Deficiencies (last 3 years)
Deficiencies (over 3 years)
2.3 deficiencies/year
Deficiencies are regulatory findings recorded during state inspections.
38% 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 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
Complaint Investigation
Deficiencies: 4
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
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
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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