Below average — CMS composite of the measures below.
A standard survey is most likely before around August 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 Mooresville during CMS and state inspections, most recent first.
Surveyors found that open food items in both the walk-in and reach-in refrigerators were not labeled or dated, and expired food items, including milk and premade sandwiches, were not discarded. The Dietary Manager, who had been on vacation, stated that staff were expected to follow procedures for labeling and discarding food, but these were not followed during her absence.
Two residents who received new diagnoses of bipolar disorder and major depressive disorder after admission did not have required PASRR Level II assessments completed. The responsible social worker was unaware of the need to initiate Level II reviews for new mental health diagnoses, and the administrator confirmed that these assessments should have been performed.
A resident with obstructive uropathy and an indwelling urinary catheter did not have a physician's order specifying the catheter size, and the catheter was not changed as scheduled. Nursing staff used the same size catheter as previously in place without an order, and the scheduled catheter change was not completed because nurses were unaware of the order and a Medication Aide, who was not authorized to perform the task, had initialed the record.
A resident dependent on oxygen therapy did not have their oxygen concentrator filter cleaned as ordered, resulting in visible buildup on the filter. Additionally, a storage room containing full oxygen tanks lacked required cautionary signage. Facility leadership confirmed expectations for both filter maintenance and signage, but these were not met.
A Wound Nurse failed to follow Enhanced Barrier Precautions by not wearing a gown and not performing proper hand hygiene during wound care for two residents, despite clear facility policies and signage requiring both gloves and gowns for such procedures. The nurse misunderstood the requirements, believing gowns were only needed if wounds were infected or posed a splash risk, leading to noncompliance with infection control protocols.
A resident with a history of atrial fibrillation, prior brain bleeds, and on anticoagulant therapy experienced a fall and subsequently developed a significant change in condition, including lethargy and unresponsiveness. Despite multiple staff observing and reporting the change, there was a delay of several hours before the provider was notified, resulting in delayed medical intervention. The resident was later found unresponsive by family and diagnosed with a large subdural hematoma at the hospital.
A resident with a history of atrial fibrillation on anticoagulation, prior brain injury, and hemiplegia experienced an unwitnessed fall and subsequently developed significant neurological decline, including lethargy and unresponsiveness. Despite multiple staff noting the change in condition, the response was limited to ordering labs and a chest x-ray, with no immediate transfer or provider evaluation. The resident was only sent to the hospital after family insistence, where a large subdural hematoma was diagnosed and the resident was transitioned to hospice care.
A resident with a history of depression, psychosis, and skin tears sustained a new skin tear when a nursing assistant attempted to provide incontinent care against the resident's will, holding the resident's arms while the resident resisted. The incident occurred after the resident refused care, and the NA returned to attempt care again, resulting in injury. The resident reported the NA was rough but did not believe the harm was intentional.
Failure to Label, Date, and Discard Expired Food Items in Kitchen Refrigerators
Penalty
Summary
Surveyors observed that the facility failed to properly label and date open food items and did not discard expired food in both the walk-in and reach-in refrigerators in the kitchen. Specifically, a plate with tomato slices was found without a use by date, and a carton of whole milk was present with a use by date that had already passed. In the walk-in refrigerator, multiple open and undated packages of meats, cheeses, and a pan of cooked pasta were found, along with 16 premade sandwiches that were past their use by date. Interviews with the Dietary Manager and the Administrator confirmed that the facility's procedures require staff to label open food items with an open date and a use by date not exceeding seven days, and to remove expired food. The Dietary Manager, who had been on vacation prior to the survey, stated that cooks were responsible for following these procedures in her absence, but was unaware of how the expired and undated items were missed. The Administrator also acknowledged that food should be dated and expired items discarded.
Failure to Complete PASRR Level II for Residents with New Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure that a Preadmission Screening and Resident Review (PASRR) Level II was completed for two residents who received new mental health diagnoses after admission. For both residents, a PASRR Level I was completed prior to admission, with recommendations to resubmit paperwork for a Level II review if a new mental health diagnosis was made or if there was a significant change in condition. Despite both residents being diagnosed with bipolar disorder and major depressive disorder after admission, no PASRR Level II was completed for either individual. Interviews with the responsible social worker revealed a lack of awareness regarding the requirement to complete PASRR Level II assessments for residents who receive new mental health diagnoses after admission or readmission. The social worker indicated that she typically only completed Level II paperwork for residents with limited Level II status or when required by periodic review or a change in condition. The administrator confirmed that PASRR Level II should be completed in a timely manner upon admission, readmission, or when a new mental health diagnosis is made, acknowledging that the required assessments were not performed for the two residents in question.
Failure to Obtain Catheter Size Order and Perform Scheduled Catheter Change
Penalty
Summary
The facility failed to obtain a physician's order specifying the size of a urinary catheter and did not change the catheter as ordered for a resident with obstructive uropathy and an indwelling urinary catheter. Staff interviews revealed that when the catheter was changed, there was no order for the catheter size, and the nurse was instructed to use the same size as the one being removed. Both the Unit Manager and Medical Director confirmed that an order specifying the catheter size should have been present, and the interim DON stated that the nurse should have obtained such an order if it was missing. Additionally, the facility did not ensure that the resident's urinary catheter was changed according to the physician's order. The Medication Administration Record indicated that the catheter change was scheduled, but it was initialed by a Medication Aide, who stated that changing catheters was outside her scope of practice. Nurses on duty during the scheduled change were unaware of the order and did not perform the catheter change. The Unit Manager confirmed that it was the nurse's responsibility to review the MAR and complete scheduled tasks, and the Medical Director expected catheter changes to be performed as ordered.
Failure to Maintain Clean Oxygen Equipment and Proper Oxygen Storage Signage
Penalty
Summary
A resident with dementia, sleep apnea, and chronic respiratory failure was dependent on staff for activities of daily living and required oxygen therapy. Physician orders specified that the oxygen concentrator filter should be rinsed or replaced weekly, specifically every Sunday on the night shift. Observations on two separate days revealed that the resident's oxygen concentrator intake filter had significant gray and white matter buildup, indicating it had not been cleaned as ordered. Review of the medication administration record showed that the responsible nurse did not confirm whether the filter was cleaned, citing being busy during the shift. The order to clean the filter was present on the medication administration record, but the task was not completed. Additionally, the facility failed to post required cautionary oxygen signage on one of two oxygen storage rooms where full portable oxygen cylinders were kept. Observations confirmed that a storage closet containing 48 full oxygen tanks lacked the necessary cautionary signage. Interviews with facility leadership confirmed that such signage was expected but not present at the time of the survey.
Failure to Follow Enhanced Barrier Precautions and Hand Hygiene During Wound Care
Penalty
Summary
The facility failed to implement its infection prevention and control program as required by policy during wound care procedures for two residents under Enhanced Barrier Precautions (EBP). The Wound Nurse did not don a gown as indicated by the EBP signage when performing wound care on a resident with a stage IV pressure ulcer and another resident with a lower right leg wound. In both cases, the signage clearly directed staff to wear gloves and a gown for high-contact resident care activities, including wound care, but the Wound Nurse only wore gloves. Additionally, during the wound care for the resident with the stage IV pressure ulcer, the Wound Nurse failed to perform hand hygiene after removing gloves and before donning new gloves, contrary to the facility's hand hygiene policy. Interviews with the Wound Nurse revealed a misunderstanding of the EBP requirements, as she believed gowns were only necessary if there was a risk of splash or if the wound was infected. The interim DON confirmed that the facility's policy required both gloves and gowns for all wound care under EBP and that hand hygiene should be performed after glove removal and before applying new gloves. These observations and staff interviews demonstrated noncompliance with the facility's infection control policies for both hand hygiene and the use of personal protective equipment during wound care.
Failure to Immediately Notify Provider of Acute Change in Condition Post-Fall
Penalty
Summary
A deficiency occurred when facility staff failed to immediately notify the medical provider of an acute change in condition for a resident who had recently experienced a fall. The resident, who had a history of atrial fibrillation, pulmonary embolism, cerebral infarction with hemiplegia, and traumatic brain injury, was on anticoagulant therapy with apixaban. After an unwitnessed fall from bed, the resident was assessed by nursing staff, found to have no visible injuries, and was returned to bed. Neurological checks were initiated, and the resident reported not hitting his head. The following day, staff observed that the resident was hard to arouse, nonverbal, unresponsive, and lethargic. Multiple staff members, including nurse aides and therapy staff, noted the resident's significant change from his baseline, describing him as limp, lethargic, and not responding as usual. These observations were communicated to nursing staff and the unit manager. However, the medical provider was not notified of the resident's acute change in condition until late in the afternoon, several hours after the initial signs were observed. During this period, assessments were performed, and vital signs were taken, but the delay in provider notification persisted. The unit manager eventually contacted the provider, who ordered diagnostic tests. The next day, the resident's family found him unresponsive and requested hospital transfer, where he was diagnosed with a large subdural hematoma. Interviews with staff and the medical director confirmed that the provider should have been notified immediately upon recognition of the change in condition, especially given the resident's medical history and anticoagulant use.
Removal Plan
- The DON re-educated the nurse on the notification policy and process to include immediately notifying the Medical Provider when a resident has a change in condition.
- The DON and Nurse Consultant completed an audit of residents on anticoagulant therapy who have experienced a fall to ensure timely notification to the Medical Provider if a change in resident condition occurs.
- The facility reviewed all residents with changes in condition to ensure immediate notification to the Medical Provider occurred.
- The Administrator, Director of Nursing, President of Risk and Quality Assurance, Nurse Consultant, Physician Assistant and Medical Director held an Ad Hoc QAPI meeting to discuss the incident to determine root cause analysis of the facility's failure to immediately notify the Medical Provider when Resident #1 had a change in condition.
- The Director of Risk of Quality Management, Nurse Consultant, Director of Nursing, Administrator, and Physician Assistant reviewed the notification and fall policy.
- The Director of Nursing, Nurse Consultant, and Nursing Administration initiated education with all facility and contracted licensed nurses and Certified Nursing Assistants on the facility Notification of Changes in Condition and Fall Prevention Policies.
- Education includes the licensed nurse's responsibility to immediately notify the Medical Provider of any resident's change in condition, especially post-fall, with a history of stroke and pulmonary embolism on an anticoagulant.
- Certified Nursing Assistants will immediately communicate to the licensed nurses any change in Residents condition.
- The Director of Nursing will ensure all newly hired licensed nurses and Certified Nursing Assistants will be educated during orientation and contracted staff educated prior to taking their assignment.
- The Administrator is ultimately responsible for the implementation and completion of this removal plan.
Failure to Recognize and Respond to Acute Change in Condition After Fall
Penalty
Summary
A resident with a complex medical history, including atrial fibrillation on anticoagulation therapy, recent pulmonary embolism, traumatic brain injury, hemiplegia, and previous subdural hematoma, experienced an unwitnessed fall from bed. Following the fall, the resident was assessed and found to have no visible injuries, and neurological checks were initiated. The resident reported not hitting his head, and his neurological status and vital signs were documented as within normal limits for the remainder of the shift and into the following day. On the morning after the fall, staff observed that the resident was hard to arouse, nonverbal, unresponsive, and lethargic, which was a significant change from his baseline. Multiple staff members, including nurse aides and therapy staff, noted the resident's altered mental status and reported it to nursing staff. Despite these observations, the response was limited to obtaining orders for bloodwork, urinalysis, and a chest x-ray later in the afternoon, rather than immediate evaluation or transfer to a higher level of care. The resident's condition continued to deteriorate, with ongoing lethargy and unresponsiveness noted by various staff members throughout the day and night. It was not until the following morning, when the resident's family arrived and insisted on hospital transfer, that the resident was sent to the emergency department. Upon arrival, the resident was diagnosed with a large left subdural hematoma with midline shift and was transitioned to hospice care, passing away several days later. The facility failed to recognize the severity of the resident's acute change in condition after the fall and did not promptly notify a medical provider or arrange for timely transfer to a higher level of care, despite clear signs of neurological decline.
Removal Plan
- The DON and Nurse Consultant completed an audit of residents on anticoagulant therapy who have experienced a fall to ensure timely recognition and response occurred if the resident experienced a change in condition.
- The DON and Unit Managers reviewed all residents with changes in condition to ensure immediate notification to the Medical Provider occurred.
- The Administrator, Director of Nursing (DON), President of Risk and Quality Assurance (VPRQA), Nurse Consultant, PA and Medical Director held an Ad Hoc QAPI meeting to discuss the incident to determine root cause analysis of the facility's failure to recognize the severity of a change in condition for Resident #1.
- The Director of Risk and Quality Assurance, Nurse Consultant, Director of Nursing, Administrator, and Physician Assistant reviewed the change in condition and fall policy. No changes were made.
- The Director of Nursing, Nurse Consultant, and Nursing Administration initiated education with all facility and contracted licensed nurses and Certified Nursing Assistants on the facility Notification of Changes in Condition and Fall Prevention policies. Education includes recognizing the severity of a change in condition status post fall to include post fall assessment changes, changes in level of consciousness, and altered mental status away from baseline. Upon licensed nurse's assessment recognizing the severity of the residents change in condition away from baseline post fall, the Medical Provider will be immediately notified.
Failure to Protect Resident from Physical Abuse During Incontinent Care
Penalty
Summary
A deficiency occurred when a nursing assistant (NA) provided incontinent care to a cognitively intact resident with a history of major depressive disorder, psychosis, and skin tears, despite the resident's refusal and resistance. The NA entered the resident's room early in the morning, introduced himself, and attempted to change the resident, who became immediately aggressive and refused care. The NA left the room to allow the resident to cool down, then returned and again attempted to provide care. During this interaction, the resident resisted, and the NA held the resident's arms while the resident was fighting, resulting in a skin tear to the resident's left lower forearm. The NA reported the resident's refusal to a nurse but could not recall which nurse instructed him to try again. Resident interviews revealed that the resident did not want to be changed, resisted the NA's attempts, and reported that the NA twisted his hands and caused a skin tear with his fingernails. The resident stated that the NA did not intend to hurt him but should have stopped when he resisted. Nursing documentation and staff statements confirmed the presence of skin tears on the resident's hand and left lower arm following the incident. The resident and a nurse both noted that the NA had a history of being rough with the resident, although the resident did not consider the incident to be intentional abuse. The facility's expectation, as stated by the DON and Administrator, was that all residents must be rounded on and provided with care, including opening briefs and cleaning as needed, regardless of behavioral history. The NA was expected to communicate refusals and resistance to the nurse, but the process for handling such refusals was not clearly documented in this incident. The event resulted in physical harm to the resident in the form of skin tears after care was provided against the resident's will.
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What surveyors actually found near you
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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.
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A prioritized, do-first checklist
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Mooresville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Crestview Health & Rehabilitation | 0.8 mi | ★★★★★ | 9 | 0 |
| Autumn Care Of Cornelius | 7.1 mi | ★★★★★ | 2 | 0 |
| Big Elm Retirement And Nursing Centers | 10.7 mi | ★★★★★ | 4 | 0 |
| Lakeside Health & Rehab Center | 11 mi | ★★★★★ | 15 | 0 |
| Huntersville Health & Rehabilitation Center | 12.1 mi | ★★★★★ | 5 | 0 |
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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.