The Citadel Rehab and Nursing Center: Abuse, Fall Citations

The Citadel Rehab and Nursing Center at Kingsbridge has received six citations for violations of public health code between 2018 and 2021, according to New York State Department of Health records accessed on February 11, 2022. The Kingsbridge nursing home’s citations resulted from a total of four surveys by state inspectors. The deficiencies they describe include the following:

1. The nursing home did not adequately prevent abuse. Section 483.12 of the Federal Code states that nursing home residents have the right to freedom from abuse. A January 2021 citation found that The Citadel Rehab and Nursing Center failed to ensure such. The citation specifically describes an instance in which a resident slapped a Certified Nursing Assistant, to which the CNA responded by slapping the resident on the left cheek. According to the citation, the resident’s care plan stated that she was verbally abusive, but “There were no instructions on the Resident Nursing Instructions for staff members to be aware that [the resident] had violent behavior and could become aggressive.” There were also no instructions warning staff that the resident “was verbally and physically abusive,” according to the citation, nor any instructions advising the staff on what they should do in the event the resident acted in a physically abusive manner. In an interview, the facility’s Director of Nursing said that with respect to the resident, Certified Nursing Assistants “were instructed to redirect the resident, approach calmly and provide diversional activities,” and further that they were “trained to back away” from aggressive residents. A plan of correction undertaken by the facility included the review of nursing instructions and re-in-servicing of staff on how to deal with aggressive behaviors. 
2. The nursing home did not adequately prevent accident hazards. Section 483.25 of the Federal Code stipulates that nursing homes must ensure resident environments are as free as possible of accident hazards, with adequate supervision of residents to prevent accidents. A February 2021 citation found “widespread” failures to ensure such at The Citadel Rehab and Nursing Center. The citation states specifically that when new windows were installed in a resident’s room on the facility’s fourth floor, the nursing home “failed to ensure the window’s safety latch was in place to prevent the window from tilting into the room and fully opening.” The nursing home goes on to describe an instance in which the resident, who had previously attempted to exit the unit and “begged” to be released to their home, jumped out of their window and was found “lying on their left side on the 2nd floor patio outside of a window below their room.” A review of surveillance video showed that the resident had opened their window, thrown tied sheets out of it, and climbed through. After being found by staff, the resident was transferred to the hospital, where they “expired.” A plan of correction undertaken by the facility included the education of staff “to never remove the screws that were placed to disable the tilting features.” 
3. The nursing home did not adequately prevent infection. Section 483.80 of the Federal Code requires nursing homes to create and abide by a program to help prevent the transmission of disease. An August 2019 citation found that The Citadel failed to ensure such. The citation specifically describes a Certified Nursing Assistant who was seen “on multiple occasions” handling, buttering, and distributing bread to residents with their bare hands; it also describes a Licensed Practical Nurse who did not change gloves and perform proper hand hygiene while providing wound care for a resident. A plan of correction undertaken by the facility included the counseling of relevant staff.

The Citadel Rehab and Nursing Center at Kingsbridge received 19 citations for violations of public health laws between 2015 and 2019, according to New York State Department of Health records accessed on November 14, 2019. Those citations include two that were found to cause immediate jeopardy to resident health, and one that authorities say reflected “a severe, systemic deficiency.” The Bronx nursing home’s citations resulted from a total of five inspections by state authorities. The violations they describe include the following:

1. The nursing home did not ensure it provided an environment free of accident hazards. Under Section 483.25 of the Federal Code, nursing home facilities are required to provide residents with an environment as free as possible from accident hazards, and with proper supervision and assistive devices to prevent accidents. An August 2016 citation states that an inspector observed more than 50 beds with siderails whose measurements “exceeded the FDA recommendation that spaces between the bed siderail bars should be no larger than 4 3/4 inches.” While the Department of Health inspector found that this deficiency had so far not resulted in actual harm, it had “the potential for more than minimal harm that was immediate jeopardy and substandard quality of care.”
2. The nursing home failed to ensure residents’ drug regimens were kept free from unnecessary drugs. Section 483.45 of the Federal Code stipulates that nursing homes must maintain “each resident’s drug regimen… free from unnecessary drugs,” defining (in part) as unnecessary any drug used in excessive dosage. A citation issued in November 2017 found that The Citadel failed to

The attorneys at the Law Offices of Thomas L. Gallivan, PLLC work diligently to protect the rights of nursing home residents. Please contact us to discuss in the event you have a potential case involving neglect or abuse.