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Deficiency Records for Citadel at Saint Benedict
A list of the most recent deficiencies for Citadel at Saint Benedict. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Citadel at Saint Benedict. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2024-05-14 | 2024-08-30 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-06-30 | 2024-07-26 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-06-30 | 2024-07-26 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2024-05-14 | 2024-06-13 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2024-05-14 | 2024-06-13 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2024-05-14 | 2024-06-13 | N |
| Establish emergency prep training and testing. | Fire Safety | 2024-05-14 | 2024-06-13 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2024-05-14 | 2024-06-13 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2024-05-14 | 2024-06-13 | N |
| Install proper backup exit lighting. | Fire Safety | 2024-05-14 | 2024-06-13 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2024-05-14 | 2024-06-13 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2024-05-14 | 2024-06-13 | N |
| Have an alternate power supply for its alarm system. | Fire Safety | 2024-05-14 | 2024-06-13 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-05-14 | 2024-06-13 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2024-05-14 | 2024-06-13 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-05-14 | 2024-06-13 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2024-05-14 | 2024-06-13 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-05-14 | 2024-06-13 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2024-05-14 | 2024-06-13 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2024-05-14 | 2024-06-13 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-05-14 | 2024-06-13 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-05-14 | 2024-06-13 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2024-05-16 | 2024-06-10 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2024-05-16 | 2024-06-10 | N |
| Ensure that residents are free from significant medication errors. | Health | 2024-05-16 | 2024-06-10 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2024-02-01 | 2024-04-06 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-05-02 | 2023-05-17 | Y |
| Install a two-hour-resistant firewall separation. | Fire Safety | 2023-04-11 | 2023-05-08 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2023-04-11 | 2023-05-08 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-04-11 | 2023-05-08 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-04-11 | 2023-05-08 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2023-04-11 | 2023-05-08 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-04-11 | 2023-05-08 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-04-11 | 2023-05-08 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-04-11 | 2023-05-08 | N |
| Have proper power supply for life support equipment. | Fire Safety | 2023-04-11 | 2023-05-08 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-04-11 | 2023-05-08 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-04-11 | 2023-05-08 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-04-11 | 2023-05-05 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-04-11 | 2023-05-02 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2023-04-11 | 2023-04-11 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-04-11 | 2023-04-11 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-04-11 | 2023-04-11 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2023-04-11 | 2023-04-11 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2023-03-08 | 2023-03-29 | Y |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2021-03-03 | 2021-04-09 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2021-03-03 | 2021-04-09 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2021-03-03 | 2021-04-09 | N |
| Establish policies and procedures including evacuation. | Fire Safety | 2021-03-03 | 2021-04-09 | N |
| Establish policies and procedures for sheltering. | Fire Safety | 2021-03-03 | 2021-04-09 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2021-03-03 | 2021-04-09 | N |
| Establish emergency prep training and testing. | Fire Safety | 2021-03-03 | 2021-04-09 | N |
| Establish staff and initial training requirements. | Fire Safety | 2021-03-03 | 2021-04-09 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2021-03-03 | 2021-04-09 | N |
| Implement emergency and standby power systems. | Fire Safety | 2021-03-03 | 2021-04-09 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2021-03-05 | 2021-04-07 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-03-05 | 2021-04-07 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-03-05 | 2021-04-07 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-03-05 | 2021-04-07 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2021-03-05 | 2021-04-07 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2021-03-05 | 2021-04-07 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-03-05 | 2021-04-07 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-03-05 | 2021-04-07 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2021-03-05 | 2021-04-07 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2021-03-03 | 2021-04-07 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2021-03-03 | 2021-03-31 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2021-03-03 | 2021-03-31 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2021-03-03 | 2021-03-31 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-03-03 | 2021-03-31 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2021-03-03 | 2021-03-31 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-03-03 | 2021-03-31 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-03-03 | 2021-03-31 | N |
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