Above average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Gold Crest Care Center during CMS and state inspections, most recent first.
Public Posting of Resident Aspiration List: A resident’s name, room number, and diet order, along with those of 12 other residents, were posted on a publicly visible bulletin board outside the dining room. Staff stated the aspiration precaution list was displayed so workers would know which residents were at risk during meals, but the RN, Nurse Manager, and SLP did not view the posting as a privacy concern; the DON stated it should have been posted behind the nurse’s station instead.
Unit 1 had multiple environmental disrepair issues that affected a resident's right to a safe, clean, comfortable, and homelike environment. Surveyors observed black substance and disrepair around windows, hanging electrical outlets, holes in walls, chipped and rust-stained bed frames, peeling wallpaper, mismatched paint, broken or missing window shades, exposed wire in the dayroom ceiling, worn and dirty furniture, and tape around an AC unit. Staff interviews confirmed the maintenance logbook process for reporting repairs, and the DOR and Administrator acknowledged awareness of needed repairs and a plan to renovate Unit 1.
Resident and representative not included in care planning. A cognitively intact resident with HF, upper respiratory tract disease, and chronic pain syndrome was documented as participating in the MDS assessment, but there was no evidence they or their representative were invited to care plan meetings. The record showed multiple care plan meetings, and the care conference noted the resident declined one annual meeting, yet staff could not explain why invitations were not consistently documented.
Unsafe and poorly maintained staff bathroom. The first-floor staff bathroom in the dayroom had minimal lighting, a cracked ceiling tile, brown discoloration on ceiling tiles, and one tile that appeared ready to fall off. The facility’s environmental policy required common areas and fixtures to be kept in clean, safe, and operable condition, and the D of Maintenance stated monthly rounds were done and administration was aware of needed repairs.
The facility failed to ensure its arbitration agreement allowed selection of a venue convenient to both parties for three residents. Staff stated residents and/or representatives were told hearings had to be held in Bronx County, where the facility is located, and leadership confirmed the agreement required that location and was drafted by the facility’s attorney.
The facility failed to develop comprehensive care plans for two residents with osteomyelitis, despite their policy requiring individualized plans for each resident's needs. One resident with osteomyelitis of the left ankle and foot, and another with osteomyelitis of the vertebra, did not have care plans addressing their infections. Nursing staff acknowledged the oversight, indicating a lapse in protocol adherence.
A resident with severe cognitive impairment and physical limitations was improperly subjected to physical restraints in the form of bed side rails, which were not documented as necessary in their care plan. Despite facility policy and an Occupational Therapist's assessment advising against their use, staff inconsistently applied the side rails, leaving them raised after care. The resident's medical records lacked a physician's order or family consent for the use of side rails, highlighting a deficiency in the facility's adherence to restraint policies.
A facility failed to assess a resident for entrapment risk and obtain informed consent before using bed rails. The resident, with severe cognitive impairment, was observed with raised bed rails without documented assessment or consent. Staff inconsistencies in bed rail use were noted, and the Occupational Therapist advised against their use due to the resident's condition.
The facility did not adhere to infection control practices during medication administration for residents with gastrostomy tubes. An LPN was observed not wearing a gown for one resident and failing to remove it after administering medication to another. The facility's policy requires enhanced barrier precautions, including gown and glove use, for residents with indwelling medical devices. Interviews confirmed the lapses in protocol adherence.
The facility failed to notify Justice Involved Residents and their representatives of their transfer or discharge, and did not inform the New York State Long Term Care Ombudsman. Four residents with various medical conditions were discharged without receiving written notices, despite having intact cognition. Staff cited security reasons and short notice as reasons for not providing the required notifications.
A resident with dementia and other health issues was allegedly handled roughly by a CNA during personal care. The incident was reported to an LPN, who informed the DON and Administrator. However, the facility did not report the allegation to the Department of Health, as they concluded it was a misunderstanding and unsubstantiated within two hours, contrary to their policy.
Public Posting of Resident Aspiration List
Penalty
Summary
The facility failed to maintain the privacy and confidentiality of residents’ personal and medical records when an Aspiration Precaution List was posted on the 3rd floor bulletin board in a hallway outside the dining room. The posted list identified Resident #48 and 12 other residents by first and last name, room number, and dietary order, and it was visible to other residents and visitors on the unit. None of the listed residents, including Resident #48, resided on the 3rd floor. The bulletin board also displayed other general notices, including Ombudsman contact information, the weekly meal menu, meal times per floor, the recreation activity calendar, and a notice related to state survey results. Resident #48 had diagnoses including cerebral infarction, hemiplegia and hemiparesis, and malnutrition. The MDS documented intact cognition and a mechanically altered and therapeutic diet. Staff interviews showed that the RN stated the Aspiration Precaution List was always posted so staff would know who was at risk of aspirating during meals, and the RN did not know whether publicly posting the resident’s name, room number, and dietary order was a privacy concern. The Nurse Manager stated the list was posted on the bulletin board and did not believe it was a privacy concern. The SLP stated the list was created so anyone working with the identified residents would know their aspiration risk status and that the list was handed to floor nurse managers, while the DON stated the list should have been posted behind the nurse’s station and not on the public bulletin board.
Unit 1 Environmental Disrepair
Penalty
Summary
The facility failed to maintain a resident's right to a safe, clean, comfortable, and homelike environment in Unit 1. During observations from 01/28/2026 to 02/05/2026, surveyors noted multiple environmental deficiencies, including windows with black substance and wood in disrepair, electrical outlets hanging off the wall, holes in hallway and room walls, chipped and rust-stained bed frames, peeling wallpaper, mismatched paint, broken or missing window shades, missing window borders, a light fixture with clothing hanging over it, exposed wire coming from the ceiling in the dayroom, dirty and mismatched furniture, a broken headboard, a closet door off its hinge, and tape surrounding an air conditioning unit. Resident #52 stated the window was covered with tape to keep the air out. Interviews confirmed that staff were aware of maintenance concerns and used a maintenance logbook to report needed repairs. The Housekeeper stated repairs were documented in the maintenance logbook and reported to Maintenance, while the Housekeeping Supervisor stated nurses were responsible for notifying the Maintenance Director by writing issues in the logbook. The Director of Maintenance stated they reviewed the logbook daily and did monthly rounds, and acknowledged that a contractor was needed to fix the windows and that administration was aware of the needed repairs. The Administrator stated there was a plan to renovate Unit 1 and was not aware of the dayroom windows needing repair.
Resident and Representative Not Included in Care Planning
Penalty
Summary
The facility failed to ensure that the resident or the resident’s representative was included in all aspects of care planning for Resident #70. The resident was admitted with diagnoses of hypertensive heart disease with heart failure, disease of upper respiratory tract, and chronic pain syndrome. The Quarterly MDS assessment documented that the resident was cognitively intact and that the resident and designated representative participated in the assessment. During an interview, the resident stated they made decisions for themselves but could not recall the last time they attended or were invited to a care plan meeting. The care plan meeting schedule showed an annual meeting, a significant change meeting, and multiple quarterly meetings in 2025. The Care Conference Report documented that Resident #70 declined to participate in the annual care plan meeting; however, there was no documented evidence in the medical record that the resident and/or designated representative were invited to participate or attend the care plan meetings. The Director of Social Services stated the social worker is responsible for inviting residents and/or representatives to care plan meetings and had no explanation for why Resident #70 was not consistently invited. The Administrator stated residents and/or representatives should be invited to all care plan meetings and was not aware they were not consistently invited.
Unsafe and Poorly Maintained Staff Bathroom
Penalty
Summary
The facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. During observations from 01/28/2026 to 02/05/2026, the staff bathroom on the first floor in the dayroom was observed with minimal lighting, a cracked ceiling tile, ceiling tiles with brown discoloration, and a tile that appeared to be about to fall off. The facility’s environmental policy, reviewed 07/2021, stated that resident rooms, common areas, furnishings, fixtures, and equipment are to be maintained in clean, safe, and operable condition through routine housekeeping, maintenance practices, and ongoing staff awareness during daily operations. On 02/05/2026 at 10:45 AM, the Director of Maintenance stated that monthly rounds are conducted to identify needed repairs and that administration was aware of the needed repairs in the building.
Arbitration Agreement Venue Not Convenient to Both Parties
Penalty
Summary
The facility failed to ensure that its binding arbitration agreement provided for the selection of a venue that is convenient to both parties for three residents reviewed for arbitration. The facility’s policy stated that it offered a voluntary arbitration agreement in accordance with federal regulations, and the signed agreements for the three residents documented that any arbitration hearing arising under the agreement would be held in the county where the facility is located. During interviews, the Social Worker stated that residents and/or their representatives were told the arbitration hearing had to be held in Bronx County, where the facility is located. The Director of Social Services confirmed that the hearing had to take place in Bronx County according to the agreement and stated that the agreement was provided by the facility’s corporation. The Director also stated they were not aware the regulation required the agreement to provide for a venue convenient to both parties. The Administrator stated the agreement was drafted by the facility’s lawyer and was not aware it was not compliant with the regulation.
Failure to Develop Comprehensive Care Plans for Osteomyelitis
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for two residents diagnosed with osteomyelitis, as required by their policy. Resident #228, admitted with acute osteomyelitis of the left ankle and foot, and diabetes mellitus with diabetic chronic kidney disease, did not have a care plan addressing the infection despite being on intravenous and oral antibiotics. The oversight was acknowledged by the nursing staff, including the Nurse Manager and Nursing Supervisor, who admitted to assuming responsibilities for care plan development and review, leading to the omission. Similarly, Resident #17, admitted with osteomyelitis of the vertebra and polyarthritis, also lacked a care plan for the infection. The Assistant Director of Nursing confirmed that the care plan for infection was overlooked. The Director of Nursing stated that it was the responsibility of the Registered Nurse Supervisor to ensure care plans were developed, indicating a lapse in the facility's protocol adherence.
Improper Use of Physical Restraints
Penalty
Summary
The facility failed to ensure that a resident was free from physical restraints that were not required for medical treatment. Specifically, a resident with severe cognitive impairment and physical limitations was observed on multiple occasions with upper quarter bed side rails raised, which were not documented as necessary in their care plan. The facility's policy defines bed rails as physical restraints, and the resident's medical records lacked a physician's order or family consent for their use. The resident's comprehensive care plan did not include the use of bed side rails, and an assessment by the Occupational Therapist had previously determined that side rails were not recommended due to the resident's inability to use them safely and the risk of entrapment. Interviews with facility staff revealed inconsistencies in the use of bed side rails. Certified Nursing Assistants admitted to raising the side rails during care but failed to lower them afterward, despite instructions to do so. The Unit Manager and Director of Nursing confirmed that side rails should only be used during personal care and acknowledged that the resident could not independently manage the side rails, classifying them as restraints. The Occupational Therapist reiterated that side rails were not recommended for the resident, who was at risk of entrapment and unable to follow instructions or use their hands purposefully.
Failure to Assess and Obtain Consent for Bed Rail Use
Penalty
Summary
The facility failed to ensure that a resident was assessed for the risk of entrapment from bed rails prior to their use, and did not discuss the risks and benefits with the resident or their representative, nor obtain informed consent. This deficiency was identified during a recertification survey, where it was observed that a resident with severe cognitive impairment and physical limitations was repeatedly found with upper quarter bed side rails raised. The facility lacked documented evidence of an assessment for entrapment risk, informed consent, or a physician's order for the use of bed rails. Additionally, there was no documentation of preventive maintenance for the bed rails. Interviews with facility staff revealed inconsistencies in the use of bed rails. Certified Nursing Assistants admitted to raising the bed rails during care and sometimes forgetting to lower them afterward. The Unit Manager confirmed that bed rails should only be used during personal care and should be lowered afterward. The Director of Maintenance stated that bed rails were supposed to be discontinued and tied down, but acknowledged that staff sometimes cut the ties to use them. The Occupational Therapist advised against the use of side rails for the resident due to their inability to use their hands purposefully and the risk of entrapment. The Director of Nursing confirmed that some beds had non-removable side rails and that staff were instructed to lower them after care.
Failure to Maintain Enhanced Barrier Precautions During Medication Administration
Penalty
Summary
The facility failed to maintain infection control prevention practices during medication administration for residents with gastrostomy tubes, as observed during the Recertification Survey. Specifically, Enhanced Barrier Precautions were not adhered to for two residents with gastrostomy tubes. The Centers for Medicare and Medicaid Services issued guidance effective April 1, 2024, requiring enhanced barrier precautions for residents with indwelling medical devices during high-contact care activities. The facility's policy, revised on March 21, 2024, mandates the use of gowns and gloves during such activities, with personal protective equipment to be removed before exiting the resident's room. During the survey, a Licensed Practical Nurse (LPN) was observed administering medication to a resident with a gastrostomy tube without wearing a gown, and later, the same LPN wore a gown for another resident but failed to remove it before leaving the room. Interviews with the LPN, the Unit Manager, and the Director of Nursing confirmed the lapses in following the enhanced barrier precautions. The Director of Nursing, who also serves as the Infection Preventionist, acknowledged the requirement for enhanced barrier precautions during medication administration for residents with gastrostomy tubes.
Failure to Notify Justice Involved Residents of Discharge
Penalty
Summary
The facility failed to provide timely notification to Justice Involved Residents and their representatives regarding their transfer or discharge, as well as failing to notify the New York State Long Term Care Ombudsman. This deficiency was identified during an abbreviated survey, where it was found that four out of five Justice Involved Residents were discharged without receiving a written notice of transfer or discharge. The facility's policy requires immediate notification to the resident, their physician, and their legal representative when a decision is made to transfer or discharge a resident, but this was not adhered to in these cases. Justice Involved Residents involved in this deficiency had various medical conditions, including Cord Compression, Hemiplegia, Cerebral Infarction, Type 2 Diabetes Mellitus, End Stage Renal Disease, Atherosclerotic Heart Disease, Peripheral Vascular Disease, Venous Insufficiency, Chronic Cellulitis, Right Above Knee Amputation, and Atrial Fibrillation. Despite having intact cognition as documented in their Minimum Data Set assessments, these residents were transferred to other facilities or federal custody without receiving the required discharge or transfer notices. Additionally, the facility did not notify the Ombudsman about these discharges, which is a requirement under their policy. Interviews with facility staff revealed that the Director of Social Service and the Admission Director were aware of the requirement to provide discharge notices and notify the Ombudsman. However, they cited security reasons and short notice from security guards as reasons for not providing the notices to Justice Involved Residents. The Administrator confirmed that notices were not provided due to these reasons and that the Ombudsman was only notified when residents were transferred to the hospital or if there were issues with the 30 days' notice requirement.
Failure to Report Alleged Abuse Incident
Penalty
Summary
The facility failed to report an alleged abuse incident involving a resident to the New York State Department of Health within the required timeframe. The incident involved a resident with diagnoses including liver cirrhosis, thrombocytopenia, and dementia, who was reported by their adult child to have been handled roughly by a Certified Nursing Assistant during personal care. The allegation was communicated to a Licensed Practical Nurse, who then informed the Director of Nursing and the Administrator. However, the facility did not report the allegation to the Department of Health as required by their policy. The Director of Nursing and the Administrator were responsible for investigating the incident and reporting it to the appropriate authorities. They concluded that the resident misunderstood the actions of the Certified Nursing Assistant, who was attempting to prevent a fall, and therefore did not report the incident as abuse. The Administrator stated that the case was not reported because they were able to rule out abuse within two hours, deeming it unsubstantiated. This decision was contrary to the facility's policy, which mandates immediate reporting of all alleged abuse incidents.
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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) |
|---|---|---|---|---|
| Kings Harbor Multicare Cente | 0.2 mi | ★★★★★ | 4 | 0 |
| East Haven Nursing & Rehabilitation Center | 0.5 mi | ★★★★★ | 0 | 0 |
| Eastchester Rehabilitation And Health Care Center | 0.7 mi | ★★★★★ | 4 | 0 |
| Morris Park Rehabilitation And Nursing Center | 1 mi | ★★★★★ | 5 | 1 |
| Workmens Circle Multicare Center | 1.1 mi | ★★★★★ | 0 | 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 August 2026) and official state health department websites.