CHARLOTTE, NC- THE CITADEL AT MYERS PARK

The Department of Health & Human Services conducted an inspection of the facility. The following highlighted decencies listed below were found in a public survey. 

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Based on record review and staff interviews the facility failed to protect a cognitively impaired resident from staff to resident physical abuse for 1 of 1 resident (Resident #396) reviewed for abuse. On 02/27/22 when nursing staff were serving breakfast, Resident #396 was standing next to the meal cart and reached for a carton of milk. Nurse Aide (NA) #9 told Resident #396 to stop twice in a loud aggressive manner and when the resident did not comply NA #9 pushed the resident on the left side of his torso above his hip onto the ground. Resident #396’s cognitive impairment prevented him from expressing an adverse outcome. A reasonable person would have been traumatized by being physically abused by a caregiver in their home environment.

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Based on record review and staff interviews the facility failed to protect residents when Nurse Aide (NA) #9 was not removed from a resident care assignment after Nurse #6 witnessed NA #9 push Resident #396 on the left side of his torso above his hip onto the ground. The facility also failed to thoroughly investigate abuse and to notify Adult Protective Services and Law Enforcement of abuse for 1 of 1 resident reviewed for abuse (Resident #396).

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Based on observation, record review, staff, resident, Nurse Practitioner and Medical Director interview the facility failed to prevent severely cognitively impaired residents from exiting the facility through unlocked doors without supervision for 2 of 2 residents reviewed for supervision to prevent accidents (Resident #88 and #68). Resident #88 who was severely cognitively impaired, exited the building through an unlocked door on the first floor to smoke without supervision. An unidentified male intruder entered facility behind Resident #88 through the unlocked door of facility and vandalized the second-floor dayroom by shattering the TV, knocking a hole in the wall, and breaking out two windows. The facility failed to repair broken windows only covering windows with cardboard and wooden board that was easily removable leaving broken windows and
shards of broken glass accessible to residents and failed to complete a facility investigation. Resident #68 was severely cognitively impaired and exited the memory care unit through an unlocked door to the staircase. The resident went down three flights of stairs and exited the facility through a side door. Resident #68 was found by a Nurse Aide (NA) when he went to his car, the resident was laying in the backseat of the NA’s car asleep. The NA left Resident #68 in the unlocked car with the windows up, unattended in 74-degree weather while he went back inside for help.