Deficiencies (last 4 years)
Deficiencies (over 4 years)
3.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
5% better than Arizona average
Arizona average: 3.7 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jul 18, 2025
Visit Reason
The inspection was conducted as a complaint investigation regarding allegations of sexual abuse between residents at Citadel Post Acute facility.
Complaint Details
The complaint involved allegations that residents #3 and #9 were sexually abused by residents #4 and #10. The facility conducted a 5-day investigation including interviews with residents and staff, review of care plans, progress notes, and camera footage. The facility concluded no abuse occurred but implemented monitoring and supervision measures. Resident #10 was discharged following the investigation. Resident #3 was also discharged later. The investigation was substantiated as the facility failed to protect residents' rights to be free from sexual abuse.
Findings
The facility failed to protect two residents (#3 and #9) from sexual abuse by other residents (#4 and #10). The investigation included clinical record review, staff interviews, and facility documentation. The facility concluded that no abuse occurred after investigation, although residents were found in situations with pants down and inappropriate contact. Interventions such as one-on-one supervision and psychosocial monitoring were implemented.
Deficiencies (1)
Failure to protect residents from sexual abuse by other residents.
Report Facts
BIMS scores: 8
BIMS scores: 5
BIMS scores: 7
BIMS scores: 8
BIMS scores: 4
Deficiency count: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #901 | Certified Nursing Assistant (CNA) | Reported observing Resident #10 touching Resident #9 and intervened |
| Staff #700 | Certified Nursing Assistant (CNA) | Reported observing Resident #4 and Resident #3 in inappropriate situation |
| Staff #41 | Certified Nursing Assistant (CNA) | Witnessed and reported inappropriate resident interaction |
| Staff #105 | Licensed Practical Nurse (LPN) | Reported on incident involving Resident #3 and Resident #4 and their behaviors |
| Staff #900 | Registered Nurse (RN) | Responded to incident, reported to administrator and called 911 |
| Staff #70 | Director of Nursing (DON) | Provided information on abuse training and investigation conclusions |
| Staff #16 | Administrator | Provided information on facility camera system and investigation |
Inspection Report
Complaint Investigation
Capacity: 128
Deficiencies: 0
Date: May 20, 2025
Visit Reason
Complaint survey conducted for intake #SF00131258 with no deficiencies cited.
Findings
Complaint survey conducted for intake #SF00131258 with no deficiencies cited.
Inspection Report
Complaint Investigation
Capacity: 128
Deficiencies: 0
Date: May 8, 2025
Visit Reason
Complaint re-investigation for intake # AZ00193297 with no deficiencies cited.
Findings
Complaint re-investigation for intake # AZ00193297 with no deficiencies cited.
Inspection Report
Complaint Investigation
Capacity: 128
Deficiencies: 0
Date: May 5, 2025
Visit Reason
Onsite complaint survey for intakes # 00128307 and 00128547 with no deficiencies cited.
Findings
Onsite complaint survey for intakes # 00128307 and 00128547 with no deficiencies cited.
Inspection Report
Complaint Investigation
Capacity: 128
Deficiencies: 0
Date: Mar 7, 2025
Visit Reason
Complaint investigation for intakes #00121563, 00120800 with no deficiencies cited.
Findings
Complaint investigation for intakes #00121563, 00120800 with no deficiencies cited.
Inspection Report
Capacity: 128
Deficiencies: 0
Date: Feb 26, 2025
Visit Reason
Recertification survey under Life Safety Code 2012 with no deficiencies cited.
Findings
Recertification survey under Life Safety Code 2012 with no deficiencies cited.
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Feb 21, 2025
Visit Reason
The inspection was conducted to investigate complaints related to the facility's failure to ensure proper safeguards and systems were in place to control and account for controlled medications, preventing loss, diversion, or accidental exposure.
Complaint Details
The complaint investigation focused on allegations of improper control and accounting of controlled medications, including missing or tampered medication seals, discrepancies in narcotic counts, improper storage of medications, and infection control issues in the medication storage room. The complaint was substantiated with findings of minimal harm or potential for actual harm affecting a few residents.
Findings
The facility failed to maintain proper control and storage of controlled substances, including Lorazepam and Alprazolam, with multiple discrepancies in medication logs, tampered seals, improper storage of discontinued and expired medications, and unsanitary conditions in the medication storage room. These deficiencies pose risks of medication diversion, cross-contamination, and infection control issues.
Deficiencies (3)
Failure to control and account for controlled medications leading to potential diversion.
Medications in the medication storage room were not stored appropriately and expired medications were not discarded properly.
Failure to provide and implement an infection prevention and control program in the medication storage room.
Report Facts
Medication quantity dispensed: 18
Medication quantity ending count: 3
Expired medications observed: 3
Residents on Enhanced Barrier Precautions: 30
Residents on Transmission Based Precautions: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding medication storage and tamper seal issues |
| Resource Licensed Practical Nurse | Licensed Practical Nurse (LPN) | Interviewed regarding medication storage and narcotic counts |
| Pharmacist | Registered Pharmacist | Interviewed regarding medication control, storage policies, and infection control |
| LPN Staff #163 | Licensed Practical Nurse | Observed medication pass and discussed narcotic count discrepancies |
| LPN Staff #105 | Licensed Practical Nurse | Interviewed regarding medication storage and infection control issues |
| LPN Staff #161 | Licensed Practical Nurse | Interviewed regarding medication cart and storage room cleanliness |
Inspection Report
Complaint Investigation
Capacity: 128
Deficiencies: 2
Date: Feb 21, 2025
Visit Reason
Recertification/complaint survey citing 2 deficiencies related to administrator policies and procedures.
Findings
Recertification/complaint survey citing 2 deficiencies related to administrator policies and procedures.
Deficiencies (2)
R9-10-403.C — Administrator policies and procedures for physical and behavioral health services
R9-10-403.C — Administrator policies and procedures for physical and behavioral health services
Inspection Report
Complaint Investigation
Capacity: 128
Deficiencies: 0
Date: Nov 6, 2024
Visit Reason
Complaint survey for AZ00218265 and AZ00218266 with no deficiencies cited.
Findings
Complaint survey for AZ00218265 and AZ00218266 with no deficiencies cited.
Inspection Report
Complaint Investigation
Capacity: 128
Deficiencies: 1
Date: Sep 4, 2024
Visit Reason
Complaint survey citing 1 deficiency related to resident abuse prevention.
Findings
Complaint survey citing 1 deficiency related to resident abuse prevention.
Deficiencies (1)
R9-10-410.B — Resident abuse prevention
Inspection Report
Complaint Investigation
Capacity: 128
Deficiencies: 0
Date: Aug 28, 2024
Visit Reason
Onsite complaint survey for intakes # AZ00215215, AZ00215119 with no deficiencies cited.
Findings
Onsite complaint survey for intakes # AZ00215215, AZ00215119 with no deficiencies cited.
Inspection Report
Complaint Investigation
Capacity: 128
Deficiencies: 0
Date: Apr 18, 2024
Visit Reason
Onsite complaint survey for intakes # AZ00209100 and AZ00209116 with no deficiencies cited.
Findings
Onsite complaint survey for intakes # AZ00209100 and AZ00209116 with no deficiencies cited.
Inspection Report
Complaint Investigation
Capacity: 128
Deficiencies: 0
Date: Sep 29, 2023
Visit Reason
Investigation of complaint AZ00201169 with no deficiencies cited.
Findings
Investigation of complaint AZ00201169 with no deficiencies cited.
Inspection Report
Complaint Investigation
Capacity: 128
Deficiencies: 0
Date: Jul 21, 2023
Visit Reason
Complaint investigation for AZ00197771 and AZ00197773 with no deficiencies cited.
Findings
Complaint investigation for AZ00197771 and AZ00197773 with no deficiencies cited.
Inspection Report
Complaint Investigation
Capacity: 128
Deficiencies: 0
Date: Jun 2, 2023
Visit Reason
Investigation of multiple complaints from AZ99194881 through AZ00184325 with no deficiencies cited.
Findings
Investigation of multiple complaints from AZ99194881 through AZ00184325 with no deficiencies cited.
Inspection Report
Routine
Deficiencies: 2
Date: Apr 14, 2023
Visit Reason
The inspection was conducted to assess compliance with food safety and sanitation standards in the facility's kitchen, including proper food storage, preparation, and handling practices.
Findings
The facility failed to maintain a clean and sanitary kitchen and allowed expired food items to be available for resident use, posing a potential risk for foodborne illness. Additionally, pureed food was not prepared to the required consistency, which could pose a choking or aspiration risk for residents on a pureed diet.
Deficiencies (2)
Failed to maintain a clean and sanitary kitchen and allowed expired food items in the refrigerator.
Pureed goulash was thick and grainy with large particles, not prepared at the required consistency, posing a risk for choking or aspiration.
Report Facts
Sanitizer buckets tested: 4
Sanitizer concentration requirement: 200
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kitchen manager | Interviewed regarding expired food items and sanitizer bucket procedures. | |
| Staff #199 | Prepared pureed goulash and stated it was ready without tasting. | |
| Staff #221 | Sampled pureed goulash and stated risks of choking or aspiration. | |
| Staff #35 | Observed during pureed food preparation and sampled pureed goulash. | |
| Staff #220 | Sampled pureed goulash. |
Inspection Report
Complaint Investigation
Capacity: 128
Deficiencies: 2
Date: Apr 14, 2023
Visit Reason
State compliance survey citing 2 deficiencies related to food safety and food establishment licensing.
Findings
State compliance survey citing 2 deficiencies related to food safety and food establishment licensing.
Deficiencies (2)
§483.60(i) — Food safety requirements
R9-10-423.A — Food establishment license and sanitary kitchen maintenance
Inspection Report
Capacity: 128
Deficiencies: 3
Date: Apr 14, 2023
Visit Reason
Recertification survey under Life Safety Code citing 3 deficiencies related to emergency preparedness, corridor doors, and utilities.
Findings
Recertification survey under Life Safety Code citing 3 deficiencies related to emergency preparedness, corridor doors, and utilities.
Deficiencies (3)
Emergency preparedness requirements — Failure to annually review and update EP plan
Corridor doors — Failure to maintain doors protecting corridor openings
Utilities - Gas and Electric — Unsafe electrical power cord usage
Inspection Report
Complaint Investigation
Capacity: 128
Deficiencies: 0
Date: Mar 29, 2023
Visit Reason
Complaint survey for intake AZ00193016 with no deficiencies cited.
Findings
Complaint survey for intake AZ00193016 with no deficiencies cited.
Inspection Report
Deficiencies: 0
Date: Feb 17, 2022
Visit Reason
The document is a statement of deficiencies and plan of correction for Citadel Post Acute, reflecting the results of a regulatory survey completed on 2022-02-17.
Findings
No health deficiencies were found during the survey.
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