Inspection Reports for The Citadel Rehab and Nursing Center at Kingsbridge
3400 Cannon Place, Bronx, NY, 10463
Back to Facility ProfileInspection Report Summary
The most recent inspection on June 20, 2025, identified one Life Safety Code citation related to the physical environment, which was corrected by August 1, 2025. Earlier inspections showed a pattern of deficiencies involving supervision and abuse reporting, including a February 2025 finding where inadequate supervision led to a resident fall causing fractures, and multiple reports in 2024 and 2022 cited failures to timely report suspected abuse incidents to the New York State Department of Health. Inspectors frequently noted issues with resident safety supervision, abuse reporting, and maintaining a hazard-free environment, along with some Life Safety Code concerns such as electrical systems and door maintenance. Complaint investigations mostly found substantiated delays in abuse reporting, with no fines, immediate jeopardy findings, or license actions listed in the available reports. While recent inspections show fewer deficiencies and timely corrections, the facility’s history reflects ongoing challenges in supervision and abuse reporting that have improved somewhat over time.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
18% worse than New York average
New York average: 5.1 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 1
Date: Jun 20, 2025
Visit Reason
One Life Safety Code citation related to physical environment with no actual harm but potential for more than minimal harm; corrected as of August 1, 2025.
Findings
One Life Safety Code citation related to physical environment with no actual harm but potential for more than minimal harm; corrected as of August 1, 2025.
Deficiencies (1)
Physical environment — Standard Life Safety Code Citation
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Feb 5, 2025
Visit Reason
The abbreviated survey was conducted to assess compliance with regulations related to resident safety and supervision, specifically following an incident where a resident fell and sustained injuries due to inadequate supervision during bed mobility care.
Findings
The facility failed to provide adequate supervision to a resident who required two-person assistance for bed mobility, resulting in the resident falling off the bed and sustaining fractures. The Certified Nursing Assistant providing care did not review the resident's nursing instructions or request assistance, leading to actual harm. The investigation concluded that neglect and abuse occurred.
Deficiencies (1)
Failure to provide adequate supervision to prevent accidents, resulting in a resident falling and sustaining fractures.
Report Facts
Residents affected: 15
Residents sampled: 3
Residents affected: 1
Medication dosage: 25
Employment duration: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant #1 | Certified Nursing Assistant | Provided bed mobility care alone, did not follow care plan, involved in resident fall |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Charge nurse on unit, observed resident on floor, responsible for staff monitoring |
| Registered Nurse Supervisor #1 | Registered Nurse Supervisor | Assessed resident after fall, no longer employed at facility |
| Assistant Director of Nursing | Assistant Director of Nursing | Provided statements on care plan requirements and staff responsibilities |
| Administrator | Administrator | Notified of incident, reported law enforcement involvement, suspended and terminated CNA |
| Nurse Practitioner #1 | Nurse Practitioner | Assessed resident post-accident, ordered x-ray, notified family |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 1
Date: Feb 5, 2025
Visit Reason
One Standard Health citation for free of accident hazards/supervision/devices with actual harm; corrected as of March 21, 2025.
Findings
One Standard Health citation for free of accident hazards/supervision/devices with actual harm; corrected as of March 21, 2025.
Deficiencies (1)
Free of accident hazards/supervision/devices — Standard Health Inspection Citation
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Mar 8, 2024
Visit Reason
The inspection was conducted as a recertification and complaint survey from 3/3/2024 to 3/8/2024, triggered by complaints NY00324696 and NY00318663 regarding alleged violations involving abuse and safety hazards.
Complaint Details
The complaint investigation found that the facility did not ensure immediate reporting of alleged abuse incidents involving Residents #265, #181, and #66 to the New York State Department of Health within the required 2-hour timeframe. The resident-to-resident altercation and injuries of unknown origin were reported late. The facility also failed to maintain a hazard-free environment for Resident #274 due to a mattress and bedframe size mismatch.
Findings
The facility failed to timely report suspected abuse incidents involving three residents to the New York State Department of Health within the required 2-hour timeframe. Additionally, the facility did not provide a hazard-free environment for one resident due to a mismatched mattress and bedframe, increasing fall risk.
Deficiencies (3)
Failure to timely report suspected abuse involving Resident #265's injuries of unknown origin to the New York State Department of Health within 2 hours.
Failure to timely report a resident-to-resident altercation between Resident #181 and Resident #66 to the New York State Department of Health within 2 hours.
Provision of a disproportionately smaller mattress atop a wider bedframe for Resident #274, creating a fall hazard.
Report Facts
Residents sampled: 38
Residents affected by abuse reporting deficiency: 3
Residents reviewed for accidents: 6
Falls documented for Resident #274: 5
Mattress width difference: 4
Bedframe width: 42
Mattress width: 38
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant #11 | Assisted Resident #274 with repositioning and provided daily care; unaware of mattress size mismatch until 3/5/2024 | |
| Registered Nurse #5 | Assisted Resident #274 with repositioning and reported mattress/bedframe mismatch to Assistant Director of Nursing | |
| Assistant Director of Nursing #1 | Responsible for coordinating bed requests and unable to explain mattress/bedframe switch for Resident #274 | |
| Maintenance Worker #1 | Conducted bed size and safety audits; noted mattress/bedframe mismatch for Resident #274 on 3/5/2024 | |
| Director of Maintenance | Observed mattress and bedframe mismatch for Resident #274 on 3/5/2024 | |
| Director of Nursing | Interviewed regarding late abuse reporting and bed safety procedures | |
| Administrator | Interviewed about lack of formal bed safety process and plans to implement one |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Mar 8, 2024
Visit Reason
The inspection was conducted as a recertification and complaint survey from 3/3/2024 to 3/8/2024, triggered by complaints NY00324696 and NY00318663 regarding alleged violations involving abuse at the facility.
Complaint Details
The complaint investigation found that the facility did not report suspected abuse incidents involving Residents #265, #181, and #66 to the New York State Department of Health within the required 2-hour timeframe. The Director of Nursing acknowledged the delayed reporting and was unable to explain the reason for the delay.
Findings
The facility failed to ensure that all alleged abuse violations were reported to the New York State Department of Health within the required 2-hour timeframe. Specifically, injuries of unknown origin to Resident #265 and a resident-to-resident altercation between Resident #181 and Resident #66 were not reported timely.
Deficiencies (2)
Failure to timely report Resident #265's abrasion and bruise of unknown origin to the New York State Department of Health within 2 hours of discovery.
Failure to timely report a resident-to-resident altercation between Resident #181 and Resident #66 to the New York State Department of Health within 2 hours of occurrence.
Report Facts
Residents sampled: 38
Residents affected: 3
Dates of incidents: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding delayed reporting of abuse incidents involving Residents #265, #181, and #66 |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 4
Date: Mar 8, 2024
Visit Reason
Multiple Standard Health and Life Safety Code citations including accident hazards and reporting of alleged violations; all corrected by April 2024.
Findings
Multiple Standard Health and Life Safety Code citations including accident hazards and reporting of alleged violations; all corrected by April 2024.
Deficiencies (4)
Free of accident hazards/supervision/devices — Standard Health Inspection Citation
Reporting of alleged violations — Standard Health Inspection Citation
Electrical systems - other — Standard Life Safety Code Citation
Maintenance, inspection & testing - doors — Standard Life Safety Code Citation
Inspection Report
Abbreviated Survey
Deficiencies: 2
Date: Feb 4, 2022
Visit Reason
The inspection was conducted as a Recertification and Abbreviated survey to assess compliance with regulatory requirements, including timely reporting of abuse and accuracy of resident assessments.
Findings
The facility failed to timely report alleged resident-to-resident abuse and a fracture of unknown origin to the New York State Department of Health within required timeframes. Additionally, the facility did not accurately capture a resident's use of a Wanderguard on the Minimum Data Set assessment.
Deficiencies (2)
Failure to timely report suspected abuse and serious bodily injury involving resident-to-resident altercations and a fracture of unknown origin to the New York State Department of Health.
Failure to ensure the Minimum Data Set assessment accurately reflected a resident's use of a Wanderguard alarm for elopement risk.
Report Facts
Residents affected: 7
Residents affected: 1
Length of cut: 7.5
Dates of incidents: May 5, 2020
Dates of incidents: May 8, 2020
Dates of incidents: Aug 5, 2020
Date of fracture x-ray: Apr 2, 2020
Date of facility report: Aug 12, 2020
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Director of Nursing #2 | Assistant Director of Nursing | Interviewed regarding late reporting of resident-to-resident abuse incidents |
| Director of Nursing | Director of Nursing | Interviewed regarding reporting responsibilities and late submissions |
| Administrator | Administrator | Interviewed regarding reporting responsibilities and acknowledged late submissions |
| Assistant Director of Nursing #1 | Assistant Director of Nursing | Conducted Accident/Incident investigation for Resident #386 and interviewed regarding reporting and investigation |
| Registered Nurse #2 | Registered Nurse | Interviewed regarding Resident #386 fall incident and A/I report completion |
| Registered Nurse Supervisor (RN #1) | Registered Nurse Supervisor | Interviewed regarding knowledge of Resident #386 fall incident |
| MDS Coordinator | MDS Coordinator | Interviewed regarding MDS assessment inaccuracies for Resident #184 |
| MDS Assessor | MDS Assessor | Interviewed regarding failure to code Wanderguard on MDS |
| Certified Nurse Aide #2 | Certified Nurse Aide | Interviewed regarding Wanderguard use and checks for Resident #184 |
| Assistant Director of Nursing (ADNS) | Assistant Director of Nursing | Interviewed regarding responsibility for MDS coding and Wanderguard documentation |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 7
Date: Feb 4, 2022
Visit Reason
Multiple Standard Health and Life Safety Code citations related to assessments, abuse prevention, notification, and egress doors; all corrected by April 2022.
Findings
Multiple Standard Health and Life Safety Code citations related to assessments, abuse prevention, notification, and egress doors; all corrected by April 2022.
Deficiencies (7)
Accuracy of assessments — Standard Health Inspection Citation
Free from abuse and neglect — Standard Health Inspection Citation
Investigate/prevent/correct alleged violation — Standard Health Inspection Citation
Notify of changes (injury/decline/room, etc.) — Standard Health Inspection Citation
Reporting of alleged violations — Standard Health Inspection Citation
Egress doors — Standard Life Safety Code Citation
Electrical systems - essential electric syste — Standard Life Safety Code Citation
Inspection Report
Annual Inspection
Deficiencies: 3
Date: Aug 26, 2019
Visit Reason
The inspection was conducted as part of the recertification survey to assess compliance with privacy, infection prevention and control, and wound care standards at Prestige Nursing Care & Rehab Center.
Findings
The facility was found deficient in maintaining resident privacy during optometry exams, infection control practices related to food handling and wound care, and proper hand hygiene during wound dressing changes. Several staff members failed to follow facility policies and procedures, resulting in minimal harm or potential for harm to a few residents.
Deficiencies (3)
The facility did not ensure that the Optometry provided resident privacy during eye examinations, as the exam was conducted in a dining room without privacy screens or curtains.
A CNA was observed handling resident bread with bare hands, buttering it, and giving it to residents without a barrier, violating infection control practices.
An LPN did not change gloves and perform hand hygiene between cleaning a wound and applying a clean dressing for a resident with a Stage 4 pressure ulcer.
Report Facts
Residents sampled: 40
Residents observed in dining room: 24
Staff assisting: 6
Pressure ulcer measurement: 0.3
Pressure ulcer measurement: 0.1
Pressure ulcer measurement: 0.2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Named in wound care hand hygiene deficiency |
| RN #1 | Supervisor for the 3rd floor | Provided information on staff training related to food handling |
| RN #2 | Infection Control and Wound Care Nurse | Provided information on hand hygiene policies and staff in-service |
| CNA #1 | Certified Nursing Assistant | Observed handling resident bread with bare hands |
| Director of Nursing | DNS | Interviewed regarding consultant privacy policy |
| Optometrist | Interviewed regarding examination practices | |
| Registered Nurse Manager | RN Manager | Interviewed regarding optometrist examination location |
Viewing
Loading inspection reports...
