Below 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 Morris Park Rehabilitation And Nursing Center during CMS and state inspections, most recent first.
A resident with severe cognitive impairment, dementia, bipolar disorder, and a known wandering/elopement risk exited the facility unsupervised after required 30-minute checks were not completed and no monitoring log was documented for the overnight shift. Video showed the resident leaving through an alarmed exit door after speaking with a security guard, while a CNA and an LPN both failed to complete required supervision and the LPN also falsely documented meds as given. The resident was not identified as missing until morning rounds.
Failure to Timely Submit PBJ Staffing Data: The facility failed to submit PBJ direct care staffing data for a quarter by the CMS deadline. The DON responsible for the submission reported an error during the upload process, was told by software support that it would go through, but no data was actually submitted. The Administrator stated they were unaware the PBJ report had not been filed until shortly before the interview.
Failure to supervise and document monitoring accurately: A severely cognitively impaired resident with dementia, bipolar disorder, CHF, wandering behavior, and elopement risk exited the facility unsupervised and was not found. Video showed the resident leaving the grounds while the chart reflected LPN documentation of meds, VS, and monitoring later that morning, but the DON stated the LPN did not complete rounds and the overnight monitoring log showed the resident was not monitored. The exit door alarm also did not activate when the resident left.
A severely cognitively impaired resident with wandering behavior and elopement risk exited through an alarmed door without supervision after the door alarm failed to activate. The resident was last seen by a CNA, but required 30-minute monitoring was not documented, an LPN did not complete rounds, and documentation in the MAR/TAR was inaccurate. The resident was not identified as missing until hours later and remained unlocated.
An LPN inaccurately documented medication administration, vital signs, and resident monitoring for a severely cognitively impaired resident with dementia, bipolar disorder, CHF, and elopement risk. The LPN later stated they did not perform the required rounds, did not enter the resident’s room, and did not actually give the medications, despite signing the MAR and treatment record as if they had. Video surveillance showed the resident leaving through an alarmed exit shortly after midnight, while the resident was not identified as missing until hours later.
The facility experienced significant staffing shortages, particularly with CNAs, leading to delayed care and unmet resident needs. Residents reported long wait times for assistance, especially on weekends, due to insufficient staffing levels. Despite efforts to hire and retain staff, high turnover and reliance on agency workers exacerbated the issue, impacting the quality of care provided.
The facility failed to properly store and label medications, with expired drugs found in an emergency box on Unit 4 and improperly stored insulin pens on Unit 5. Nursing staff did not adhere to procedures for checking and labeling medications, and the Consultant Pharmacist's audits were insufficient.
The facility failed to store food according to professional standards, with unlabeled and undated items found in the kitchen and 5th floor unit refrigerators. The Food Service Director and nursing staff acknowledged lapses in following policies for labeling and monitoring food items.
A resident with Bipolar Disorder, Psychotic Disorder, and Depression exited the facility undetected and was found four days later. The facility's policies on Wandering and Elopement and Security Risk Management Plan were not effectively implemented, leading to a lack of communication and verification of the resident's whereabouts. The security guard did not stop the resident from leaving, contributing to the elopement incident.
Failure to Supervise an Elopement-Risk Resident
Penalty
Summary
The facility failed to ensure adequate supervision to prevent elopement for a resident who was severely cognitively impaired, had a history of wandering behavior, and was identified as an elopement risk. The resident had diagnoses including dementia, bipolar disorder, and chronic heart failure. The resident’s assessment and care plan identified the need for daily monitoring and 30-minute checks, and physician orders also directed 30-minute monitoring for elopement risk and behavior. On the night of the incident, there was no documented monitoring log for the 11:00 PM to 7:00 AM shift. A CNA stated the resident was last seen sitting in a hallway chair after being given a sandwich and juice around 12:15 AM, but the CNA also stated they did not complete the required 30-minute checks after the start of the shift. An LPN stated they assumed the CNAs were rounding, did not perform initial rounds, and did not visually check the resident during the night because they did not want to disturb them. The LPN also stated they signed the MAR as if medications had been given even though they had not been administered. Video surveillance showed the resident speaking with a security guard in the lobby, walking toward the elevator, then moving through the lobby and exiting through an alarmed door at 12:30:40 AM. The resident was not identified as missing until the morning when a supervisor found the resident absent from the room during rounds. The report states the exit door alarm did not activate because of a malfunction, and the resident remained missing after the facility confirmed the elopement.
Failure to Timely Submit PBJ Staffing Data
Penalty
Summary
The facility failed to ensure that direct care staffing information based on payroll and other verifiable, auditable data was submitted to CMS in a timely manner for fiscal year Quarter 1/2026 (10/01/2025 - 12/31/2025). CMS Payroll-Based Journal staffing data showed no submission for that quarter, even though the CMS policy manual required quarterly staffing and census data to be submitted by the end of the 45th calendar day after the close of the quarter. The facility policy also stated that staffing information was to be reported through the PBJ system no later than forty-five days after the end of the reporting quarter. During interview, the Director of Payroll stated they were responsible for submitting the PBJ data after verifying information from Human Resources and using Simple Payroll-Based Journal software to analyze and submit the report. The Director of Payroll stated an error message occurred during submission, customer service was contacted, and they were told everything would go through, but nothing was actually submitted and nothing was issued. The Director of Payroll stated they later realized Quarter 1 data had not been submitted when attempting to upload Quarter 2 data. The Administrator stated they were not aware the Quarter 1 PBJ submission had not been completed until the day before the interview.
Failure to Supervise and Accurately Document Monitoring
Penalty
Summary
The facility failed to ensure that services provided or arranged met professional standards of quality when a severely cognitively impaired resident with dementia, bipolar disorder, chronic heart failure, wandering behavior, and elopement risk exited the facility grounds unsupervised and was not found. The resident had been assessed as needing ongoing monitoring and had orders for daily blood pressure and pulse checks before metoprolol, along with monitoring every shift and as needed for ID and a neon arm band placement. The resident was last seen by a CNA in a hallway on the first-floor unit shortly after midnight, and the resident was not identified as missing until the morning. The record showed that an LPN documented administering medications and taking vital signs at 7:00 AM, including a blood pressure of 130/80, and also documented monitoring the resident at 7:30 AM. However, the facility’s video surveillance footage showed the resident exited the facility grounds unsupervised at 12:30:40 AM. The treatment record for the overnight shift also reflected monitoring documentation, but the DON stated the LPN did not perform nursing rounds to check the resident and that the resident’s monitoring log from 11:00 PM to 7:00 AM showed the resident was not monitored. The report also states that the facility later found the exit door alarm had malfunctioned and did not activate when the resident left. The Administrator stated that the resident remained missing as of the interview on 05/12/2026, and that staff had contacted hospitals, shelters, and other locations while also communicating with police. The DON stated the findings included failures in required supervision and monitoring, inaccurate nursing documentation, and the malfunctioned exit alarm door that failed to alert staff when the resident exited unnoticed.
Elopement Supervision Failure
Penalty
Summary
The facility failed to ensure adequate supervision and monitoring for a severely cognitively impaired resident who had a history of wandering behavior and was identified as being at risk for elopement. The resident exited the facility unsupervised through the New Wing Hall lobby exit door at 12:30:40 AM after talking with a security guard in the lobby and walking past the elevator area. The resident was last seen by a CNA at 12:15 AM in a hallway on the first-floor unit and was not identified as missing until the morning. The report states that the resident had been required to receive 30-minute monitoring for elopement risk behavior, but there was no documented monitoring log sheet for the overnight shift from 11:00 PM to 7:00 AM. The report also states that an LPN did not perform nursing rounds to check on the resident. During the investigation, the facility found that the exit door alarm did not activate because of an alarm system malfunction, allowing the resident to leave through the alarmed door without staff being alerted. The Administrator and DON were aware that the resident had not been located after the elopement and that the resident remained missing at the time of the survey. The report also notes inaccurate documentation in the medication administration and treatment record, including conflicting documentation about when the resident was seen and when medications were administered. The resident was described as severely cognitively impaired, with wandering behavior and elopement risk identified in the record.
Inaccurate MAR and treatment documentation for an elopement-risk resident
Penalty
Summary
The facility failed to ensure that Resident #1’s medical record was complete and accurately documented in accordance with accepted professional standards. On 05/08/2026, an LPN documented in the Medication Administration Record that medications were administered to Resident #1 and that vital signs were taken at 7:00 AM, and also documented in the Treatment Record that Resident #1 was monitored at 7:30 AM. During interview, the LPN stated they did not perform the rounding they were supposed to do, did not go to Resident #1’s room, and did not actually give the medications, but signed the MAR as if the medications had been given. Resident #1 had diagnoses including dementia, bipolar disorder, and chronic heart failure, and the MDS documented severely impaired cognition. The resident was also assessed as being on diuretic and anticonvulsant medications. Physician orders included Furosemide, Metoprolol Succinate ER, Valproic Acid, Thiamine, and daily blood pressure and pulse monitoring before Metoprolol administration. The record also included an order for monitoring every shift and as needed for ID and a neon arm band due to elopement risk. Video surveillance showed Resident #1 talking with a security guard in the lobby shortly after midnight, walking through the first-floor lobby area, and exiting through an alarmed door at 12:30:40 AM. The resident was last seen by a CNA at 12:15 AM in a hallway on the first-floor unit and was not identified as missing until 8:20 AM. The RN supervisor stated Resident #1 was not wearing a wander guard because the resident had refused it and had been placed on 30-minute monitoring due to wandering and elopement risk. The RN supervisor and DON stated the resident was confirmed missing later that morning, and the facility concluded the resident had eloped from the facility at 12:30 AM.
Staffing Shortages Lead to Delayed Resident Care
Penalty
Summary
The facility failed to ensure sufficient nursing staff was consistently provided to meet residents' needs, as evidenced by multiple observations and interviews during the Recertification and Abbreviated Survey. Several residents reported that the facility was short-staffed, particularly with Certified Nursing Assistants (CNAs), leading to delays in staff response to residents requiring assistance. For instance, a resident with morbid obesity and other health conditions reported that their call bell was not answered during both day and evening shifts, resulting in unmet care needs. This issue was corroborated by interviews with CNAs and the staffing coordinator, who confirmed that staffing levels were below the facility's assessed requirements. The Payroll Based Journal Staffing Data Report for the 4th Quarter of 2024 highlighted excessively low weekend staffing levels, which were below the facility's par levels. Interviews with residents and staff revealed that the shortage of staff on weekends led to delayed care and unmet needs. The facility's staffing schedule documented several instances where the number of CNAs working was below the required par levels, particularly on weekends. This shortage was further exacerbated by the facility's reliance on agency staff, who often chose higher-paying assignments elsewhere, leaving permanent staff to work overtime or with minimal days off. The facility's administration acknowledged the staffing challenges and described various strategies employed to attract and retain staff, including offering sign-in bonuses and other incentives. Despite these efforts, the facility continued to experience high turnover rates, with many newly hired CNAs leaving due to no-call-no-show incidents. The Director of Nursing and other staff members expressed the stress and difficulty in maintaining adequate care levels due to the persistent staffing shortages, particularly during weekends and shifts with high resident care demands.
Deficiencies in Medication Storage and Labeling
Penalty
Summary
The facility failed to ensure proper storage and labeling of drugs and biologicals in accordance with professional standards of practice, as observed during the Recertification Survey. On Unit 4, the emergency drug box contained expired medications, including a Diphenhydramine vial and Epinephrine ampules, despite the facility's policy requiring regular checks by nursing staff and audits by the Consultant Pharmacist. Interviews revealed that the responsibility for checking expired medications was not clearly documented, and the frequency of audits by the Pharmacy Consultant was insufficient. On Unit 5, the medication cart was found with insulin pens improperly stored and not marked with opening dates, contrary to the facility's policy. Insulin pens for different residents were stored together, and unopened pens were not refrigerated as required. Interviews with nursing staff indicated a lack of adherence to procedures for labeling and storing insulin pens, with staff citing workload as a reason for not inspecting the cart. The Director of Nursing confirmed the expectations for medication storage and labeling, highlighting a gap in compliance with established protocols.
Deficiency in Food Storage and Labeling Practices
Penalty
Summary
The facility failed to ensure that food was stored in accordance with professional standards for food service safety, as observed during a recertification survey. In the kitchen, the walk-in refrigerator and freezer contained opened and undated food items, specifically six plastic bins of frozen meats and four bins of thawed meat, along with an opened container of tartar sauce, all without labels or dates. The Food Service Director acknowledged that the meat was delivered over the weekend and was placed in the freezer without proper labeling, contrary to the facility's policy which requires labeling with delivery date, date taken out of the box, and use by date. On the 5th floor unit, the pantry refrigerator contained unlabeled and undated food items, including a package of smoked salmon, a container of fruit salad, and an unknown food item in a Chipotle paper bag. Interviews with nursing staff revealed that they were responsible for ensuring food was labeled with the resident's name and date received, and for discarding expired food after 72 hours. However, the Director of Nursing confirmed that the policy was not followed, as food must be labeled and dated before storage, and nursing staff are tasked with monitoring compliance.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to ensure that a resident received adequate supervision to prevent an elopement. Resident #1, who had diagnoses including Bipolar Disorder, Psychotic Disorder, and Depression, exited the facility undetected by staff. The resident was last seen at around 4:00 pm and was discovered missing at 7:10 pm. Surveillance footage showed that Resident #1 left the facility at 4:22 pm behind a pharmacy delivery person while the security guard was on the phone and did not notice the resident leaving. The resident was found four days later at a bus stop and returned to the facility without visible injuries but was sent to the hospital for a wellness check. The facility's policies on Wandering and Elopement and Security Risk Management Plan were not effectively implemented. Staff interviews revealed that there was a lack of communication and verification regarding Resident #1's whereabouts during dinner time. The recreation leader and certified nurse assistants did not verify if Resident #1 ate their dinner or was present in the dining room. The security guard did not stop the resident from leaving the facility, as they were preoccupied with a phone call and did not see the resident exit. The facility's investigation concluded that abuse, neglect, or mistreatment did not occur. However, the staff failed to notice that Resident #1 did not eat their dinner and did not report the untouched tray. The security guard's failure to stop the resident and the lack of monitoring and verification of the resident's whereabouts contributed to the elopement incident. The facility identified these deficiencies and took corrective actions to address the issues and prevent future occurrences.
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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) |
|---|---|---|---|---|
| Pelham Parkway Nursing Care & Rehab Facility L L C | 0.3 mi | ★★★★★ | 9 | 0 |
| Morningside Nursing And Rehabilitation Center | 0.4 mi | ★★★★★ | 1 | 0 |
| East Haven Nursing & Rehabilitation Center | 0.5 mi | ★★★★★ | 0 | 0 |
| Eastchester Rehabilitation And Health Care Center | 0.7 mi | ★★★★★ | 4 | 0 |
| Williamsbridge Center For Rehabilitation And Nrsg | 0.9 mi | ★★★★★ | 0 | 0 |
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