The Citadel Rehab and Nursing Center Cited for Abuse, Elopement

The Citadel Rehab and Nursing Center at Kingsbridge has received eight citations for violations of public health laws between 2017 and 2021, according to New York State Department of Health records accessed on June 18, 2021. Those citations include a finding of systemic accident hazards in the facility, which also received a $10,000 fine in 2016. 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 take adequate steps to prevent accidents such as elopement. Section 483.25 of the Federal Code stipulates that nursing homes must keep their facilities “as free of accident hazards as is possible” and provide residents with adequate supervision to prevent accidents. A February 2021 citation found that The Citadel Rehab and Nursing Center failed to ensure such for one resident. The citation states specifically that after new windows were installed in the resident’s rom, 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 resident had been identified as at risk for elopement, and had been observed exhibiting increased “exit-seeking behaviors” that were not reported to the physician. At a redacted date, surveillance video showed, the resident opened the window in their room, “threw tied sheets out, and climbed out the window.” They then fell to the ground and were found by staff several hours later, after which they were “transferred to the hospital and expired.” A plan of correction undertaken by the facility included the termination of two Certified Nursing Assistants and a Licensed Practical Nurse.

2. The nursing home did not take adequate steps to prevent physical abuse. Section 483.12 of the Federal Code ensures nursing home residents “the right to be free from abuse.” A January 2021 citation found that The Citadel Rehab and Nursing Center failed to ensure such for one resident. The citation states specifically that during an incident in which a resident slapped a Certified Nursing Assistant, the Certified Nursing Assistant “retaliated and slapped” the resident’s left cheek, causing the resident’s eyeglasses to fall to the floor. The citation states that the incident was witnessed by a housekeeper and another Certified Nursing Assistant. A plan of correction undertaken by the facility included the suspension and then the termination of the Certified Nursing Assistant.

3. The nursing home did not ensure residents were properly cared for. Section 483.21 of the Federal Code stipulates that nursing homes must ensure residents receive services “provided by qualified persons in accordance with each resident’s written plan of care.” A November 2017 citation found that The Citadel Rehab and Nursing Center failed to ensure such for one resident. The citation states specifically that the facility did not ensure the physician’s orders were followed when a nurse “administered insulin multiple times to a resident when the blood glucose levels were below the ordered parameters.” The citation states that this deficiency had the “potential to cause more than minimal harm.” A plan of correction undertaken by the facility included the suspension and re-in-servicing of the nurse.

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.

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