The Citadel Rehab and Nursing Center Cited for Systemic Accident Hazards

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 did meet infection prevention and control standards. Section 483.80 of the Federal Code states that nursing homes “must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment.” According to a citation issued August 30, 2019, an inspector observed a Certified Nursing Assistant handling bread with their bare hands—including buttering the bread and handing it to residents—then completing wound observations, including cleaning a wound and applying dressing, without first changing her gloves or performing proper hand hygiene. The inspector found that this activity constituted a contravention of facility policy requiring the used of alcohol-based hand rub or soap and water before cleaning resident body sites.

3. 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 comply with this section when a nurse gave a resident insulin when that patient’s “blood glucose levels were below the ordered parameters.” Medical records showed that a the nurse in question administered insulin to the patient “on many occasions” when the resident’s blood sugar levels did not meet the parameters set by the physician’s orders. The citation states that this lapse had the “potential to cause more than minimal harm” to residents.

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.

Contact Information