Average — CMS composite of the measures below.
The next survey window likely opens around November 2026
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 Bronx Center For Rehabilitation & Health Care during CMS and state inspections, most recent first.
Failure to follow a resident’s diabetes orders: a resident with Type 2 DM, PVD, and a wound infection had repeated FSBS readings over 300 mg/dL, but the LPN did not notify the RN supervisor or MD as ordered. Notes showed no documentation of physician notification, and the RN supervisor and MD both stated they were not informed of the high readings.
Surveyors found expired and undated meds stored on two units, including an expired IV dextrose bag, an open undated bottle of liquid hydromorphone, expired arginine powder, and multiple open undated liquid and ophthalmic meds on a medication cart. Staff stated that opened multi-dose meds should be dated and expired meds should not remain in storage, but the observed items were still present despite routine cart and storage audits.
Infection control practices were not maintained during meal service when a dietary aide used the same glove to pick up a cover from the floor and then continued serving residents’ food. Clean resident laundry was also observed uncovered on carts in the lobby and on the 3rd floor hallway, despite facility policy and leadership statements that laundry should remain covered until placed in residents’ closets.
Pest Control Program Not Maintained in Dining Area: A live cockroach was observed crawling on the pantry counter in the 4th Floor dining room under the ice machine while food was being plated and served to residents. Records showed repeated roach and mouse sightings on the unit, and pest control reports documented positive roach findings in other areas. The dining/pantry area was later observed dirty and damp, with roach traps on a wet floor, and the sighting was not documented in the consumer sighting log.
Failure to report alleged abuse to the State agency: A resident with cerebral infarction, DM, and moderate cognitive impairment reported that a CNA made an inappropriate sexualized comment during incontinence care. The family notified Social Work, the DON investigated, but the concern was treated as unprofessional language rather than a potential abuse allegation and was not reported to DOH as required.
Failure to Thoroughly Investigate an Abuse Allegation: The facility did not thoroughly investigate a family-reported allegation that an aide made an inappropriate sexual remark during incontinence care for a resident with cerebral infarction, DM, and moderate cognitive impairment. The DON spoke with the accused CNA and concluded the issue was poor judgment and unprofessional language, but the investigation did not include interviews with other unit staff who may have witnessed the event. Later interviews showed the resident found the comment inappropriate and reported it to staff.
A resident with CVA and hemiplegia had a contracted right hand and was recommended by OT to use a right palm guard except for skin checks, ADLs, and hygiene. However, the device was not entered into the EMR or added to the CNA Kardex, and staff observed the resident without the palm guard on multiple occasions. Interviews with rehab and nursing leadership confirmed the therapy recommendation was not carried over for implementation.
A resident with diabetes, influenza, and severely impaired cognition was observed receiving oxygen via nasal cannula at 2.5 L/min without a physician order. Nursing notes documented ongoing oxygen use, but the MAR/order record had no attending practitioner order or indication for oxygen, and staff interviews confirmed they could not explain the current oxygen use or flow rate.
A resident with DM and recent influenza was observed on oxygen via nasal cannula, and nursing notes documented ongoing oxygen use while the resident was being weaned off. Although a PM&R note said the acute condition had resolved and oxygen could continue PRN, the MAR/order record had no attending provider order or indication for oxygen use. An RN stated an order should be present whenever oxygen is used, and the Medical Director reported no hypoxic reports had been received.
Survey results were not posted in a readily accessible location for residents, visitors, or legal representatives to review without asking staff. Survey results from the most recent recertification survey were kept in a binder on the inner side of the reception desk, and residents stated they did not know where to find them. The Receptionist said the binder was usually kept there and handed out on request, while the DON said it was supposed to be on the outer side of the desk and noted there was no policy or procedure for survey result accessibility.
Nurse staffing information was not consistently posted in a prominent location, and the posting did not include the daily resident census as required. During survey, the lobby posting lacked census documentation, and at another point no staffing information was posted at all. The DON stated the Staffing Coordinator posts the information on weekdays and the morning shift nursing supervisor posts it on weekends, and was not aware the census was missing from the posting.
Failure to Notify Physician of Repeated High Blood Sugar Results
Penalty
Summary
The facility failed to provide treatment and care according to physician orders and the resident’s comprehensive diabetes care plan for one resident with Type 2 Diabetes Mellitus, Peripheral Vascular Disease, and a wound infection. The resident had intact cognition and a physician’s order to notify the physician if finger stick blood sugar results were below 80 mg/dL or above 300 mg/dL, with blood glucose monitoring ordered three times daily before meals. The facility’s diabetes policy stated that residents with diabetes would receive individualized management in accordance with regulations and current standards of practice. The resident’s electronic MAR documented finger stick blood sugar results above 300 mg/dL on multiple occasions, including 383 mg/dL, 360 mg/dL, 396 mg/dL, and 341 mg/dL. Review of nurses’ and medical progress notes showed no documentation that the physician was notified for any of these elevated results. An LPN stated they should have notified the nursing supervisor immediately when the blood sugar was over 300 mg/dL, but they were busy and by the time they remembered the supervisor had left for the day. The RN supervisor stated they were not notified of any high blood sugar results that month, and the Medical Director stated they were not notified when the resident’s blood sugar was above 300 mg/dL as ordered.
Expired and Undated Medications Found on Medication Cart and in Storage Room
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored in accordance with professional standards. During observation of medication administration and storage on two units, surveyors found an expired 1-liter bag of dextrose IV solution and an open, undated bottle of liquid hydromorphone in the 4th Floor medication storage room. The 5th Floor medication cart also contained expired arginine powder. On the 4th Floor medication cart, surveyors observed multiple open and undated medications, including sertraline liquid prescribed for one resident, iron liquid prescribed for another resident, lactulose liquid prescribed for a third resident, ergocalciferol liquid prescribed for a fourth resident, and several ophthalmic solutions prescribed for a fifth resident. An 887-milliliter bottle of Pro-Stat liquid protein supplement was also observed with an expiration date. The facility policy stated that expired, discontinued, or contaminated medications would be removed from storage areas and that opened multi-dose vials should be dated and discarded within 28 days unless the manufacturer specified otherwise. Staff interviews confirmed that opened multi-dose medications should be dated when first opened and that expired medications should not remain on carts or in storage rooms. An LPN stated that IV bags were not to be left in the medication storage room unless actively being administered, and that both nurses counting controlled medications at shift change should have noticed the undated hydromorphone. The unit manager and DON stated that expiration dates and open dates should be checked during routine audits, but the audit form provided documented compliance in all areas despite the observed expired and undated medications.
Infection Control Lapses During Meal Service and Laundry Handling
Penalty
Summary
Infection prevention and control practices were not maintained during resident meal service on one of five units observed. During dining on 12/15/2025 at 12:28 PM, a Dietary Aide used a gloved hand to pick up a cover that had fallen on the floor and then continued serving residents’ food with the same glove. The surveyor instructed the aide to change gloves, wash hands, and put on clean gloves, but the aide was reluctant and continued using the same glove to serve food. When interviewed later that day, the Dietary Aide stated the box of gloves kept at the back of the serving area had been taken downstairs. The Food Service Director later stated that the aide should have known to change dirty gloves, wash hands, and put on new gloves before continuing to serve residents. The facility also failed to maintain clean laundry in a covered cart as required by policy. Residents’ washed clothes were observed uncovered and hanging on a cart in the lobby on 12/16/2025, with draft and cold air blowing on them as staff and visitors entered and exited through the sliding door. The same day, clean laundry was later observed uncovered on a cart in the hallway near the staircase on the 3rd Floor, and again on 12/19/2025 in the same area. Housekeeping staff stated the cover had been removed after delivery to the facility gate or was wet and removed outside before taking the cart to the unit. The RN unit manager, Housekeeping staff, the Director of Maintenance and Housekeeping, and the DON all stated that residents’ clean clothes were to remain covered until placed in residents’ closets.
Pest Control Program Not Maintained in Dining Area
Penalty
Summary
The facility failed to maintain an effective pest control program to keep the building free of pests and rodents. During lunch observation in the 4th Floor dining room, a live cockroach was seen crawling on the pantry counter under the ice machine, in the area where sandwiches, fruit, and cold desserts were being placed while dietary staff plated food and CNAs and nurses served residents. A CNA killed the cockroach with a paper towel, and the sighting was not documented on the consumer sighting report. Record review showed repeated pest activity on the 4th Floor, including multiple reports of roaches and mice in rooms, bathrooms, and the unit, as well as pest control reports documenting positive roach findings in other areas. On later observation of the 4th Floor dining room and pantry, the area beneath the ice machine was found damp and dirty, with black dirt smudging, a half-torn floor covered with a wet towel, and roach traps on the dirty wet floor. The Director of Housekeeping and Maintenance stated the area should have been cleaned after the ice machine filter was changed, especially because roaches had been sighted there, and also stated that the logbook did not document the 12/15/2025 roach sighting.
Failure to Report Alleged Abuse to State Agency
Penalty
Summary
The facility failed to ensure that an allegation involving possible abuse was reported to the New York State Department of Health within the required timeframe. Resident #11, who had diagnoses including cerebral infarction and diabetes mellitus and was documented as having moderate cognitive impairment, was alleged to have been subjected to inappropriate sexualized language by Certified Nursing Assistant #2 during incontinence care. The resident stated that the aide said, "I hear you like to have your balls rubbed," and the resident reported feeling that the comment was inappropriate. The resident’s care plan identified them as being at risk for abuse, neglect, misappropriation, and exploitation due to dependence on others for care. The grievance investigation documented that the family member reported the concern to Social Work, the DON spoke with CNA #2, and the aide stated they used the word "balls" because the resident used it. The investigation concluded there was no evidence of abuse or neglect and that the Department of Health was not notified. The DON stated the concern was treated as unprofessional language rather than a potential abuse allegation, so it was not reported to the State agency. The report also states that CNA #2 was removed from employment at the facility.
Failure to Thoroughly Investigate an Abuse Allegation
Penalty
Summary
The facility failed to ensure that an allegation involving possible abuse was thoroughly investigated for Resident #11. On 10/20/2025, the resident’s family member reported that on 10/19/2025, Certified Nursing Assistant #2 allegedly made an inappropriate remark during incontinence care, stating, "I hear you like to have your balls rubbed." The facility initiated an investigation, but the record shows it did not fully investigate the allegation as required by its abuse policy. Resident #11 had diagnoses including cerebral infarction and diabetes mellitus, and the Quarterly MDS documented moderate cognitive impairment. The resident’s comprehensive care plan identified the resident as at risk for misappropriation, neglect, abuse, and/or exploitation due to dependence on others for care. The grievance investigation documented that the DON spoke with Certified Nursing Assistant #2, who said they used the word "balls" because the resident used it, and the investigation concluded there was no evidence of abuse or neglect and that the Department of Health was not notified. Certified Nursing Assistant #2 was removed from employment at the facility. The investigation did not document interviews or statements from other staff members on the unit who may have witnessed the incident or had contact with Resident #11 during the relevant period. A written statement from Certified Nursing Assistant #2 denied any inappropriate conversation. Later interviews documented that Resident #11 reported the comment to staff and stated it was inappropriate, and Certified Nursing Assistant #3 reported that the resident told them the aide had asked if the resident wanted their balls massaged. The DON stated they were not aware the allegation involved a possible abuse concern and could not explain why other staff members were not interviewed.
Failure to Provide Recommended Palm Guard for Contracture Management
Penalty
Summary
The facility failed to ensure that a resident with limited range of motion received the recommended treatment and services to prevent further decrease in ROM. Resident #9, who had diagnoses including cerebrovascular accident and hemiplegia, was assessed as having intact cognition and impaired mobility with functional limitation in ROM on one side of the upper and lower extremities. On observation, the resident’s right hand was contracted and unsupported, and no device was seen on the affected extremity during two separate observations. The resident stated they could not recall having a device applied to the hand or arm in 2025. The rehabilitation record documented that Resident #9 was placed in skilled therapy for contracture management and that a right palm guard was provided to replace the right-hand resting splint. The occupational therapy discharge summary stated the right palm guard was to be used at all times except for skin checks, ADLs, and hygiene. A care plan activity report also documented that the resident had a musculoskeletal flexion impairment to the right upper extremity and that a right palm guard should be applied during the day. Interviews with rehab and nursing staff indicated the recommendation was communicated to nursing, but the DON later stated the therapy recommendation for the right palm guard was not picked up and entered into the EMR, so it was not added as a Kardex task for CNAs and was not performed.
Oxygen Used Without Physician Order
Penalty
Summary
The facility failed to ensure that Resident #159 received respiratory care in accordance with professional standards of practice when the resident was observed using oxygen via nasal cannula at 2.5 liters per minute without a physician's order. Resident #159 had diagnoses of Diabetes Mellitus and Influenza, and the admission MDS documented severely impaired cognition and oxygen therapy use. The care plan addressed an alteration in the respiratory system and oxygen use, and the Medical Director's history and physical noted the resident had been treated in the hospital for Influenza A and was being weaned off oxygen. Review of the record showed nursing progress notes from 12/04/2025 through 12/16/2025 documenting oxygen via nasal cannula, and a rehabilitation note stated the influenza had resolved and to continue oxygen via nasal cannula as needed. However, the physician's order record for 12/2025 contained no attending practitioner order or indication for oxygen use. Staff interviews confirmed the lack of an order and uncertainty about the oxygen flow rate: an LPN stated the resident had an oxygen order on admission but could not explain the current use without a doctor's order, an RN stated there should be an order when oxygen is used and it was their fault there was no order, and the Medical Director stated the resident was not using oxygen or complaining of shortness of breath when seen after admission and no hypoxic reports had been received.
Missing Physician Order for Oxygen Therapy Review
Penalty
Summary
The facility failed to ensure that a physician reviewed Resident #159’s total program of care, including oxygen treatment, at each required visit. Resident #159 had diagnoses of Diabetes Mellitus and Influenza, and the admission MDS documented severely impaired cognition and oxygen therapy. The resident was observed receiving oxygen via nasal cannula at 2.5 liters per minute on 12/17/2025 and 12/18/2025, and the care plan included interventions for altered respiratory status and oxygen use. The medical record showed that the resident had been treated in the hospital for Influenza A infection and was being weaned off oxygen, with nursing notes from 12/04/2025 through 12/16/2025 documenting oxygen via nasal cannula. A PM&R note stated the acute influenza condition had resolved and to continue oxygen via nasal cannula as needed. However, the physician order record for 12/2025 contained no attending practitioner’s orders or indication for oxygen use, and the interdisciplinary meeting note documented that nursing reported the resident was being weaned off oxygen. During interviews, an RN stated there should be an order when oxygen is used, and the Medical Director stated the resident was not using oxygen when first seen after admission and that no hypoxic reports had been received.
Survey Results Not Readily Accessible to Residents and Visitors
Penalty
Summary
The facility did not ensure that the results of the most recent health survey were posted in a place readily accessible to residents, visitors, or legal representatives without needing to ask staff to see them. During multiple observations on 12/15/2025 and 12/16/2025, the survey results from the Recertification Survey conducted from 07/10/2023 to 07/14/2023 were found in a binder on the inner side of the reception desk, where individuals had to ask the Receptionist to hand them the binder in order to review it. On 12/16/2025 at 10:30 AM, 11 residents of the Resident Council stated they did not know where to locate the survey results in the facility. At 12:04 PM, the Receptionist stated the binder was typically stored in its current location on the inner side of the reception desk and would be handed to anyone who requested it. At 12:09 PM, the DON stated the binder was supposed to be stored on the outer side of the desk so it would be accessible without asking the Receptionist, but could not explain why it was observed on the inner side on both days. The DON also stated there was no facility policy or procedure related to accessibility of survey results.
Nurse Staffing Posting Missing Required Census Information
Penalty
Summary
Nurse staffing information was not consistently posted in a prominent place readily accessible to residents and visitors, and the posting did not include the daily resident census as required by facility policy. During the survey entrance on 12/15/2025 at 9:00 AM, the nurse staffing information posted in the facility lobby did not document the resident census for that day. On 12/22/2025 at 8:36 AM, there was no nurse staffing information posted in the facility lobby or another prominent place readily accessible to residents and visitors, and there was no documented evidence of resident census on the nurse staffing information dated from 12/15/2025 to 12/19/2025. The facility policy titled Staffing-Posting of Hours, Payroll Based Journal required daily posting in a clear readable format with the facility name, current date, and resident census. During interview on 12/22/2025 at 12:23 PM, the DON stated the Staffing Coordinator posts the information on weekdays and the morning shift nursing supervisor posts it on weekends, and stated they were not aware that the resident census was not being documented on the nurse staffing information.
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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) |
|---|---|---|---|---|
| Grand Manor Nursing & Rehabilitation Center | 0.5 mi | — | 29 | 2 |
| Rebekah Rehab And Extended Care Center | 0.7 mi | ★★★★★ | 2 | 0 |
| Williamsbridge Center For Rehabilitation And Nrsg | 1.5 mi | ★★★★★ | 0 | 0 |
| St Vincent Depaul Residence | 1.9 mi | ★★★★★ | 0 | 0 |
| Morningside Nursing And Rehabilitation Center | 2.1 mi | ★★★★★ | 1 | 0 |
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