Inspection Reports for
The Citadel Rehab and Nursing Center at Kingsbridge

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.

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.

One Standard Health citation for free of accident hazards/supervision/devices with actual harm; corrected as of March 21, 2025.

Multiple Standard Health and Life Safety Code citations including accident hazards and reporting of alleged violations; all corrected by April 2024.

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.

Multiple Standard Health and Life Safety Code citations related to assessments, abuse prevention, notification, and egress doors; all corrected by April 2022.

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.