20 Reports
Inspection Report — Apr 1, 2026
Complaint Investigation
Date: Apr 1, 2026
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On-site complaint investigation of intake #00163902 and federal intake #2969508 at a Nursing Care Institution, conducted 1 April 2026.
Complaint Details
Investigation of intake #00163902 and federal intake #2969508 was conducted on April 1, 2026. No deficiencies were cited.
Findings
No deficiencies were cited during this complaint investigation.
Inspection Report — Dec 1, 2025
Complaint Investigation
Date: Dec 1, 2025
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On-site complaint investigation of intake #00147308 and intake #2638823 at a Nursing Care Institution, conducted 24 October 2025.
Complaint Details
The complaint survey was conducted on October 24, 2025, investigating intake #00147308 and intake #2638823. No deficiencies were cited.
Findings
No deficiencies were cited during this complaint investigation.
Inspection Report — Nov 20, 2025
Complaint Investigation
Date: Nov 20, 2025
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On-site complaint investigation of intake 2654364 at a Nursing Care Institution, conducted 12 November 2025.
Complaint Details
The complaint investigation was conducted on November 12, 2025, with investigation of intakes:2654364. There were no deficiencies cited.
Findings
No deficiencies were cited during this complaint investigation.
Inspection Report — Jul 18, 2025
Complaint Investigation
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 of sexual abuse between residents #3 and #9 as victims and residents #4 and #10 as alleged perpetrators. The facility conducted a 5-day investigation including interviews with residents and staff, review of care plans, progress notes, and police involvement. The investigation concluded no abuse occurred, though inappropriate behaviors were documented. Residents #3 and #4 were interviewed and denied abuse, and monitoring and interventions were put in place.
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 reviews, staff interviews, and facility documentation, concluding that while inappropriate behaviors occurred, no abuse was confirmed. Residents were monitored and interventions such as one-on-one supervision were implemented.
Deficiencies (1)
Failure to protect residents from all types of abuse including sexual abuse.
Report Facts
Residents involved: 4
BIMS scores: 8
BIMS scores: 5
BIMS scores: 7
BIMS scores: 8
BIMS scores: 4
Dates of care plans: 2023
Dates of care plans: 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #901 | Certified Nursing Assistant (CNA) | Reported observing Resident #10's hands on Resident #9 and ensured residents were separated |
| Staff #700 | Certified Nursing Assistant (CNA) | Reported observing Resident #4 and Resident #3 in inappropriate situation and notified nurse |
| Staff #41 | Certified Nursing Assistant (CNA) | Observed residents during investigation and described abuse reporting procedures |
| Staff #105 | Licensed Practical Nurse (LPN) | Described responsibilities and observations related to abuse incident involving residents |
| Staff #900 | Registered Nurse (RN) | Reported abuse training and involvement in incident response and reporting |
| Staff #70 | Director of Nursing (DON) | Provided information on abuse training, investigation conclusions, and resident monitoring |
| Staff #16 | Administrator | Provided information on facility camera system and investigation procedures |
Inspection Report — May 20, 2025
Complaint Investigation
Date: May 20, 2025
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On-site complaint investigation of intake SF00131258 and intake AZ00224589 at a Nursing Care Institution, conducted 20 May 2025.
Complaint Details
A complaint survey was conducted on May 20, 2025 for the investigation of intake #SF00131258. A complaint survey was conducted on May 20, 2025 for the investigation of intake #AZ00224589. No deficiencies were cited.
Findings
No deficiencies were cited during this complaint investigation.
Inspection Report — May 8, 2025
Complaint Investigation
Date: May 8, 2025
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On-site complaint investigation of intake AZ00193297 and AZ00193287 at a Nursing Care Institution, conducted 8 May 2025.
Complaint Details
A complaint survey was conducted on May 8, 2025 for the re-investigation of intake # AZ00193297 and intake # AZ00193287. No deficiencies were cited.
Findings
No deficiencies were cited during this complaint investigation.
Inspection Report — May 5, 2025
Complaint Investigation
Date: May 5, 2025
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On-site complaint investigation of intakes 00128307, 00128547, AZ00224296, and AZ00224357 at a Nursing Care Institution, conducted 5 May 2025.
Complaint Details
An onsite complaint survey was conducted on May 5, 2025 for the investigation of intake # 00128307 and 00128547. An onsite complaint survey was conducted on May 5, 2025 for the investigation of intake # AZ00224296 and AZ00224357. There were no deficiencies cited.
Findings
This inspection resulted in no deficiencies cited.
Inspection Report — Mar 7, 2025
Complaint Investigation
Date: Mar 7, 2025
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On-site complaint investigation of intakes 00121563, 00120800, AZ00223704 and AZ00223627 at a Nursing Care Institution, conducted 7 March 2025.
Complaint Details
A complaint investigation was conducted on March 7, 2025 for intakes #00121563, 00120800. No deficiencies were cited. A complaint investigation was conducted on March 7, 2025 for intakes #AZ00223704 and AZ00223627. No deficiencies were cited.
Findings
No deficiencies were cited during this complaint investigation.
Report Facts
Complaints investigated: 4
Inspection Report — Feb 26, 2025
Date: Feb 26, 2025
Visit Reason
On-site inspection of type Other at a Nursing Care Institution, conducted 26 February 2025.
Findings
No deficiencies were found during this inspection.
Inspection Report — Feb 21, 2025
Complaint Investigation
Date: Feb 21, 2025
Visit Reason
The inspection was conducted to investigate complaints related to the facility's pharmaceutical services, specifically regarding the control, storage, and disposition of controlled medications to prevent loss, diversion, or accidental exposure.
Complaint Details
The visit was complaint-related, focusing on medication control and storage issues. The complaint was substantiated with findings of minimal harm or potential for actual harm affecting a few residents.
Findings
The facility failed to ensure proper safeguards and systems were in place to control and account for controlled medications, resulting in issues such as tampered medication seals, improper storage, missing medication counts, expired medications, and unsanitary conditions in the medication storage room. These deficiencies posed risks of medication diversion, improper medication disposal, and potential infection control problems.
Deficiencies (4)
Failure to control and account for controlled medications, including tampered seals and missing disposition dates.
Improper storage of medications, including co-mingling of discontinued medications and lack of organizational system.
Expired medications found in the medication storage room, including emergency kits.
Unsanitary conditions in the medication storage room, including debris in sink, stained medication bottles, and contaminated glucometer.
Report Facts
Residents on Enhanced Barrier Precautions: 30
Residents on Transmission Based Precautions: 7
Quantity dispensed of Alprazolam tablets: 18
Ending quantity count of Alprazolam tablets: 3
Expired Octreotide acetate injections: 2
Expired Nystatin suspension: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing (DON) | Interviewed regarding medication storage and tampered medication seal | |
| Resource Licensed Practical Nurse (LPN) | Interviewed regarding medication storage and tampered medication seal | |
| Registered Pharmacist | Interviewed regarding medication control, storage policies, and infection control | |
| Licensed Practical Nurse (Staff #163) | Observed medication pass and discussed narcotic counts and medication discrepancies | |
| Licensed Practical Nurse (Staff #105) | Interviewed about medication storage and infection control issues | |
| Licensed Practical Nurse (Staff #161) | Interviewed about medication cart cleanliness and infection control |
Inspection Report — Feb 21, 2025
Annual Inspection
Date: Feb 21, 2025
Visit Reason
On-site complaint and annual recertification survey conducted February 18 through February 21, 2025, in conjunction with complaints AZ00197103, AZ00197106, AZ00197112, AZ00196990, AZ00197017, AZ00196960, AZ00196675, AZ00196432, AZ00185911, AZ00195836, AZ00195788, and AZ00195582 at a Nursing Care Institution.
Complaint Details
The recertification/complaint survey was conducted February 18, 2025 through February 20, 2025 in conjunction with the Complaints of AZ00197103, AZ00197106, AZ00197112, AZ00196990, AZ00197017, AZ00196960, AZ00196675, AZ00196432, AZ00185911, AZ00195836, AZ00195788, AZ00195582.
Findings
Two deficiencies were cited related to policies and procedures for medication management and infection control. No evidence text was provided for either deficiency.
Deficiencies (2)
R9-10-403 — No evidence was provided regarding policies and procedures covering storing, dispensing, administering, and disposing of medication.
R9-10-403 — No evidence was provided regarding policies and procedures covering infection control.
Report Facts
Deficiencies cited: 2
Inspection Report — Nov 6, 2024
Complaint Investigation
Date: Nov 6, 2024
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On-site complaint investigation of complaints AZ00218265 and AZ00218266 at a Nursing Care Institution, conducted 6 November 2024.
Complaint Details
The complaint survey was conducted on November 6, 2024 through November 6, 2024 of the following complaint #s AZ00218265 and AZ00218266. There were no deficiencies cited.
Findings
This inspection resulted in no deficiencies cited.
Report Facts
Complaints investigated: 2
Inspection Report — Sep 4, 2024
Annual Inspection
Date: Sep 4, 2024
Visit Reason
On-site complaint investigation and annual compliance inspection conducted on September 4, 2024, for intake numbers AZ00147293, AZ00155653, AZ00157343, AZ00159348, AZ00158544, AZ00167684, AZ00167947, AZ00173817, AZ00175098, AZ00175323, AZ00175989, and AZ00181572 at a Nursing Care Institution.
Complaint Details
A complaint survey was conducted on September 4, 2024 for investigation of intake numbers AZ00147293, AZ00155653, AZ00157343, AZ00159348, AZ00158544, AZ00167684, AZ00167947, AZ00173817, AZ00175098, AZ00175323, AZ00175989, and AZ00181572.
Findings
The inspection found one deficiency related to failure to ensure residents were free from abuse by other residents. A plan of correction was provided.
Deficiencies (1)
R9-10-410 — The facility failed to ensure that residents were free from abuse by other residents, as evidenced by multiple incidents where residents physically harmed their roommates and staff interventions were required.
Report Facts
Deficiencies cited: 1
Complaints investigated: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #204 | Licensed Practical Nurse | Noticed red mark on resident #3 and assessed the situation. |
| Staff #205 | Licensed Practical Nurse | Interviewed resident #192 who admitted to hitting roommate. |
| Staff #206 | Licensed Practical Nurse | Responded to yelling and separated residents #197 and #200. |
| Staff #207 | Certified Nurse Assistant | Responded to yelling and reported resident #197 hit resident #200. |
Inspection Report — Aug 28, 2024
Complaint Investigation
Date: Aug 28, 2024
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On-site complaint investigation of intakes AZ00215215, AZ00215119, and AZ00215214 at a Nursing Care Institution, conducted 28 August 2024.
Complaint Details
An onsite complaint survey was conducted on August 28, 2024 for the investigation of intake # AZ00215215, AZ00215119, and AZ00215214. There were no deficiencies cited.
Findings
This inspection resulted in no deficiencies cited.
Inspection Report — Apr 18, 2024
Complaint Investigation
Date: Apr 18, 2024
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On-site complaint investigation of intakes AZ00209100 and AZ00209116 at a Nursing Care Institution, conducted 18 April 2024.
Complaint Details
An onsite complaint survey was conducted on April 18, 2024 for the investigation of intake #s AZ00209100 and AZ00209116. Federal comments also note investigation of intake #s AZ00209100 and AZ00209112. There were no deficiencies cited.
Findings
No deficiencies were cited during this complaint investigation.
Report Facts
Complaints investigated: 3
Inspection Report — Sep 29, 2023
Complaint Investigation
Date: Sep 29, 2023
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On-site complaint investigation of complaints AZ00201169 and AZ00201168 at a Nursing Care Institution, conducted 29 September 2023.
Complaint Details
The investigation of complaint AZ00201169 was conducted on 9/29/23. The investigation of complaint AZ00201168 was conducted on 9/29/23. No deficiencies were cited.
Findings
No deficiencies were cited during this complaint investigation.
Report Facts
Complaints investigated: 2
Inspection Report — Jul 21, 2023
Complaint Investigation
Date: Jul 21, 2023
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On-site complaint investigation of complaints AZ00197771, AZ00197773, AZ00197768, and AZ00197772 at a Nursing Care Institution, conducted 21 July 2023.
Complaint Details
The Complaint AZ00197771 and AZ00197773 were investigated on 7/21/23. The Complaint AZ00197768 and AZ00197772 were investigated on 7/21/23. No deficiencies were cited.
Findings
No deficiencies were found during this complaint investigation.
Report Facts
Complaints investigated: 4
Inspection Report — Jun 2, 2023
Complaint Investigation
Date: Jun 2, 2023
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On-site complaint investigation of multiple complaints at a Nursing Care Institution, conducted 2 June 2023.
Complaint Details
The investigation of complaints AZ99194881, AZ00194809, AZ00194784, AZ00194289, AZ00194218, AZ00194133, AZ00194166, AZ00194198, AZ00193441, AZ00193354, AZ00193297, AZ00193184, AZ00192960, AZ00192877, AZ00192805, AZ00192839, AZ00192064, AZ00191801, AZ00191808, AZ00191770, AZ00191548, AZ00191581, AZ00191499, AZ00191428, AZ00191128, AZ00190981, AZ00190715, AZ00190663, AZ00190502, AZ00190262, AZ00190197, AZ00190077, AZ00190040, AZ00189840, AZ00189714, AZ00189531, AZ00189485, AZ00189411, AZ00187805, AZ00187798, AZ00187744, AZ00187510, AZ00187464, AZ00187120, AZ00187077, AZ00187050, AZ00187021, AZ00186768, AZ00186412, AZ00186388, AZ00186053, AZ00185989, AZ00185940, AZ00185914, AZ00185785, AZ00185751, AZ00185652, AZ00185475, AZ00185479, AZ00185416, AZ00184959, AZ001849791, AZ00184785, AZ00184794, AZ00184741, AZ00184638, AZ00184660, AZ00184517, AZ00184484, AZ00183327, AZ00184325 was conducted on May 30, 2023 through June 2, 2023. No deficiencies were cited.
Findings
No deficiencies were cited during this complaint investigation.
Inspection Report — Apr 14, 2023
Routine
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 — Feb 17, 2022
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.
4 CMS Surveys
CMS Survey — Jul 18, 2025
Jul 18, 2025
CMS Survey — Feb 17, 2022
Feb 17, 2022
CMS Survey — Apr 14, 2023
Apr 14, 2023
CMS Survey — Feb 21, 2025
Feb 21, 2025
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