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 Mosholu Parkway Nursing & Rehabilitation Center during CMS and state inspections, most recent first.
The facility did not promptly report suspected abuse, neglect, or theft, nor did it communicate the results of its investigation to the proper authorities as required.
A resident did not receive treatment and care in accordance with physician orders and their own preferences and goals, as observed by surveyors and confirmed through record review.
A resident with dementia and unsteadiness was improperly restrained with a bedsheet tied to a wheelchair by an LPN, contrary to the facility's restraint-free policy. The restraint was applied after unsuccessful attempts to calm the agitated resident, who was at high risk for falls. The incident was discovered by a physical therapist, who removed the restraint and reported it to the rehabilitation supervisor.
The facility failed to adhere to professional standards for food service safety, as evidenced by improperly stored and expired food items in refrigerators, lack of temperature monitoring, and staff handling food with bare hands. The Director of Food Service acknowledged the absence of kitchen supervision on weekends, contributing to the oversight in discarding expired food. The Director of Nursing confirmed that staff should have worn gloves during meal service, and the facility Administrator deemed the storage and handling practices unacceptable.
The facility failed to maintain sanitary conditions in its garbage storage areas, with uncovered and overflowing dumpsters and improper handling of kitchen trash. The Director of Food Service and the facility Administrator acknowledged issues with broken dumpster lids and unauthorized use by neighborhood residents. Additionally, a kitchen trash can was observed being handled without a lid or gloves, contrary to facility policy.
The facility failed to maintain an effective pest control program, as evidenced by the presence of dead cockroaches, water bugs, spiders, and silverfish in the food storage room. Staff interviews revealed awareness of the issue, with the Food Service Director attributing it to rain and inadequate trap disposal. The Administrator acknowledged the situation, but the facility was unable to produce a Pest Control Log for the Kitchen, indicating a lack of proper documentation and follow-up.
The facility failed to develop comprehensive care plans for two residents, one involving abuse after an altercation and another for insulin management. Despite documented incidents and physician orders, care plans were not initiated or updated, as confirmed by nursing staff interviews.
A LTC facility failed to implement Enhanced Barrier Precautions during care for residents with chronic wounds or indwelling devices. Staff were unaware of the need for such precautions, leading to improper use of PPE and inadequate hand hygiene. The Director of Nursing admitted that training was insufficient, as it focused only on residents with MDROs.
A resident with Alzheimer's Disease was found with a scratch on their cheek, but the facility failed to conduct a thorough investigation as per their policy. Only one staff statement was collected, and no investigation summary was documented. Staffing records showed discrepancies, and interviews revealed procedural lapses, including the absence of a regular supervisor and limited documentation by the DON.
A resident with Osteoporosis, Diabetes, and Alzheimer's Disease had a Skin Integrity Care Plan that was not updated after a scratch was observed on their cheek. The RN responsible for updates was not regularly on duty, and the DON acknowledged the oversight during a survey.
A resident with cognitive impairment eloped from an LTC facility due to inadequate supervision and protocol adherence. The resident, who had a history of wandering, was able to leave through an unlocked door while a porter, filling in at the reception desk, failed to check identification protocols. The resident was later found at their previous shelter.
A resident with severe cognitive impairment was not provided showers as scheduled, despite family preference for showers. Staff were unaware of the resident's shower schedule, and there was no documentation of shower refusals, indicating a failure to honor the resident's bathing preferences.
A resident with Alzheimer's Disease sustained a scratch and possible bruise, which were not reported to the Department of Health within the required timeframe. The facility's policy requires immediate reporting of suspected abuse or injury, but the incident was not reported until the resident's family member raised concerns. Staff interviews revealed confusion about reporting responsibilities, leading to the deficiency.
A resident with severe cognitive impairment and multiple diagnoses, including Parkinson's Disease, did not have the prescribed bilateral hand gauze applied to prevent flexion contracture. Despite a physician's order for the gauze to be worn at all times, observations revealed it was not in place. Interviews with staff indicated inconsistent application and awareness of the order, with some staff unaware of the requirement and others noting the gauze had not been applied for days.
A resident with End-Stage Renal Disease had inaccurate medical records documenting the use of an AV fistula for dialysis, while a central venous catheter was actually used. Despite a doctor's order noting the non-functioning AV fistula, nurse progress notes incorrectly documented its use. An LPN admitted to overlooking the catheter documentation, and the DON confirmed the error.
During a survey, it was found that handrails in Unit #2 were loose and not fully connected, violating the facility's safety policy. Observations revealed a lack of documentation in the Maintenance Logbook, and interviews highlighted communication gaps. The maintenance worker, being the only one in the department, was unable to address the issue, and the Administrator acknowledged the need for replacement and additional staffing.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on the facility's lack of prompt action in notifying the appropriate agencies when an incident of suspected abuse, neglect, or theft occurred. The report indicates that the required notifications and investigation results were not communicated as mandated.
Failure to Provide Care According to Orders and Resident Preferences
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders, as well as the resident’s preferences and goals. This deficiency was identified through surveyor observation and review of records, which showed that care provided did not align with the documented orders or the expressed wishes and objectives of the resident. The report does not specify the exact nature of the treatment or the resident’s medical history, but it clearly states that the care delivered was inconsistent with established directives and resident-centered planning.
Resident Improperly Restrained with Bedsheet
Penalty
Summary
The facility failed to ensure that a resident was free from physical restraints, which were not required for medical treatment. On the morning of the incident, a physical therapist observed a resident in their room, sitting in a wheelchair with a bedsheet wrapped around their waist and tied to the wheelchair. The resident, who had diagnoses including dementia, a stroke, and unsteadiness on their feet, was assessed by a registered nurse supervisor and found to have no visible injuries. The facility's policy emphasized a commitment to being restraint-free, yet the resident was restrained by a licensed practical nurse (LPN) after unsuccessful attempts to redirect the resident, who was agitated and at high risk for falls. The LPN involved stated that the restraint was applied for a brief period to prevent the resident from falling or sustaining self-injury. The LPN admitted that it was not the facility's policy to restrain residents but believed it was necessary at that moment. The physical therapist who discovered the restraint removed the bedsheet and reported the incident to the rehabilitation supervisor. Interviews with other staff members revealed that the resident was agitated and unsteady, and the restraint was applied as a temporary measure to ensure safety. The assistant director of nursing, who was a registered nurse supervisor at the time, was informed of the incident and confirmed that the resident was not injured. The assistant director stated that the LPN should have contacted the nursing supervisor to assign a one-to-one staff member to assist the resident. The director of nursing, who was not present during the incident, emphasized that all staff members are responsible for ensuring residents remain free from restraints. The facility was cited for past non-compliance due to this incident.
Food Storage and Handling Deficiencies
Penalty
Summary
The facility failed to ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. During the recertification survey, it was observed that the dairy and meat walk-in refrigerators contained opened cans and undated, unlabeled, expired food items. Additionally, there were no thermometers located in the walk-in and ice cream freezers, and the unit refrigerator temperatures were not maintained. The refrigerators contained spilled, spoiled, undated, and unlabeled food items. Furthermore, during meal service, staff was observed handling residents' food with bare hands. The facility's policies and procedures were not adhered to, as evidenced by the presence of undated and improperly stored food items in the refrigerators. The Director of Food Service acknowledged that opened cans of fruits should not be stored in their original metal containers and that leftovers must be transferred to plastic containers with lids, dated, and discarded if not used within 24 hours. The Director also noted that there was no kitchen supervision during weekends, which contributed to the oversight in discarding expired food items. Additionally, the lack of thermometers in the refrigerators and freezers and the absence of temperature logs indicated a failure to consistently monitor and maintain appropriate storage conditions. The deficiency was further compounded by the improper food handling practices observed during meal service. Certified Nursing Assistants were seen buttering bread with bare hands, and they reported not being provided with food handling gloves. The Director of Nursing confirmed that staff should have worn clean vinyl gloves when handling food and that a nurse should have supervised the dining process to ensure infection control practices were maintained. The facility Administrator acknowledged the issues with food storage and handling, stating that it was unacceptable for food to be stored incorrectly and not discarded as required.
Improper Garbage Disposal and Sanitation Issues
Penalty
Summary
The facility failed to maintain its garbage storage areas in a sanitary condition, as observed during a recertification survey. Specifically, the outside garbage dumpsters were found uncovered, with one overflowing with black and clear plastic bags, another with cardboard, and a third three-quarters full with white plastic bags. The Director of Food Service acknowledged that the dumpsters should be covered, and the facility Administrator noted that two dumpster lids were broken and that neighborhood residents were placing their garbage in the facility bins. There was no evidence provided that the broken lids were scheduled for repair or replacement. Additionally, during a kitchen garbage disposal observation, a trash can was removed from the kitchen to the outside dumpster, emptied, and returned without a lid. The Food Service Worker involved in this process did not wear gloves, which was noted during the observation. The Director of Food Service confirmed that kitchen garbage lids and dumpsters should always be covered, indicating a lapse in adherence to the facility's policy and procedure for food-related garbage and refuse disposal.
Deficiency in Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by the presence of multiple dead cockroaches, water bugs, spiders, and silverfish in the food storage room during a kitchen observation. The facility's pest control policy, revised in January 2024, mandates an ongoing program to keep the building free of insects and rodents, with services provided by JB Pest Control. However, the service agreement was unsigned, and the service logs were not properly maintained. During the survey, glue boards dated 7/30/2024 were found with multiple dead pests, and several dead roaches were observed on the floor. Interviews with staff revealed awareness of the pest issue, with the Food Service Director attributing the presence of roaches to rain and stating that traps are set but not discarded daily. The Administrator acknowledged the unacceptable situation and mentioned recent communication with the pest control company. Despite multiple requests, the facility was unable to produce a Pest Control Log for the Kitchen, indicating a lack of proper documentation and follow-up on pest control measures. Additionally, the 4th Floor Pest Control Logbook documented sightings of roaches and a mouse in various areas, further highlighting the deficiency in pest management.
Deficiencies in Care Planning for Abuse and Insulin Management
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for two residents, leading to deficiencies in care planning. For one resident, who had diagnoses including hypertension and depression, a care plan related to abuse was not created following a resident-to-resident altercation. Despite the incident being documented and investigated, there was no evidence of a care plan being developed to address the abuse, as confirmed by interviews with the Assistant Director of Nursing and the Director of Nursing. Both acknowledged the oversight and the responsibility of registered nurses and the social worker in ensuring care plans are in place. Another resident, admitted with diagnoses including diabetes mellitus, liver cirrhosis, and schizoaffective disorder, did not have a care plan addressing their insulin use. Despite having physician orders for insulin, the care plans reviewed did not include diabetes or insulin management. The Assistant Director of Nursing noted that baseline care plans should be completed within 48 hours of admission, but the unit's lack of a regular registered nurse led to supervisors providing coverage, which may have contributed to the oversight. The Director of Nursing also acknowledged the oversight but could not explain why the care plan was not initiated.
Inadequate Infection Control Practices in LTC Facility
Penalty
Summary
The facility failed to maintain proper infection control practices, specifically Enhanced Barrier Precautions, during care activities for residents with chronic wounds or indwelling medical devices. This deficiency was observed in three residents. One resident with a central venous catheter for hemodialysis did not have Enhanced Barrier Precautions in place, and staff were unaware of the need for such precautions. The Director of Nursing, who is also the Infection Preventionist, incorrectly believed that Enhanced Barrier Precautions were only necessary for residents with multidrug-resistant organisms. Another resident with a Foley catheter had their urinary drainage bag improperly managed, as it was observed on the floor, and the assigned Certified Nursing Assistant (CNA) did not use appropriate Personal Protective Equipment (PPE) or follow hand hygiene protocols during catheter care. The CNA touched multiple surfaces with contaminated gloves and failed to wash hands between glove changes, leading to potential cross-contamination. The CNA was unaware of the need for Enhanced Barrier Precautions, and the oversight was acknowledged by the Director of Nursing. A third resident with a skin tear on a below-the-knee amputation site received wound care from an LPN who did not wear a gown or change gloves appropriately. The LPN was not informed about Enhanced Barrier Precautions and did not perform hand hygiene after removing soiled dressings. The Director of Nursing admitted that staff training on Enhanced Barrier Precautions was inadequate, as it was only provided for residents with MDROs, not for those with wounds or indwelling devices.
Inadequate Investigation of Resident Injury
Penalty
Summary
The facility failed to ensure a thorough investigation of an alleged abuse incident involving a resident with a reported injury of unknown origin. The resident, who had diagnoses including Osteoporosis, Repeated Falls, and Alzheimer's Disease, was observed with a linear scratch across their left cheek. The facility's policy required a comprehensive investigation, including gathering statements from all personnel who had contact with the resident in the 24-48 hours prior to the incident. However, only one written statement from a Certified Nursing Assistant was collected, and no investigation summary was documented. The Occurrence Report, signed by the Director of Nursing, concluded that no abuse or mistreatment had occurred, but lacked supporting documentation and a detailed investigation summary. Further discrepancies were noted in the staffing records, which showed that the staff member who provided the statement was not working on the dates in question. Interviews with the Assistant Director of Nursing and the Director of Nursing revealed procedural lapses, such as the absence of a regular supervisor on the day shift and the Director of Nursing's decision to limit documentation to their own conclusions. Additionally, the Director of Nursing was not present at the facility during the incident and could not locate any other written statements. These actions and inactions led to the deficiency in the investigation process, as outlined in the facility's policy.
Failure to Update Resident's Care Plan for Skin Integrity
Penalty
Summary
The facility failed to ensure that a person-centered comprehensive care plan was reviewed and revised to accurately reflect a resident's current status. Specifically, a resident with a new skin break did not have their Skin Integrity Care Plan updated to reflect the change. The resident, who was admitted with diagnoses including Osteoporosis, Diabetes, and Alzheimer's Disease, had a Skin Integrity Care Plan initiated in 2018 with various interventions. However, after a linear scratch was observed on the resident's left cheek on January 1, 2024, the care plan was not updated to include this new development. The Assistant Director of Nursing indicated that the Registered Nurse on the unit is typically responsible for updating care plans, but there was no regular RN on duty during the day shift. The Director of Nursing, who was not working at the facility when the incident occurred, stated that care plans are reviewed quarterly and updated as needed, acknowledging that the care plan should have been updated in this case. The deficiency was identified during a Recertification Survey conducted from August 12 to August 16, 2024.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to ensure adequate supervision to prevent accidents, resulting in a resident eloping from the facility. The resident, who was admitted with diagnoses including Seizure Disorder and Vascular Dementia, was assessed as severely cognitively impaired. Despite the facility's policy requiring monitoring of residents with wandering behavior, the resident was able to leave the facility without being stopped by the porter filling in at the reception desk. The porter did not check the photos of new admissions or the visitors log, allowing the resident to exit through an unlocked door due to a malfunctioning buzzer. The resident had been observed wandering at night on previous occasions, indicating a potential risk for elopement. However, there was no formal monitoring program in place for the resident, and staff did not document the resident's whereabouts on any monitoring sheet. On the day of the incident, the resident was last seen in the rehab gym and was assumed to be there when they did not return for lunch. A Code Grey was activated when the resident was reported missing, but the resident was not found until later that evening at their previous shelter. Interviews with staff revealed a lack of communication and adherence to protocols. The Occupational Therapist returned the resident to the unit without endorsing them to unit staff, and the charge nurse assumed the resident was still in the gym. The Director of Nursing stated that employees at the reception desk are cross-trained to follow protocols, but the porter failed to do so. The facility's failure to ensure proper supervision and adherence to protocols led to the resident's elopement.
Failure to Honor Resident's Bathing Preferences
Penalty
Summary
The facility failed to promote and facilitate resident self-determination by not honoring a resident's bathing preferences. Specifically, a resident with severe cognitive impairment and requiring substantial assistance was scheduled for showers twice a week, but there was no documented evidence that these showers were provided. The resident's family representative expressed a preference for the resident to receive showers, but the facility's records did not reflect compliance with this preference. Interviews with staff revealed a lack of awareness regarding the resident's shower schedule, and there was no documentation of the resident refusing showers. The Assistant Director of Nursing and the Director of Nursing both acknowledged that the resident was supposed to receive showers on specific days, but the Certified Nursing Assistant assigned to the resident was unaware of this schedule. Additionally, there was no documentation to indicate that the resident refused showers, which should have been recorded if it occurred.
Failure to Timely Report Alleged Abuse and Injury
Penalty
Summary
The facility failed to report an alleged violation involving a resident who sustained a scratch and possible bruise, as required by their policy and state regulations. The incident involved a resident with diagnoses of Osteoporosis and Alzheimer's Disease, who was found with a linear scratch on their left cheek. The scratch was noted by a caregiver at 2:30 PM, but the incident was not reported to the New York State Department of Health within the required timeframe. The facility's policy mandates that any suspicion of abuse or injury of unknown origin should be reported immediately, but not later than 2 hours if it involves serious bodily injury, or within 24 hours if it does not. The incident was documented in a nursing progress note, and an occurrence report was initiated. However, the Director of Nursing concluded that no abuse or mistreatment had occurred, and no report was made to the Department of Health between the dates of the incident. The resident's family member, upon noticing the scratch and a bruise on the resident's forehead, reported the incident to the Department of Health as a possible abuse allegation. Interviews with facility staff revealed a lack of clarity and responsibility regarding the reporting process, contributing to the deficiency.
Failure to Apply Prescribed Hand Gauze for Resident with Limited ROM
Penalty
Summary
The facility failed to ensure that a resident with limited range of motion received appropriate treatment and services to prevent further decrease in range of motion. This deficiency was identified during a recertification survey, where it was observed that a resident with severe cognitive impairment and multiple diagnoses, including Parkinson's Disease, did not have the prescribed bilateral hand gauze applied to prevent flexion contracture at the digits. The physician's order required the gauze to be worn at all times, except during activities of daily living and skin checks, but observations on multiple occasions revealed that the gauze was not in place. Interviews with various staff members, including LPNs, an occupational therapist, a rehab supervisor, and a CNA, indicated a lack of consistent application and awareness of the physician's order for the hand gauze. Some staff members were unaware of the requirement, while others noted that the gauze had not been applied for several days. The Director of Nursing was also unaware of the non-compliance with the physician's order, highlighting a breakdown in communication and adherence to care protocols within the facility.
Inaccurate Dialysis Documentation for Resident
Penalty
Summary
The facility failed to maintain accurate and complete medical records for a resident undergoing dialysis, as required by professional standards. Specifically, the medical records for a resident with End-Stage Renal Disease and Diabetes Mellitus inaccurately documented the use of an AV fistula for hemodialysis, while the resident actually had a non-functioning AV fistula and was using a central venous catheter in the right upper chest for dialysis. This discrepancy was observed during a recertification survey, where the resident was noted to have a chest catheter, and the resident confirmed its use during an interview. Despite the presence of a medical doctor's order indicating the non-functioning status of the AV fistula and the use of a central venous catheter, the nurse progress notes from 08/05/2024 to 08/15/2024 incorrectly documented the use of an AV fistula. An LPN admitted to overlooking the documentation of the catheter in the resident's medical record. The Director of Nursing confirmed that the AV fistula was not in use and that the staff had been incorrectly documenting the dialysis method.
Loose Handrails in Unit #2
Penalty
Summary
The facility failed to ensure that handrails were firmly affixed and secured to the wall in Unit #2, as observed during the recertification survey. Specifically, two sections of handrails in the hallway near the elevator were found to be loose and not fully connected at a joint connection. This deficiency was noted during multiple observations conducted between August 12 and August 15, 2024. The facility's policy titled 'Homelike Environment' emphasizes providing residents with a safe environment, yet there was no documented evidence in the Maintenance Logbook of the loose handrail being reported from December 2023 to August 15, 2024. Interviews conducted during the survey revealed a lack of communication and documentation regarding maintenance issues. A Certified Nursing Assistant stated they were unaware of a Maintenance Logbook used to report repair concerns and typically called the maintenance worker directly when something needed fixing. The Maintenance Worker confirmed that they addressed repair concerns documented in the logbook and performed daily rounds, including checking handrails. However, they mentioned being unable to fix the loose handrails due to being the sole worker in the maintenance department. The Administrator acknowledged the issue and indicated plans to discuss replacing the handrails with the facility owner and hiring an additional maintenance worker.
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What surveyors actually found near you
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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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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Bronx
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Wayne Center For Nursing & Rehabilitation | 0.3 mi | ★★★★★ | 0 | 0 |
| Bainbridge Nursing & Rehabilitation Center | 0.3 mi | ★★★★★ | 0 | 0 |
| Beth Abraham Center For Rehabilitation And Nursing | 0.4 mi | ★★★★★ | 0 | 0 |
| Bronx Park Rehabilitation & Nursing Center | 0.8 mi | ★★★★★ | 1 | 0 |
| St Patrick's Home | 0.9 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 July 2026) and official state health department websites.