBP) and failed to change gloves or perform hand hygiene after cleaning the resident. The facility's policies on hand hygiene and Enhanced Barrier Precautions were not followed. The hand hygiene policy requires hand hygiene before moving from a soiled to a clean body site on the same resident, and the EBP policy mandates the use of gowns and gloves during high-contact care activities for residents at risk of transmitting multidrug-resistant organisms (MDROs). Despite these policies, staff did not wear gowns or change gloves during high-contact care activities for residents with wounds or indwelling medical devices, increasing the risk of infection transmission.
Failure to Supervise Medication Administration
Penalty
Summary
The facility failed to adequately supervise a resident during medication administration, leading to the resident storing medications in his room. The resident, who was part of a sample reviewed for safety and supervision, was observed by a surveyor to have several pills, identified as Norco, stored in a cup on his over-bed table. The resident claimed that he finds medications in his bed and expressed concerns about the facility's lack of accountability for controlled medications. During an interaction with the surveyor, the resident demonstrated his routine of taking pictures of his medications before ingestion, which he claimed was for verification purposes with a hospital. The Licensed Practical Nurse (LPN) responsible for administering the resident's medications confirmed that the resident typically refuses to take medications in her presence, insisting on privacy. On the day of the survey, the LPN was surprised when the resident took the medication in front of her, as this was not his usual behavior. The facility's policies on controlled substances and medication administration were not adhered to, as controlled substances were found unsecured in the resident's room, and there was no documented assessment allowing the resident to self-administer medications safely.
Failure to Administer Anticoagulant Medication
Penalty
Summary
The facility failed to ensure a resident was free from significant medication errors. Resident R2, who has a medical history including Parkinson's Disease, Type 2 Diabetes, hypertension, chronic kidney disease, paroxysmal atrial fibrillation, and a prosthetic heart valve, did not receive his prescribed anticoagulant medication, Coumadin, for eight days. This lapse occurred from 3/10/24 to 3/19/24. The error was identified when a nurse noticed the absence of a Coumadin order in the electronic health record and reported it to the on-call Nurse Practitioner. The resident's Power of Attorney was informed, and an INR test was ordered to monitor the resident's blood clotting levels. Interviews with staff revealed that the Coumadin order was not entered into the system after the resident's lab results were reviewed, leading to the missed doses. The facility's policy requires that anticoagulant therapy be prescribed and monitored according to recognized guidelines, including appropriate lab testing and the use of a monitoring tool to track anticoagulant dosage and response. The failure to enter the new Coumadin order into the system resulted in the resident not receiving the necessary medication to ensure the proper functioning of his artificial heart valve.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 236 citations issued within 25 miles in the last 12 months — including the 4 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Rockford
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pa Peterson At The Citadel | 1.4 mi | ★★★★★ | 4 | 0 |
| Alden Park Strathmoor | 1.7 mi | ★★★★★ | 4 | 0 |
| Fairhaven Christian Ret Center | 1.7 mi | ★★★★★ | 5 | 0 |
| Forest City Rehab & Nrsg Ctr | 1.9 mi | ★★★★★ | 19 | 0 |
| Alpine Fireside Health Center | 2 mi | ★★★★★ | 12 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for The Citadel At Saint Anne Place.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.