Below average — CMS composite of the measures below.
The next survey window likely opens around March 2027
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 Prestige Nursing Care & Rehab Center during CMS and state inspections, most recent first.
Surveyors found that the facility did not maintain a safe, homelike environment in two shower rooms when overhead light covers in one unit were cracked or broken and a sink faucet in another unit was loose and partially detached during use. Facility policies required maintaining safe, functional electrical fixtures and plumbing, and a prior maintenance log entry had documented needed repairs to the bathroom ceiling area, but the work on the lights had been delayed. A maintenance worker reported not being aware of the loose faucet because it was not in the unit’s repair log, and leadership stated that earlier environmental issues identified by an external assessment had been addressed, yet they had not identified these specific problems during their own environmental rounds.
Surveyors found multiple food storage and labeling violations, including unlabeled almond milk in a walk-in refrigerator, cooked chicken and vegetables held beyond the facility’s 72-hour limit, and a defrosted container of whole eggs without a defrost date. In a pantry refrigerator, several 4-oz fruit and pudding cups were undated, illegibly dated, or past the facility’s allowed holding time, despite policies requiring all perishable and pantry-refrigerated items to be labeled, dated, and discarded after 72 hours. The Food Service Director and dietary staff confirmed the 72-hour standard and labeling requirements and acknowledged that daily rounds intended to remove outdated or improperly labeled items did not prevent these issues.
The facility failed to develop and implement person-centered comprehensive care plans for two residents’ identified needs. One resident with multiple medical conditions and malnutrition had an inaccurate dental care plan that described functioning with dentures, while the resident actually had many missing teeth, had never seen a dentist since admission despite repeated requests, and was observed struggling to chew food. Another resident with severe cognitive impairment and behavioral symptoms was consistently provided plastic utensils with no knife due to behavioral concerns, but this intervention was not documented in the ADL or behavior care plans or in CNA accountability records, contrary to facility policy and staff descriptions of required practice.
A resident with dementia, depression, psychotic disorder, and severely impaired cognition was receiving Olanzapine 5 mg daily. A pharmacy drug regimen review, reflecting a psychiatry consult, recommended a gradual dose reduction of the antipsychotic due to drowsiness. The attending physician documented agreement with the recommendation but did not change the medication order or document any action in the medical record. Although staff later reported the resident was aggressive and refused care, no follow-up note or rationale for not implementing the agreed-upon gradual dose reduction was entered, contrary to facility policy requiring timely prescriber response and documentation to drug regimen review recommendations.
A resident with chronic pain and multiple comorbidities was maintained on Morphine ER 15 mg ordered every 12 hours PRN, without a clear PRN indication or defined duration, contrary to appropriate opioid prescribing standards. Facility records showed intact cognition and no documented pain or PRN pain medication use on the MDS, yet the MAR reflected several administrations of Morphine ER. The care plan cited osteoarthritis-related pain and directed staff to administer medications as ordered, while interviews with an NP, MD, DON, and Medical Director revealed that the resident refused scheduled dosing, insisted on PRN use, and was non-compliant with pain clinic follow-up. The attending MD acknowledged ER Morphine should not have been ordered PRN, and the DON was unaware of the PRN ER regimen, demonstrating a lack of proper oversight and justification for this extended-release opioid order.
A resident with CAD, DM, and dementia was observed being transferred by Hoyer lift to a bariatric Geri chair that had been placed in the hallway outside the room. As two CNAs moved the resident through the doorway, one CNA had to steer and protect the resident's head from the doorway. Staff said this hallway transfer was routine because the chair would not fit in the room, and nursing leadership was aware of the practice.
A resident with anemia, renal insufficiency, renal failure, and malnutrition did not receive timely dental services after admission. The resident reported missing teeth, difficulty chewing, and repeated requests to see the dentist, while staff were unsure about denture status and when the resident was last seen. Charting showed multiple dental consult orders, but the documented dental follow-through was inconsistent, and the dentist acknowledged the resident’s evaluation was delayed and may have been confused with another resident.
A resident with severe cognitive impairment and multiple diagnoses fell and sustained fractures after a CNA provided bed mobility care alone, contrary to the care plan requiring two-person assistance. The CNA did not review care instructions or receive a proper report, leading to the incident being deemed neglectful.
The facility failed to report alleged abuse and a resident altercation to the New York State Department of Health within the required 2-hour timeframe. One resident with severe cognitive impairment was found with injuries of unknown origin, and an altercation between two residents with dementia was reported late. The Director of Nursing acknowledged the delays in reporting.
Failure to Maintain Safe and Homelike Shower Room Environment
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe, clean, and homelike environment in two shower rooms. During an environmental observation of the Six [NAME] unit shower room, two of three clear overhead light fixture coverings were found in disrepair: one was cracked and another was broken with two circular holes visible. The facility’s Homelike Environment policy requires maintaining a clean, comfortable, and safe environment with appropriate lighting, and its Routine Maintenance policy requires that essential electrical and structural elements be kept in safe operating condition. A maintenance repair log entry dated more than a month earlier documented a request for repair of bathroom ceiling tiles in this area, and a maintenance worker acknowledged that the ceiling tiles and lights in the Six [NAME] unit shower room were supposed to have been repaired about a week prior to the observation but had been delayed. In the Four East unit shower room, a sink faucet was observed to be loose and became partially detached from the sink base when used. A maintenance worker on that unit stated they had not been made aware of the loose faucet and were only following up on repairs already documented in the floor’s maintenance logbook. The Director of Housekeeping and the Administrator both referenced a prior unannounced physical environment assessment by the Comptroller’s Office, which had identified needed repairs and was verbally reported at exit; both stated that all needed repairs from that assessment had been completed, and the Administrator reported conducting environmental rounds. However, the Administrator stated they did not notice the need for repair of the Six [NAME] shower room light fixtures or the Four East shower room faucet during those rounds, while also characterizing the loose faucet base as normal wear and tear. These conditions resulted in the facility not honoring residents’ right to a safe, homelike environment as required by policy and regulation.
Improper Labeling and Storage of Refrigerated and Defrosted Food Items
Penalty
Summary
The deficiency involves failure to store and label food in accordance with the facility’s own food storage policies and professional standards. During an initial kitchen observation, surveyors found that walk-in refrigerator #1 contained two unlabeled and undated Styrofoam cups of almond milk, contrary to the policy requiring all perishable food to be dated and stored immediately upon receipt. In walk-in refrigerator #2, surveyors observed a metal pan of cooked ground chicken and a metal pan of mixed vegetables, both labeled with the date 04/02/2026, which exceeded the facility’s stated 72-hour limit for use or discard of cooked foods. A one-gallon container of whole eggs in citric acid was also found defrosted without a defrost date, despite the policy that frozen food placed in the refrigerator for defrosting must be clearly labeled with the date it was placed there. Surveyors also identified multiple issues in the kitchen pantry refrigerator, where several 4-ounce fruit cups and a 4-ounce chocolate pudding cup were either undated, illegibly dated, or labeled with dates beyond the facility’s 72-hour standard for prepared items. Interviews with the Food Service Director and dietary staff confirmed that prepared or cooked foods and prepared fruit cups should be labeled with preparation dates and used or discarded within three days, and that any food placed in the pantry refrigerator must be labeled, dated, and discarded after 72 hours or if undated. Staff acknowledged that the cooked chicken and vegetables should have been discarded if not used within three days, that defrosting items should be dated, and that daily rounds are intended to identify and discard outdated or improperly labeled items, but these processes did not prevent the observed deficiencies.
Failure to Develop and Implement Person-Centered Care Plans for Dental Needs and Plastic Utensil Use
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement person-centered comprehensive care plans addressing identified dental and safety needs for two residents. For one resident with anemia, renal insufficiency, renal failure, and malnutrition, the MDS documented intact cognition, independence with most ADLs, and no swallowing or oral/dental concerns, while the existing dental care plan stated the resident was partially edentulous with full upper and partial lower dentures, functioning well and to be treated symptomatically. However, the resident reported having many missing teeth, never having seen a dentist since admission despite repeated requests, and not receiving help from staff to obtain a dental appointment. During a dining observation, the resident was seen with only one upper front tooth and many missing lower teeth, having difficulty chewing chopped meat and stating eating would be easier with dentures and that they had been waiting a long time to see a dentist. There was no documented evidence that a person-centered comprehensive care plan was developed and implemented to address this resident’s actual dental care needs. Interviews with nursing staff revealed that the unit RN was unsure whether the resident had dentures or when they were last seen by a dentist, and that the night nursing supervisor responsible for reviewing the comprehensive care plan had copied and pasted an inaccurate dental note into the care plan. Facility leadership and nursing staff acknowledged that the existing dental care plan did not reflect the resident’s true dental status or needs and that care plan reviews by the night shift supervisor had not ensured accuracy or appropriateness. For another resident with seizure disorder, dementia, and traumatic brain injury, the MDS documented severely impaired cognition, behavioral symptoms including rejection of care and wandering, and a need for supervision or touching assistance with eating, all personal care, ADLs, and mobility. This resident was repeatedly observed eating meals in their room using plastic cutlery, with tray tickets specifying plastic utensils and no knife. Facility policy and staff interviews indicated that plastic utensils are used for residents with behavioral issues such as suicidal or homicidal ideation or threatening behaviors, and that such interventions are to be documented in the ADL or behavior care plans and carried over to CNA accountability records. Despite this, the resident’s ADL and behavior care plans and CNA accountability documentation did not include the intervention for plastic utensils, and nursing staff, including the nurse manager, acknowledged that the care plan had not been completed or updated to reflect this intervention.
Failure to Implement and Document Drug Regimen Review Recommendation for Antipsychotic GDR
Penalty
Summary
The deficiency involves the facility’s failure to ensure that recommendations from the monthly drug regimen review were acted upon and appropriately documented for one resident receiving antipsychotic medication. Facility policy required the consultant pharmacist to perform monthly medication regimen reviews, provide written recommendations, and for the prescriber or designee to respond within 7–14 days, documenting agreement or disagreement and a brief clinical rationale. For a resident with non-Alzheimer’s dementia, depression, psychotic disorder, severely impaired cognition, and receiving antipsychotic and antidepressant medications, the consultant pharmacist’s drug regimen review dated 02/09/2026 noted that the most recent psychiatry consult recommended a gradual dose reduction (GDR) of Olanzapine 5 mg daily, tapering to discontinuation. The attending physician documented on 02/11/2026 that they agreed with the recommendation and would implement it. Despite this documented agreement, a review of physician orders from 02/11/2026 to 04/15/2026 showed no change in the Olanzapine order to reflect the recommended GDR, and the resident’s medical progress notes contained no documentation that any action was taken to address the recommendation. The psychiatric NP reported that the resident was drowsy, leading to the GDR recommendation, but stated the recommendation was not carried out and was beyond their control. The attending physician confirmed agreement with the pharmacy consultant’s recommendation but stated the order was not changed after staff reported the resident was aggressive and refused care, and no follow-up note was added. The Medical Director and DON both stated that clinicians are required either to implement accepted recommendations or document the rationale if they do not, and the DON confirmed there was no documentation in the resident’s chart explaining why the recommendation was not followed.
Unnecessary PRN Use of Morphine ER Without Clear Indication or Duration
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s drug regimen was free from unnecessary drugs, specifically related to the use of Morphine ER 15 mg ordered on an as-needed (PRN) basis without an adequate indication or duration for its use. The facility’s pain policy required evaluation of pain regimens and assessment of medication effectiveness, but the resident’s records showed inconsistencies. The Quarterly MDS documented intact cognition, no pain, no behavioral symptoms, and no scheduled or PRN pain medication use, despite the presence of a PRN Morphine ER order and documented administration of the drug on several dates. Resident #131 had diagnoses including COPD, renal insufficiency, and obstructive uropathy, and a care plan for pain related to primary generalized osteoarthritis with interventions to administer medications as ordered. The physician’s order, originally written and later renewed, specified Morphine ER 15 mg by mouth every 12 hours PRN, and the MAR showed the resident received this medication on multiple mornings in April. However, the MDS indicated the resident did not receive scheduled or PRN pain medications, and there was no clear documentation of an appropriate PRN indication or defined duration for the extended-release opioid. Interviews with clinical staff revealed further issues with the appropriateness and oversight of the Morphine ER regimen. The NP reported that an outside pain management specialist had ordered a standing Morphine regimen, but the resident was non-compliant with the scheduled dosing, refused appointments, and insisted on taking the medication only when they felt it was needed. The attending MD acknowledged that Morphine ER should not have been ordered on a PRN basis and that an immediate-release formulation would have been more appropriate for PRN use. The DON stated they were not aware the resident was receiving Morphine ER PRN, while the Medical Director stated the regimen worked for the resident and that residents can determine what is best for them, indicating reliance on resident preference rather than adherence to appropriate prescribing standards for PRN extended-release opioids.
Resident transferred through doorway during Hoyer lift transfer
Penalty
Summary
The facility failed to ensure that a resident was treated with respect and dignity during a Hoyer lift transfer. Resident #4, who had diagnoses including Coronary Artery Disease, Diabetes Mellitus, and Non-Alzheimer's Dementia, was observed being transferred from bed to a bariatric Geri chair. The resident was hoisted with the assistance of two CNAs, but the bariatric Geri chair was positioned in the hallway in front of the room doorway rather than inside the room. As the resident was turned and moved through the doorway, the resident's head had to be steered away and protected from the doorway by one of the CNA's hands. The transfer continued through the doorway and into the bariatric Geri chair. The resident's quarterly MDS documented severe cognitive impairment, impairment on both sides of the upper and lower extremities, and dependence on staff for bed mobility and chair-to-bed transfer. The care plan directed out-of-bed transfers to a Geri chair with two-person assistance via Hoyer lift. Staff interviews confirmed that this was a routine practice because the bariatric Geri chair would not fit in the resident's room. The CNA stated the resident was usually transferred to the chair in the hallway, and nursing leadership stated they were aware of the practice and did not identify an issue. The OT stated the chair size was related to the resident's contractures, and the Rehab Director stated the assessment had been conducted after the resident was already seated in the chair and was not aware of an issue with the actual transfer into the chair.
Delayed Dental Services and Inconsistent Follow-Through
Penalty
Summary
The facility failed to ensure that a resident received dental services in a timely manner. Resident #60 was admitted with diagnoses including anemia, renal insufficiency, renal failure, and malnutrition, and the record showed intact cognition and independence with most activities of daily living. The care plan documented dental impairment, and the resident was described as partially edentulous with a full upper denture and partial lower denture, functioning well and without oral pain or discomfort in the dental note. Despite the resident’s dental needs and repeated consult orders, the record and interviews showed inconsistent and delayed follow-through. Documentation reflected dental consult orders on multiple occasions, while the last clearly documented dental visit in the chart was on 11/21/2025. During interview, the resident stated they had a lot of missing teeth, had never seen the dentist since admission, had been asking staff to help with dental appointments, and had been waiting a long time to see the dentist. During observation, the resident was eating with only one upper front tooth and many missing lower teeth and had difficulty chewing chopped meat. Staff interviews showed uncertainty about the resident’s dental status and when the resident was last seen by the dentist. A CNA stated the resident had never been seen wearing dentures, several nurses were unsure whether the resident had dentures or when dental care last occurred, and the ADON could not confirm the denture status. The dentist stated the initial evaluation could not be completed because the resident was tired, believed a later evaluation may have been mixed up with another resident, and acknowledged the resident was eventually seen much later. The Medical Director stated newly admitted residents should have been seen within 2-3 weeks and was surprised the resident had not received needed dental services since admission.
Inadequate Supervision Leads to Resident Fall and Injury
Penalty
Summary
The facility failed to provide adequate supervision to a resident, resulting in a fall and subsequent injuries. A resident with severe cognitive impairment and multiple diagnoses, including Non-Alzheimer's Dementia and Osteoporosis, was dependent on two or more helpers for bed mobility. However, a Certified Nursing Assistant (CNA) provided care alone, without reviewing the resident's care instructions or receiving a proper report from the charge nurse. This led to the resident falling off the bed and sustaining multiple fractures. The CNA, who was new to the unit, was informed by other CNAs that the resident required one person for washing and two for transfers. Despite this, the CNA proceeded to provide bed mobility care alone, without the bed rails up, and without consulting the Resident Nursing Instructions. The CNA had received training on reviewing care instructions and was aware of the need to call for assistance but failed to do so. The incident was reported to the charge nurse, and the resident was assessed and transferred to the hospital with significant injuries. The facility's policies on falls and accident investigations were not followed, and the CNA's actions were deemed neglectful. The facility concluded that the fall was avoidable, and the CNA was subsequently terminated for not adhering to the care plan.
Failure to Timely Report Alleged Abuse and Resident Altercation
Penalty
Summary
The facility did not ensure that all alleged violations involving abuse were immediately reported to the New York State Department of Health within the required 2-hour timeframe. This deficiency was evident in the cases of three residents. Resident #265, who had diagnoses of non-Alzheimer's dementia and aphasia, was found with an abrasion and bruise on the left side of their face and back of their head. These injuries of unknown origin were not reported to the New York State Department of Health within 2 hours of discovery. The Director of Nursing confirmed that they were informed of the injuries more than 2 hours after they were discovered and could not explain the delay in reporting to the state authorities. Additionally, a resident-to-resident altercation between Resident #181 and Resident #66 was not reported within the required timeframe. Resident #181, who had severe cognitive impairment, and Resident #66, who had Alzheimer's dementia and displayed behavioral symptoms, were involved in an altercation where Resident #66 alleged they were slapped by Resident #181, and Resident #181 alleged Resident #66 threw coffee at them. The incident was reported to the New York State Department of Health more than 2 hours after it occurred. The Director of Nursing acknowledged that the delay in reporting was not in compliance with regulatory requirements.
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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) |
|---|---|---|---|---|
| Manhattanville Health Care Center | 0 mi | ★★★★★ | 0 | 0 |
| New Riverdale Rehab And Nursing | 0.4 mi | ★★★★★ | 0 | 0 |
| Hudson Pointe At Riverdale Center For Nursing And | 0.4 mi | ★★★★★ | 1 | 0 |
| Schervier Nursing Care Center | 0.5 mi | ★★★★★ | 0 | 0 |
| Independence Care Center For Nursing And Rehabilit | 0.6 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.