Above average — CMS composite of the measures below.
A standard survey is most likely before 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 Pelham Parkway Nursing Care & Rehab Facility L L C during CMS and state inspections, most recent first.
An alleged sexual abuse incident involving a cognitively impaired resident with cerebral palsy, aphasia, and seizure disorder was reported by a CNA to an RN supervisor, who then informed the DON. Despite a facility policy requiring immediate notification to the Administrator and reporting to state officials within two hours, the DON delayed notifying the Administrator because they questioned the credibility of the allegation. As a result, the Administrator, state health department, and law enforcement were not notified until roughly two days after the initial report.
A resident with epilepsy and Alzheimer's was found on the floor with facial injuries of unknown origin and was unable to explain the incident. Despite facility policy and state regulations requiring prompt reporting of such events, the incident was not reported to the Department of Health because facility leadership attributed it to a fall and did not consider it a major injury.
Disposable Meal Service Used for Most Residents: During dining and kitchen observations, residents on multiple units were served meals on Styrofoam plates with plastic utensils instead of regular dishware. The FSD stated the facility had no metal silverware and limited China plates due to hoarding, breakage, and behavioral concerns, while the Admin said only certain residents should have been restricted to disposable items and everyone else should have received regular plates and utensils.
Missing Care Plan for Resident With GERD: A resident with Vascular Dementia, psychotic disorder, depression, and GERD was prescribed Pantoprazole, but no GI status care plan was documented in the EMR. The RN supervisor said the GI care plan had not been initiated and had followed what was already in place, while the DON stated a GI care plan would have been appropriate and should have been included in the resident’s comprehensive plan of care.
Care plans were not reviewed and revised as required for two residents. One resident on hospice had a hospice care plan that was not updated after a quarterly assessment, and another resident with dementia and psychiatric diagnoses had multiple psychosocial-related care plans that remained outdated despite repeated care plan meetings. Interviews with the SW and DON showed the updates were expected quarterly, but some revisions were missed and not noticed.
Inaccurate and incomplete medical record documentation was identified for two residents. One resident had a schizophrenia care plan in the chart even though the diagnosis had been removed, and the DON stated it was added in error after an audit. Another resident’s MAR/TAR showed wound care as completed even though the resident refused staff-performed treatment and often performed the dressing changes independently, with staff documenting completion without always observing the care.
A facility failed to maintain a clean, comfortable, and homelike environment on multiple units. Surveyors observed chipped and scraped paint, uneven plaster, peeling tape, ripped and missing window coverings, broken or missing blind slats, a cracked window, brown ceiling stains, a dirty AC grill taped in place, and a TV remote that did not work properly; the DOR and maintenance staff acknowledged several of the issues.
The facility did not timely report or submit required investigation results to authorities following incidents involving two residents—one with mobility issues who sustained knee fractures after a transport incident, and another with behavioral health diagnoses who alleged staff abuse. In both cases, mandated notifications to the State Survey Agency and, in one case, to law enforcement, were not completed within regulatory timeframes.
Failure to Timely Report Alleged Sexual Abuse to Required Authorities
Penalty
Summary
The facility failed to ensure timely reporting of an alleged abuse incident in accordance with its Abuse Prevention policy and regulatory requirements. The policy, dated 01/05/2026, required that allegations of abuse be reported immediately to the Administrator and no later than two hours to other officials, including the State Survey Agency. On 02/08/2026 at approximately 10:30 PM, a CNA informed an RN Supervisor that they had entered a resident's room and observed another CNA on their knees, in the dark, inappropriately touching the resident's private organ. The resident involved had diagnoses including cerebral palsy, aphasia, and seizure disorder, and an MDS dated 11/27/2025 documented short- and long-term memory problems. According to the facility’s investigation summary dated 02/12/2026, the Administrator was not informed of the allegation until 02/10/2026 at approximately 11:00 AM, and the incident was reported to the New York State Department of Health at 1:20 PM and to local law enforcement at 1:24 PM on the same day. During interview, the DON stated that on 02/08/2026 at around 11:00 PM, the RN Supervisor informed them of the alleged sexual abuse and that the alleged perpetrating CNA was removed from the unit, but the DON did not notify the Administrator at that time because they believed the event was not credible, citing lack of other witnesses and concerns about the reporting CNA’s credibility. The Administrator later confirmed in interview that they first learned of the allegation on 02/10/2026 around 11:00 AM and acknowledged that they and the DON were responsible for reporting the allegation to police and the Department of Health within two hours after the allegation was made.
Failure to Timely Report Unwitnessed Injury of Unknown Origin
Penalty
Summary
The facility failed to ensure timely reporting of an unwitnessed incident involving a resident who was found on the floor with injuries of unknown origin. According to the facility's policy and state regulations, all alleged violations involving abuse, neglect, or injuries of unknown source must be reported immediately, but not later than 2 hours if abuse or serious bodily injury is suspected, or within 24 hours if not. In this case, a resident with diagnoses of epilepsy and Alzheimer's disease was found on the floor with swelling to the forehead, left peri-orbital swelling, and an abrasion on the nose. The resident was unable to explain the occurrence due to cognitive impairment, and the incident was not witnessed by staff. Documentation showed that the incident was assessed by a Registered Nurse, who noted the injuries and arranged for the resident to be transferred to the hospital for further evaluation. The facility's Accident Investigation Report recorded the event and the injuries, but there was no documented evidence that the incident was reported to the New York State Department of Health as required by policy and regulation. Interviews with the DON, Medical Doctor, and Administrator revealed that the incident was attributed to a fall, and since there was no fracture or major injury, it was not considered reportable by the facility's leadership. Despite the facility's policy requiring reporting of injuries of unknown origin, the unwitnessed nature of the incident and the resident's inability to explain the injuries were not considered sufficient to trigger a report to the state. The lack of camera footage and the resident's history of falls were cited as reasons for attributing the incident to a fall rather than an injury of unknown source. As a result, the required notification to the Department of Health was not made.
Disposable Meal Service Used for Most Residents
Penalty
Summary
The facility did not ensure that residents were treated with respect, dignity, and care in a manner that promoted quality of life and recognized individuality during meal service. During kitchen and dining observations on five units, residents’ meals were served on disposable dishware with plastic cutlery. On Unit 2, during lunch observations, all residents except those receiving puree meals were observed eating from Styrofoam plates with plastic utensils. During a kitchen observation, dinner trays were set up with plastic utensils for all residents. The Food Service Director stated the facility did not have any metal silverware and had never seen metal silverware in the facility since starting in December 2024. The Food Service Director also stated they were told metal silverware had been used by residents with behavioral issues to potentially hurt each other and that other residents were hoarding the silverware. The Food Service Director further stated the facility had not had enough China plates because they were chipped, broken, and hoarded by residents and not replaced, so Styrofoam plates were used. The Administrator later stated there had been a misunderstanding and that not all residents should have been eating on Styrofoam plates and using plastic utensils; only residents with behavioral issues were supposed to be on that list, while everyone else should have received regular plates and metal utensils.
Missing Care Plan for Resident With GERD
Penalty
Summary
A comprehensive care plan was not developed within 7 days after completion of the comprehensive assessment for one sampled resident. Resident #192, who was admitted with diagnoses including Vascular Dementia, Psychotic Disorder, and Gastroesophageal Reflux Disease with Esophagitis, had an Annual MDS dated 03/20/2025 listing active diagnoses of Gastroesophageal Reflux Disease, Non-Alzheimer's Dementia, Depression, and Psychotic Disorder. Physician orders dated 08/12/2025 showed the resident was prescribed Pantoprazole 40 mg once daily for Gastroesophageal Reflux Disease, but there was no documented evidence that a care plan was created to address the resident's Gastroesophageal Reflux Disease. During interview on 08/25/2025, the RN Supervisor stated they usually enter care plans into the electronic medical record and that a Gastrointestinal Status care plan had not been initiated for Resident #192. The RN Supervisor also stated they were new to the facility and had not reviewed the resident's medical diagnoses when reviewing care plans, but had followed what was already in place. On 08/26/2025, the DON stated that because the resident was taking Pantoprazole, the resident had symptomatic Gastroesophageal Reflux Disease and a Gastrointestinal Status care plan would have been appropriate, and further stated it was possible the care plan had been discontinued for some reason, but it should have been included within the resident's comprehensive plan of care.
Care Plans Not Reviewed and Revised After Assessments
Penalty
Summary
The facility did not ensure that residents’ comprehensive care plans were reviewed and revised by the interdisciplinary team after assessments, including episodic, comprehensive, and quarterly reviews. For Resident #8, who had diagnoses including Alzheimer’s disease and hypertension and was on hospice care, the hospice care plan was initiated on 10/01/2024 and was last updated on 04/09/2025. The quarterly MDS documented severe cognitive impairment, rare or no decision-making ability, and hospice status, but there was no documented evidence that the hospice care plan was reviewed and revised after the quarterly assessment on 06/27/2025. For Resident #192, who had diagnoses including anxiety disorder, mood disorder, psychotic disorder, and vascular dementia, the care plan was not kept current across multiple psychosocial-related areas. The cognitive skills for daily decision-making care plan was last updated on 01/03/2025, the social isolation/loneliness care plan was last reviewed on 10/22/2024, and the psychosocial well-being, mood state, discharge planning, and advance directives care plans were last reviewed on 07/22/2024 or earlier. The resident’s MDS dated 03/20/2025 listed active diagnoses including non-Alzheimer’s dementia, depression, psychotic disorder, and mood disorder. Interviews with the SW and DON showed that care plans were expected to be updated quarterly and after care plan meetings, but the SW stated some updates did not get done while working alone and that the missed revisions were not noticed by supervisory staff.
Inaccurate and Incomplete Medical Record Documentation
Penalty
Summary
Medical records were not maintained in accordance with accepted professional standards and practices and were not complete and accurately documented for each resident. During the recertification survey, this was identified for Resident #57 and Resident #174, out of 85 sampled residents, based on record review, observation, and interviews with facility staff. For Resident #57, the record showed diagnoses including dementia, depression, adjustment disorder, and psychotic disorder, with multiple assessments and physician notes documenting those conditions. However, a schizophrenia care plan with a creation and onset date of 08/18/2025 was present in the record even though the psychiatrist had removed the schizophrenia diagnosis on 08/07/2023. The Director of Nursing stated the schizophrenia care plan was added in error after an audit, and the MDS Coordinator stated the resident never had a schizophrenia care plan in the medical record until 08/18/2025. For Resident #174, the record included peripheral vascular disease and multiple venous or arterial ulcers, and the resident had a wound care plan for a left lower leg skin graft failure/venous stasis ulcer. A waiver/choice of treatment form documented refusal of weekly wound rounds and daily wound care. Despite this, the MAR/TAR documented daily wound care as completed over the review period. The resident stated they performed their own dressing changes, and staff interviews confirmed nursing staff were entering checkmarks to indicate treatments were completed even though the resident refused staff-performed care and staff often did not observe the resident perform the treatment.
Unsafe and Unkempt Resident Areas
Penalty
Summary
The facility did not maintain a clean, comfortable, and homelike environment on Unit 1, Unit 2, and Unit 4 during the recertification survey. On Unit 1, the doors to the foyer and utility room had multiple large areas of chipped and scraped paint, the wall by the pull station had uneven dried plaster, and the first-floor conference room windowsills had peeling tape and a ripped window shade. The Environmental Director stated staff do environmental rounds and sometimes assign staff to paint and plaster, while the Director of Maintenance stated they were aware of the chipped paint, were considering a vinyl covering for the doors, said the pull station had been plastered a week earlier and would be sanded down, and were unaware of the ripped shade and hanging duct tape in the conference room. On Unit 2, multiple resident rooms had broken or missing slats from vertical blinds, one room had 11 of 20 slats missing, the dining room window was missing a covering, and the adjacent wall was unevenly plastered and unpainted. Another room on Unit 2 had peeling paint, a cracked window, and a ceiling above bed B with brown stains. On Unit 4, a resident room had missing slats on the vertical blinds, a dirty air conditioner grill attached with paper tape, and a television remote that did not work properly. The Unit 4 maintenance book was referenced in the report, but no additional details were provided in the excerpt.
Failure to Timely Report and Submit Investigation Results for Abuse and Injury Incidents
Penalty
Summary
The facility failed to report the results of all investigations of suspected abuse, neglect, or theft to the administrator or their designated representative and to other officials, including the State Survey Agency, within five working days as required by regulation. In two cases, the facility did not submit timely follow-up investigation reports to the New York State Department of Health and, in one instance, did not notify local law enforcement as required. One resident with a history of morbid obesity and spina bifida experienced an incident during transport where they slid forward in their wheelchair. The incident was not immediately reported by the Certified Nursing Assistant involved. The resident later reported the event to a Registered Nurse Supervisor, who assessed the resident and found no initial injuries. However, several days later, the resident developed symptoms and was found to have acute fractures in both knees. The facility did not report the incident to the State Department of Health in a timely manner and failed to submit the required follow-up investigation within five days. In another case, a resident with thyroid disorder, bipolar disorder, and depression alleged being attacked by staff, resulting in a scratch on the cheek. The allegation was reported to the State Department of Health the following day, but not within the required two-hour window, and local law enforcement was not notified. The facility's investigation could not substantiate the claim due to inconsistencies and lack of surveillance evidence. Interviews with staff revealed a lack of awareness regarding the timely submission of investigation reports and proper notification procedures.
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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) |
|---|---|---|---|---|
| Morris Park Rehabilitation And Nursing Center | 0.3 mi | ★★★★★ | 5 | 1 |
| Morningside Nursing And Rehabilitation Center | 0.4 mi | ★★★★★ | 1 | 0 |
| East Haven Nursing & Rehabilitation Center | 0.7 mi | ★★★★★ | 0 | 0 |
| Eastchester Rehabilitation And Health Care Center | 0.7 mi | ★★★★★ | 4 | 0 |
| Williamsbridge Center For Rehabilitation And Nrsg | 1.1 mi | ★★★★★ | 0 | 0 |
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