While a 29-year-old detainee with severe mental illness was on the brink of death in his Rikers Island cell last month, a medical staffer stood outside his door spraying air freshener, according to an oversight report obtained by THE CITY.
The striking detail appears in the Board of Correction’s initial review of Ardit Billa’s August 23 death inside the George R. Vierno Center. The case has already led to the suspension of two correction officers for four weeks for failing to conduct mandated routine checks and allegedly falsifying an internal logbook entry.
Surveillance footage shows a Correctional Health Services employee pulling out a small bottle of air freshener around 7:34 p.m. on August 22 and dousing the dayroom before approaching Billa’s cell and spraying again near the door, according to the Board’s initial death review report.
Minutes later, other staffers peered into his cell but did not intervene, despite Billa clearly having a mental health meltdown inside his cell, according to the Board’s timeline.
The seven-page report also reveals that the floor correction officer assigned to Billa’s housing unit abandoned his post for nearly two hours shortly before Billa died, a clear violation of department rules requiring constant supervision.
Another officer assigned to watch the unit — known as the “B” officer — claimed in official logs that he conducted supervision tours every 30 minutes the night Billa died. But surveillance video told a different story.
Between 9:30 p.m. and 12:20 a.m., records show, he only made two rounds. That discrepancy amounts to falsifying entries, a violation of Department of Correction rules that require logbooks to be accurate and updated in real time, according to the Board of Correction’s review.
Meanwhile, suicide prevention aides assigned to monitor detainees in the area failed to conduct required 10-minute checks, the report said. And a supervisor who briefly saw Billa at 11:32 p.m., seated on the floor with his back against the toilet and moving one arm, left without ensuring he received medical care, according to the board’s timeline.
Less than an hour later, when staff finally re-entered the cell, Billa was unresponsive. Correction officers dragged him out by his feet and began CPR. Medical staff arrived minutes later with resuscitation equipment, followed by EMS. Despite their efforts, he was pronounced dead at 12:58 a.m.
The city’s Office of Chief Medical Examiner hasn’t determined the cause of death yet.
The Board of Correction conducts initial probes into each death in Department of Correction custody. THE CITY obtained the report by filing a Freedom of Information Law request.
Spokespeople for the city’s Department of Correction and NYC Health + Hospitals Correctional Health Services (CHS) did not respond to an email request seeking comment.
Medical staff are rarely disciplined after jail fatalities — and CHS does not publicly disclose any reviews it conducts into deaths or suggested recommendations.
On Rikers, Billa was being held in a so-called Program to Accelerate Clinical Effectiveness unit. That housing complex holds the most high-need detainees and is supposed to offer intense mental health programming.
A jail source familiar with the death said Billa spent his last few days barely, if ever, leaving his cell, THE CITY reported two days after his death. The source also said his body had feces on it.
Another source added that he was diagnosed as schizophrenic by the DOC, based on his intake evaluation.
Chased the American Dream
Billa landed on Rikers after police picked him up on Feb. 23 for skipping a court date in a Brooklyn slashing case, records show. Prosecutors alleged he cut a 52-year-old neighbor across the face with a razor during a feud inside their East New York apartment building, according to the criminal complaint.
Initially, a judge released him without bail under supervised release. But when he failed to show up for his first hearing, a warrant was issued. Officers arrested him again on Feb. 23, and this time he was ordered held on $25,000 bail.
Before his arrest, he was a sociable young man who came to the U.S. from Albania with a green card eight years ago, chasing the American dream, his aunt told THE CITY.
He worked a series of construction and restaurant jobs to support himself and dreamed of hitting it big as a music composer, the aunt said.
On Rikers, Billa cycled through multiple facilities and city hospital wards before being housed at GRVC, according to the board report.
Records show he had been written up by correction officers six times for fighting and failing to obey orders. After one fight with another detainee, Billa was sent to Bellevue Hospital for “further evaluation,” the report shows.
Inmate advocates point out it is hard for people diagnosed with serious mental illness to follow orders, especially in a regimented setting like Rikers.
People locked up alongside him told Board investigators that Billa kept to himself, rarely leaving his cell. “He was a loner,” one suicide prevention aide recalled. Another said Billa accepted food brought to his cell but often refused to interact with others.
The death report comes as Laura Taylor Swain, the chief district judge for Manhattan federal court, is in midst of reviewing potential candidates for the so-called remediation manager role to supervise parts of Rikers Island as part of a class action lawsuit.
Swain has not publicly said when she will make her final decision. She has kept the potential candidates’ names off the public docket.
Normally when a detainee is decompensating and their cell is covered in feces, a medical staffer would send that person to Bellevue Hospital where they could get additional medical care, said Justyna Rzewinski, who worked as clinical supervisor on Rikers 2023 and 2024, of Billa’s treatment.
The cells are only cleared out when someone is moved to a hospital or sent to court, she added.
As for using air freshener, she said, it “shows they just didn’t care about the person sitting in the cell with the smell.”
