The Citadel Assisted Living Facility

Based on documentation review, record review, and interview, the manager failed to ensure a resident provided evidence of freedom from infectious tuberculosis (TB) as specified in R9-10-113, for three of four residents sampled. The deficient practice posed a TB exposure risk to residents. Findings include: 1. R9-10-113.A states "If a health care institution is subject to the requirements of this Section, as specified in an Article in this Chapter, the health care institution's chief administrative officer shall ensure that the health care institution establishes, documents, and implements tuberculosis infection control activities that...2. Include: a. For each individual who is employed by the health care institution, provides volunteer services for the health care institution, or is admitted to the health care institution and who is subject to the requirements of this Section, screening, on or before the date specified in the applicable Article of this Chapter, that consists of: i. Assessing risks of prior exposure to infectious tuberculosis, ii. Determining if the individual has signs or symptoms of tuberculosis, ... according to subsection (B)(1)..." 2. A review of R2’s medical records showed documentation of a TB risk assessment for prior exposure to infectious tuberculosis and a determination of whether the residents had signs or symptoms of TB, which were electronically signed by O1; however, the document was not signed twelve months before or within seven calendar days after the resident’s date of occupancy and a review of the National Council of State Boards of Nursing website revealed that O1 was a Licensed Practical Nurses (LPNs), and the documentation was required to have been signed by a registered nurse, medical practitioner, or the local health department. Based on R2’s admission dates, this documentation was required. 3. A review of R3’s medical records showed documentation of a TB risk assessment for prior exposure to infectious tuberculosis and a determination of whether the resident had signs or symptoms of TB, which were electronically signed by O1; however, the document was not signed twelve months before or within seven calendar days after the resident’s date of occupancy and a review of the National Council of State Boards of Nursing website revealed that O1 was a Licensed Practical Nurse (LPN), and the documentation was required to have been signed by a registered nurse, medical practitioner, or the local health department. Based on R3’s admission date, this documentation was required. 4. A review of R4’s medical records showed documentation of a TB risk assessment for prior exposure to infectious tuberculosis and a determination of whether the residents had signs or symptoms of TB, which O2 electronically signed; however, a review of the National Council of State Boards of Nursing website revealed no search results for O2, and the documentation was required to have been signed by a registered nurse, medical practitioner, o

Based on observation, interview, and record review, the manager failed to ensure the facility premises were cleaned and disinfected in one of four residents’ rooms observed. This deficient practice posed a health risk as the presence of cockroaches indicated an unsanitary condition that could increase the risk of infection by exposing residents to potential pathogens and compromising resident health and safety. Findings include: 1. During the environmental tour with E1 and E2, the Compliance Officers observed evidence of both live and dead cockroaches in R4’s room inside a kitchen cabinet used for food storage and on a bookshelf, including visible debris and multiple small dark spots consistent with cockroach droppings along corners, edges, and surfaces, indicating the areas were not clean and showed evidence of pest presence. 2. In an interview, R4 reported noticing cockroaches and R4 had informed facility staff, but was unable to recall to whom the concern was reported. 3. A review of R4's service plan for personnal care services stated the following services were provided, "Housekeeping: Provide Housekeeping and Laundry Service weekly and PRN; and Pick up Trash Daily." 4. In an interview, E2 reported that the facility was not aware of the situation. 5. In an exit interview, the findings were reviewed with E1, E2, E3, and E4, and no additional information was provided. This is a repeat deficiency from the inspections conducted on May 5, 2023, August 30, 2023, July 01, 2025, and an uncorrected deficiency from the complaint inspection conducted on November 17, 2025.

Based on observation, record review and interview, the manager failed to ensure before providing personal care services or directed care services to a resident, a caregiver provided documentation of valid cardiopulmonary resuscitation (CPR) training certification specific to adults, for one of three caregivers sampled. The deficient practice posed a risk if an employee was unable to meet a resident's needs during an emergency. Findings include: 1. A review of E2's personnel record revealed CPR training certification dated June 30, 2025, from the NationalCPRFoundation. However, this was an online-only course that did not include a return demonstration of the employee's ability to perform CPR as required in A.A.C. R9-10-803.C.1.e.i. This training was therefore invalid. 2. In an interview, E1 acknowledged E2's CPR training certification was from the NationalCPRFoundation, and there was no additional documentation available for review. This is a repeat deficiency from the compliance inspection and complaint investigation conducted on September 18, 2025.

Based on record review and interview, the manager failed to ensure a resident had a service plan that was established, documented, and implemented, which included the amount, type, and frequency of assisted living services being provided to the resident.  Findings include: 1. A review of R2’s medical record contained a service plan dated September 16, 2025, which reflected that R2 required assistance with incontinence care, hygiene service, and dressing services; however, the amount, type, and frequency of the above services were not established and documented on R2’s service plan. In an interview, E1 reviewed and acknowledged that R2’s established and documented service plan did not include the amount, type, and frequency of the above assisted living services. This is a repeat deficiency from the complaint investigations conducted on January 19, 2024, and April 21, 2025.

Based on record review, observation and interview, the manager failed to ensure a caregiver or assistant caregiver provided a resident with the assisted living services in the resident’s service plan, assisted with activities of daily living according to the resident’s service plan, and provided assistance with, supervised, or directed a resident’s personal hygiene according to the resident’s service plan, for one of three residents sampled. The deficient practice posed a risk as the service plan to direct services was not followed, and the Department was provided false and misleading information. Findings include: 1. A review of R2’s medical record contained a service plan dated September 9, 2024, which reported R2 would be provided the following assistance: "incontinence of bladder requires assistance from staff, requires daily assistance with oral care, skin care, grooming, and dressing, house keeping weekly, pick up trash daily, provided three meals daily and snack, and meal trays per resident request". R2’s service plan reported that R2 required the assistance of two for transfer via Hoyer lift. 2. A review of R2’s medical record contained “Schedule for November 2025” and “Schedule for October 2025,” which stated, “I attest to providing services in accordance with the resident’s individualized service plan," which reflected that all assistance was provided according to R2’s service plan. 3. In an interview, R2 reported lying in R2’s feces for hours, and reported going weeks without showers. R2 reported attempting to clean the floors because housekeeping does not sweep and mop the floors. R2 reported that the caregivers often did not escort R2 to meals, and R2 often did not eat. R2 reported often not being assisted with meals and was not provided with three meals daily. 4. In a review of documentation, a report was submitted to the Department, which alleged that [R2] was found to be soiled with urine and stool, with old stains of urine on the sheets. [R2] cried and asked for help, but no one came to help. [R2] stated [R2] has not eaten since Friday and [caregivers] left a box of cereal, but [R2] was not able to eat it without help. 5. The compliance officer observed R2’s flooring throughout the residential unit was heavily soiled, with visible layers of dirt and debris. The shower area exhibited significant accumulation of grime, dirt, and residue. The toilet was unclean and contained various unknown stains and colors. Various types of trash and discarded items were scattered across multiple areas of the floor. 6. In an interview, E1 acknowledged the documentation provided for review, attested to providing services in accordance with R2’s individualized service plan.

Based on record review, observation, and interview, the manager failed to ensure a resident is treated with dignity, respect, and consideration for one of three residents. Findings include: 1. The compliance officer observed R2’s flooring throughout the residential unit was heavily soiled, with visible layers of dirt and debris. The shower area exhibited significant accumulation of grime, dirt, and residue. The toilet was unclean and contained various unknown stains and colors. Various types of trash and discarded items were scattered across multiple areas of the floor. 2. In a review of documentation, a report was submitted to the Department, which alleged that [R2] was found to be soiled with urine and stool, with old stains of urine on the sheets. [R2] cried and asked for help, but no one came to help. [R2] stated [R2] has not eaten since Friday and [caregivers] left a box of cereal, but [R2] was not able to eat it without help. 3. In an interview, R2 reported lying in R2’s feces for hours, and reported going weeks without showers. R2 reported attempting to clean the floors because housekeeping does not sweep and mop the floors. R2 reported that the caregivers often did not escort R2 to meals, and R2 often did not eat. R2 reported often not being assisted with meals and was not provided with three meals daily. R2 confirmed not being treated with dignity, respect, and consideration. 4. In an interview, E1 acknowledged that the above information presented reflected that R2 was not treated with dignity, respect, and consideration. This is a repeat deficiency from the compliance inspections and complaint investigations conducted on May 5, 2023, and September 18, 2025.

Based on record review and interview, the manager failed to ensure medication administered to a resident was administered in compliance with a medication order, for one of three sampled residents.  Findings include: 1. A review of R1’s, R2’s and R3’s medical records contained service plans that reflected R1, R2, and R3 received medication administration services. 2. A review of R1’s medical record contained medication orders dated September 17, 2025 for Atorvastatin Calcium one tablet daily at bedtime, Quetiapine Fumarate 400 mg one tablet at bedtime, Insulin Glargine 100 unit/ml inject 20 unit subcutaneously at bedtime; Senna 8.6-50 mg two tablets at bedtime; Tizanidine 2 mg one tablet at bedtime, Trazadone 150 mg one tablet at bedtime, Tresiba subcutaneous pen injector 100 unit/ml inject 25 units at bedtime, Buspirone 30 mg one tablet twice daily, Glipizide 5mg two tablets twice daily; Metformin 1000 mg one tablet twice daily; Oxybutynin 5mg one tablet twice daily; Pepcid 20mg one tablet twice daily; Triamcinolone cream apply twice daily; and Hydroxyzine tablet 25 mg one tablet four times daily. There were no stipulations reported on R1’s medication orders to hold any of the above-listed medications. 3. A review of R1’s medical record contained a November 2025 medication administration record (MAR) which reported R1’s Atorvastatin 20 mg, Tizanidine 2 mg, Trazadone 150 mg, Tresiba subcutaneous pen injector 100 unit/ml inject 25 units, Buspirone 30 mg, Glipizide 5 mg, Metformin 1000 mg, Oxybutynin 5 mg were held on November 3, 2025, November 9, 2025, and November 16, 2025; and R1’s Atorvastatin 20 mg was held on November 2, 2025, November 9, 2025, and November 16, 2025. 4. R1’s 2025 November MAR reflected Senna was out of stock on November 2, 2025, November 4, 2025, November 8, 2025, November 12, 2025, and November 15, 2025; and was held on November 3, 2025, November 9, 2025, and November 16, 2025. However, R1’s November 2025 MAR reflected that R1 was administered Senna on November 3, 2025, November 5 through 7, 2025; November 9 through November 11, 2025; November 13 through November 14, 2025, despite R1’s Senna being reported as unavailable. 5. R1’s progress note reported R1’s Senna 8.6-50 mg was not stocked at the facility on November 3, 2025, November 6, 2025, and on November 11, 2025, the progress note reported “last dose of medication given to [R1]. [R1] will have [R1's] medication pick up from CVS". 6. A review of R1’s medical record revealed that a document titled “Progress Notes” did not report the reasons R1’s Atorvastatin, Tizanidine 2 mg, Trazadone 150 mg, Tresiba subcutaneous pen injector 100 unit/ml inject 25 units, Buspirone 30 mg, Glipizide 5 mg, Metformin 1000 mg, Oxybutynin 5 mg were withheld from administration. 7. R1’s progress note reported that R1’s Pepcid 20mg was not administered for the following reasons: · November 13, 2025, medication not being at the facility; · November 15, 2025, medication not being at the facility;

Based on observation and interview, the manager failed to ensure the premises at the assisted living facility were cleaned. Findings include: 1. The compliance officer observed R2’s flooring throughout the residential unit was heavily soiled, with visible layers of dirt and debris. The shower area exhibited significant accumulation of grime, dirt, and residue. The toilet was unclean and contained various unknown stains and colors. Various types of trash and discarded items were scattered across multiple areas of the floor. 2. In an interview, R2 reported attempting to clean R2’s room despite R2’s inability to walk or bear R2’s own weight. R2 acknowledged that the premises were not cleaned.  3. In an interview, E1 acknowledged that R2’s residential unit was observed to have R2’s flooring throughout the residential unit that was heavily soiled, with visible layers of dirt and debris. This is a repeat deficiency from the compliance inspection and complaint investigation conducted on May 5, 2023, and the complaint investigations conducted on August 30, 2023, and July 01, 2025.