Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Archcare At Providence Rest during CMS and state inspections, most recent first.
A resident with a history of falls and severe cognitive impairment experienced an unwitnessed fall in their room, resulting in a fractured femur. The facility failed to review and update fall prevention interventions and did not provide adequate supervision, as there was no documented monitoring schedule. Staff interviews revealed the resident was impulsive and attempted to ambulate without assistance, highlighting the need for consistent supervision.
The facility experienced significant staffing shortages, particularly on weekends, as evidenced by the CASPER report and staff interviews. A resident reported long wait times for call bells, and staff described difficulties in completing duties due to insufficient staffing. The facility's staffing plan was not met, with fewer nurses and CNAs than required, impacting the ability to provide timely care. Efforts to recruit and retain staff were ongoing but challenged by the facility's location and loss of staffing agency contracts.
The facility failed to post notices about the availability of the New York State Department of Health survey results in prominent areas, as required by policy. Observations showed no postings in the lobby or other key areas, and Resident Council members were unaware of where to find the survey results. The Administrator admitted the signage was not visible, leading to the deficiency.
A resident with dementia and anxiety experienced an unwitnessed fall resulting in a major injury, which was not reported to the New York State Department of Health as required. The facility's DON reviewed video footage and concluded no one entered the room before the fall, leading to the decision not to report the incident. The Administrator was unsure about the reporting requirement, and the video footage was later deleted.
A facility failed to accurately document a resident's use of a feeding tube in the MDS assessment, despite medical records and staff confirming its use. The resident, with conditions like Atrial Fibrillation and Dysphagia, relied on enteral feeding. Staff interviews revealed a coding error, which the MDS Coordinator acknowledged should have been corrected.
A facility failed to provide a written summary of the Baseline Care Plan to a resident's representative within 48 hours of admission, as required by policy. The resident, who was cognitively impaired, did not have a family representative sign for receipt of the care plan. Staff left a copy at the bedside but had difficulty reaching the family. This lack of documentation led to the deficiency.
A facility failed to create a comprehensive care plan for a resident prescribed antibiotics for a UTI. Despite the resident's complex medical history and impaired cognition, no care plan was developed for the antibiotic therapy. Staff interviews revealed a lack of communication and awareness, with the interdisciplinary team failing to initiate the necessary care plan.
A resident with Atrial Fibrillation, Hypertension, and Dementia received multiple doses of Warfarin Sodium due to a medical doctor's error in scheduling the medication four times a day instead of once at bedtime. The nursing staff followed the incorrect order, leading to the administration of extra doses over two days. The error was identified when a nurse questioned the order, and the medication was placed on hold. Despite the error, the resident experienced no adverse reactions.
Inadequate Supervision Leads to Resident Fall and Injury
Penalty
Summary
The facility failed to provide adequate supervision to prevent accidents for a resident identified as high risk for falls. The resident, who had a history of multiple falls and was diagnosed with Non-Alzheimer's Dementia, Anxiety, and Depression, experienced an unwitnessed fall in their room, resulting in a fracture of the left femur. The resident required partial/moderate assistance for daily activities and had previously fallen on two occasions, one of which resulted in a minor injury. The facility's care plan for the resident included interventions such as keeping the bed in a low position and using nonskid socks, but there was no evidence that these interventions were reviewed or updated following the resident's falls. Additionally, there was no documented schedule for monitoring or supervising the resident to prevent further falls. On the day of the incident, the resident was last seen by staff at 9:05 AM and was found on the floor at 9:10 AM, indicating a lack of adequate supervision. Interviews with staff revealed that the resident was impulsive and attempted to get up without assistance. The facility did not have a specific rounding or monitoring schedule for the resident, and staff left the resident unattended in the day room on a previous occasion. The Director of Nursing and the Administrator acknowledged the lack of supervision and monitoring, which contributed to the resident's fall and subsequent injury.
Staffing Shortages Impact Resident Care
Penalty
Summary
The facility failed to ensure sufficient staffing levels to meet the needs of residents, particularly on weekends, as evidenced by the CASPER Payroll Based Journal Staffing Data report for the 4th quarter of 2024, which triggered for low weekend staffing. The facility's staffing plan, reviewed in July 2024, indicated that each nursing unit should be staffed by a nurse and certified nursing assistants (CNAs), with specific numbers outlined for each shift. However, staffing sheets revealed that actual staffing levels frequently fell below these par levels, with less than 1 nurse per unit on several shifts and fewer CNAs than required on numerous occasions. Interviews with residents and staff highlighted the impact of these staffing shortages. A resident reported that the number of CNAs on their unit had decreased, leading to long wait times for call bells to be answered, especially on weekends. Staff members, including LPNs and CNAs, expressed difficulties in completing their duties due to insufficient staffing, with some nurses having to cover multiple roles, such as passing medications and assisting CNAs. The staffing coordinator and director of nursing acknowledged the chronic understaffing issue, citing challenges in recruitment and retention due to the facility's location and loss of staffing agency contracts. The administrator confirmed efforts to address staffing challenges, including recruitment initiatives and salary increases, but acknowledged the ongoing difficulties in maintaining adequate staffing levels. Despite these efforts, the facility continued to experience staffing shortages, impacting the ability to provide timely and adequate care to residents. The deficiency was further corroborated by staff interviews, which described a hectic and rushed atmosphere, particularly on weekends, leading to delays in medication administration and unmet resident needs.
Deficiency in Posting Survey Results
Penalty
Summary
The facility failed to ensure that notices regarding the availability of the most recent New York State Department of Health survey report and plan of correction were prominently posted in areas accessible to the public. Observations conducted during the recertification survey revealed that there were no notices posted in the facility lobby or other key areas as required by the facility's policy. Interviews with members of the Resident Council confirmed that they were unaware of any postings indicating where the survey results could be found. Further investigation with the Director of Nursing and the Facility Administrator revealed that the signage was missing from the lobby and other designated areas. The Administrator acknowledged that the posting had fallen behind a bulletin board and was not visible. Despite the facility's policy to maintain transparency and compliance, the lack of visible postings led to the deficiency noted in the survey report.
Failure to Report Unwitnessed Fall with Major Injury
Penalty
Summary
The facility failed to report an unwitnessed fall incident involving a resident, which resulted in a major injury, to the New York State Department of Health within the required timeframe. The incident involved a resident with diagnoses of Non-Alzheimer's Dementia, Anxiety, and Depression, who was found on the floor with mild bleeding to the back of their head and complained of pain in the left hip area. An X-ray revealed an acute, mild displaced avulsion periprosthetic fracture of the lesser Trochanter of the left femur. Despite the severity of the injury, the facility did not report the incident as required by their policy and state regulations. The Director of Nursing reviewed video footage and concluded that no one entered the resident's room before the fall, leading to the decision not to report the incident. The Administrator was unsure if the incident should have been reported, and the video footage was later deleted due to the machine's self-deleting feature. The facility's policy mandates that all alleged violations involving abuse, neglect, or injuries of unknown source be reported immediately, but this protocol was not followed in this case.
Inaccurate MDS Assessment for Resident's Feeding Tube
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessments accurately reflected the status of a resident, specifically regarding the use of a feeding tube. This deficiency was identified during a recertification survey, where it was found that the MDS quarterly assessment for a resident did not document the presence of a feeding tube, despite medical records and staff interviews confirming its use. The resident, who was admitted with conditions including Atrial Fibrillation, Chronic Obstructive Pulmonary Disease, and Dysphagia, relied entirely on enteral feeding for nutritional and fluid needs. Interviews with facility staff, including Certified Nursing Assistants, Registered Nurses, and Dieticians, confirmed that the resident had been on tube feeding since admission. The Registered Dieticians responsible for completing the nutrition section of the MDS acknowledged the oversight, attributing it to a possible error in coding. The Minimum Data Set Coordinator, who is responsible for ensuring the accuracy of assessments before submission, also confirmed the oversight, indicating that the feeding tube should have been coded in the assessment.
Failure to Provide Baseline Care Plan to Resident's Representative
Penalty
Summary
The facility failed to ensure that residents and their representatives were provided with a written summary of the Baseline Care Plan within 48 hours of admission, as required by their policy. This deficiency was identified during a recertification survey, specifically involving a resident with multiple sclerosis and depression, who was cognitively impaired. The facility's policy, last revised in March 2019, mandates that a Baseline Care Plan be developed and implemented within 48 hours for all newly admitted residents, with a copy provided to the resident or their representative. However, there was no documented evidence that the family representative of the resident in question received a written copy of the Baseline Care Plan. Interviews with facility staff, including the Minimum Data Set Coordinator, Director of Social Service, and Director of Nursing, revealed that the interdisciplinary team met with the resident at the bedside and explained the fall protocol and medications. Despite the resident's cognitive impairment, a copy of the Baseline Care Plan was left at the bedside, as the staff had difficulty reaching the family representative. The staff stated that they always leave a copy with the resident at the bedside, but there was no signature from the resident or their family representative to confirm receipt of the care plan. This lack of documentation and confirmation of receipt led to the identified deficiency.
Failure to Develop Care Plan for Antibiotic Therapy
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a resident who was prescribed an antibiotic for a urinary tract infection. The resident, who had a medical history of Diabetes Mellitus, Cerebrovascular Accident, and Hypertension, was admitted with severely impaired cognition. Despite being prescribed Amoxicillin Clavulanate Potassium for a urinary tract infection, no care plan was created to address the antibiotic therapy. This oversight was identified during a recertification survey, where it was noted that the facility's policy required comprehensive care plans to be developed and updated on an ongoing basis. Interviews with facility staff revealed a lack of communication and awareness regarding the resident's antibiotic treatment. Registered nurses and the Minimum Data Set Coordinator were unaware that a care plan had not been initiated, and the Director of Nursing Services confirmed that the interdisciplinary team, responsible for developing and updating care plans, had not created one for the resident's antibiotic therapy. The deficiency was attributed to a failure in communication and notification processes within the facility, as the Minimum Data Set Coordinator did not recall receiving any notification about the resident's antibiotic treatment.
Medication Administration Error with Warfarin Sodium
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, as evidenced by the incorrect administration of Warfarin Sodium. The error occurred when a medical doctor mistakenly scheduled the medication to be administered four times a day instead of once at bedtime. This mistake led to the resident receiving multiple doses of Warfarin Sodium over two days, contrary to the intended prescription. The error was initially made by the medical doctor who entered the incorrect frequency into the Electronic Medical Record, which was then followed by the nursing staff. The resident involved in the incident was admitted with a diagnosis of Atrial Fibrillation, Hypertension, and Dementia, and was identified as having severely impaired cognition. The resident's care plan included anticoagulant therapy, with specific instructions to administer the medication as per the medical doctor's order. Despite the error, the resident's blood work remained within the normal range, and there were no adverse reactions reported. The nursing staff, including Registered Nurses, administered the medication according to the incorrect schedule entered by the medical doctor. The error was eventually identified by a nurse who questioned the order, leading to the medication being placed on hold pending clarification. The facility's policies on medication administration required that any uncertainty about medication orders be clarified before administration, which was not adhered to in this case.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Bronx
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Throgs Neck Extended Care Facility | 0.6 mi | ★★★★★ | 3 | 0 |
| Rebekah Rehab And Extended Care Center | 1.6 mi | ★★★★★ | 2 | 0 |
| Gold Crest Care Center | 1.7 mi | ★★★★★ | 0 | 0 |
| Williamsbridge Center For Rehabilitation And Nrsg | 1.7 mi | ★★★★★ | 0 | 0 |
| Kings Harbor Multicare Cente | 1.8 mi | ★★★★★ | 4 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.