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 Pinnacle Multicare Nursing And Rehab Center during CMS and state inspections, most recent first.
The facility did not ensure that an area was free from accident hazards and failed to provide adequate supervision to prevent accidents. Surveyors observed environmental hazards and insufficient staff monitoring, resulting in a deficiency related to resident safety.
Respiratory care was not provided consistently with professional standards for several residents. Surveyors found undated and exposed oxygen tubing, cannulas, and nebulizer equipment at bedside, and an LPN and RN supervisor stated the tubing should have been dated and changed. One resident with COPD and respiratory failure had an undated nebulizer mask and tubing at bedside, another resident with CVA and orthopnea had an undated oxygen cannula hanging from the tank, and a third resident was receiving oxygen without an active order, which the physician said was not needed.
Failure to report an unwitnessed injury with major laceration: A resident with dementia and severely impaired cognition was found on the floor with a forehead laceration and could not explain what happened. The resident was transferred to the hospital, where the wound required 5 sutures, but the facility did not report the incident to DOH because it concluded the injury was due to a fall.
Undated and unlabeled IV dressing, tubing, and fluids were observed for a resident receiving IV therapy for seizures. The resident had severely impaired cognition and an IV order for D5 0.45% NS. Staff, including an LPN, RN supervisor, and DON, confirmed the dressing, tubing, and fluid bag should have been labeled with the required date, resident information, and flow rate.
Food Served at Unsafe Temperatures: Hot foods on one unit were found below the facility’s required 140-degree Fahrenheit standard during breakfast tray checks, including oatmeal, eggs, turkey, and coffee served at lukewarm to cold temperatures. A resident with DM, HTN, and ESRD reported that hot foods were often delivered lukewarm and sometimes cold, and the FSD acknowledged the temperatures were not appropriate for hot foods.
The facility failed to report alleged abuse incidents within the required timeframe for two residents. In one case, a resident's child reported a CNA shoving the resident with a table, but the facility delayed reporting to authorities. In another case, a resident's fracture was not reported promptly, despite hospital records suggesting potential abuse. Both incidents were only reported when surveyors were onsite, highlighting a deficiency in timely reporting.
A resident's family member reported witnessing a CNA using a table to shove the resident into a wheelchair. The facility's investigation concluded no abuse occurred but failed to interview other residents or staff present during the incident, leading to a deficiency in the investigation process.
Failure to Maintain Safe Environment and Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. This deficiency was identified based on direct observations and findings during the survey, which indicated lapses in maintaining a safe environment and in providing necessary supervision to prevent accidents.
Respiratory Equipment Not Dated or Stored Properly; Oxygen Given Without Order
Penalty
Summary
Safe and appropriate respiratory care was not provided for residents who needed oxygen therapy. During the recertification survey, surveyors observed that respiratory equipment at the bedside of multiple residents was undated and not stored properly, including nebulizer masks, oxygen cannulas, and tubing that were exposed rather than kept in a bag. The facility policy stated that oxygen therapy must be ordered by a physician except in an emergency, and that nasal catheters, masks, tubings, and cannulas are to be changed every week. Resident #27 had diagnoses including cerebral palsy, COPD, and respiratory failure, and the assessment documented severely impaired cognition, shortness of breath when lying flat, and need for oxygen. Although the resident had an order for oxygen by nasal cannula or mask as needed for shortness of breath, surveyors observed an undated and unlabeled nebulizer mask with tubing and an oxygen concentrator with an undated nasal cannula at the bedside, along with a bottle of sterile water dated 06/15/2025. The nebulizer mask and tubing were exposed and not stored in a bag, and the resident had no active order for nebulization because the prior ipratropium and albuterol order had been discontinued. Resident #451 had diagnoses including CVA with hemiplegia and orthopnea, and the assessment documented severely impaired cognition and shortness of breath when lying flat. The resident had an order for oxygen by nasal cannula or mask as needed for shortness of breath, but surveyors observed an undated oxygen nasal cannula hanging from an oxygen tank at the bedside and exposed rather than kept in a bag, with no documentation showing when the tubing was last changed. Resident #412 had no respiratory diagnoses on assessment and no oxygen therapy documented in the medical orders, yet was observed using oxygen via nasal cannula at 2 liters per minute daily during the survey period. Staff interviews confirmed that the resident was receiving oxygen without an active order, and the physician stated the resident was stable, had no need for oxygen, and had not been informed that oxygen was being used.
Failure to Report Unwitnessed Injury With Major Laceration
Penalty
Summary
The facility failed to ensure that an alleged violation involving abuse or neglect, including an injury of unknown source, was reported immediately, and no later than 2 hours after the allegation was made, to the New York State Department of Health. This deficiency involved Resident #318, who was admitted with diagnoses of Non-Alzheimer's Dementia, Depression, and Hypertension and had severely impaired cognition on the Minimum Data Set. On 07/10/2025 at approximately 5:00 AM, nursing staff found the resident on the floor in a supine position with a laceration to the left forehead, and the resident was unable to explain what happened. The resident's family and medical doctor were notified, and the resident was transferred to the hospital for evaluation and treatment. The incident report documented that the resident had an unwitnessed event with a forehead laceration, and the hospital discharge summary later documented that the injury was from an unwitnessed fall at the nursing home and required repair with 5 sutures. The facility's investigation concluded there was no reasonable suspicion of abuse, neglect, or mistreatment, and the Director of Nursing stated the incident was not reported to the Department of Health because the facility concluded the injury resulted from a fall. There was no documented evidence that the unwitnessed incident resulting in injury was reported to the New York State Department of Health.
Undated and Unlabeled IV Dressing, Tubing, and Fluids
Penalty
Summary
Parenteral fluids were not administered consistent with professional standards of practice for Resident #451. The resident was admitted with diagnoses including Seizure Disorder and Intracranial Lesions, and the MDS documented severely impaired cognition and intravenous medication administration. A physician’s order dated 07/27/2025 directed 1000 milliliters of Dextrose 5 percent and 0.45 percent Sodium Chloride IV solution every shift for 2 days for other seizures. During observations on 07/28/2025 and 07/29/2025, Resident #451 was seen with a left upper extremity peripheral IV catheter dressing that was undated, with undated tubing, and with a 1-liter IV fluid bag that was also undated and unlabeled. The facility policy required IV fluids to be labeled with the resident’s name, time, date, and rate of flow, and required IV catheters to be changed every 72 hours unless otherwise ordered. Staff interviews confirmed the dressing, tubing, and fluid bag were not labeled as required, and the Nursing Supervisor and DON stated these items should have been labeled and dated during care and rounds.
Food Served at Unsafe Temperatures
Penalty
Summary
The facility failed to ensure that food was served at a safe and appetizing temperature on Unit 5 during breakfast service. The facility policy titled Food Temperature Policy, revised 05/2025, required hot food items to be cooked to appropriate internal temperatures and held and served at a temperature of at least 140 degrees Fahrenheit. During the survey, test trays were requested for Unit 5, and meal carts arrived at 08:25 AM with tray distribution continuing until 08:57 AM. When temperatures were checked on the test trays with the Food Service Director, the regular diet tray had oatmeal at 112 degrees Fahrenheit, cheddar eggs at 94 degrees Fahrenheit, and coffee at 132 degrees Fahrenheit; the puree diet tray had cinnamon oatmeal at 120 degrees Fahrenheit, puree turkey at 90 degrees Fahrenheit, and pureed eggs at 100 degrees Fahrenheit. Resident #20, who had diagnoses including DM, HTN, and ESRD, was admitted as cognitively intact and independent for eating. During an interview, the resident stated hot foods were delivered lukewarm most of the time and sometimes cold. The Food Service Director later stated the temperatures were not appropriate for hot foods during the checks and that hot foods should be above 140 degrees Fahrenheit. The DON stated they had not heard of any food-related issues until recently, and the Administrator stated they were recently hired and were not aware of any food quality issues prior to the survey.
Failure to Timely Report Alleged Abuse Incidents
Penalty
Summary
The facility failed to report alleged abuse incidents within the required timeframe, as evidenced by two separate cases involving residents. In the first case, a resident's adult child reported witnessing a Certified Nursing Assistant (CNA) using a dining room table to shove the resident into their wheelchair. Although the facility conducted an investigation and concluded that no abuse occurred, they did not report the allegation to the New York State Department of Health or local law enforcement within the mandated two-hour window. The report was only made on January 3, 2025, when surveyors were onsite. In the second case, a resident was observed with swelling and discoloration on their finger, which was later diagnosed as a fracture. The facility became aware of the injury on December 10, 2024, but did not report it to the New York State Department of Health until January 3, 2025. The facility's investigation suggested the injury occurred due to a fall, but the hospital discharge summary indicated potential abuse, which was not reported to the authorities in a timely manner. Both incidents highlight the facility's failure to adhere to their own policy and state regulations requiring immediate reporting of suspected abuse or injuries of unknown origin. The Director of Nursing and the Administrator both acknowledged the delay in reporting, citing a lack of evidence of abuse as the reason for not notifying the authorities sooner. This oversight resulted in a deficiency citation during the survey.
Incomplete Investigation of Alleged Abuse Incident
Penalty
Summary
The facility failed to thoroughly investigate an alleged violation of abuse involving a resident with dementia, persistent mood disorder, and depression. The incident occurred when the resident's adult child reported witnessing a Certified Nursing Assistant (CNA) using a dining room table to shove the resident into their wheelchair. The facility's investigation concluded that no abuse occurred, but it was found that the investigation was incomplete as it did not include interviews with other residents present in the dining room or other staff members who might have witnessed the event. The facility's policy on abuse prevention requires thorough investigation and documentation of any allegations of abuse, including interviews with potential witnesses. However, in this case, the Director of Nursing and the Administrator acknowledged that the investigation was insufficient as it did not include interviews with other residents or staff who were present at the time of the incident. The failure to conduct a comprehensive investigation led to the deficiency noted in the survey report.
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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) |
|---|---|---|---|---|
| Regeis Care Center | 0.4 mi | ★★★★★ | 5 | 1 |
| Workmens Circle Multicare Center | 0.5 mi | ★★★★★ | 0 | 0 |
| Split Rock Rehabilition And Health Care Center | 0.6 mi | ★★★★★ | 0 | 0 |
| Kings Harbor Multicare Cente | 1.2 mi | ★★★★★ | 4 | 0 |
| Eastchester Rehabilitation And Health Care Center | 1.2 mi | ★★★★★ | 4 | 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.