Above average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Rebekah Rehabilitation And Extended Care Center during CMS and state inspections, most recent first.
The facility failed to consistently provide sufficient nursing staff as defined in its Facility Assessment, particularly on higher-acuity units and on weekends, resulting in repeated LPN and CNA shortages across multiple floors and shifts. Payroll Based Journal data and staffing schedules showed that actual staffing frequently fell below par levels, especially on the 2nd and 6th floors, which care for residents with high ADL dependence, enteral feedings, fractures, joint replacements, IV therapy, and LTC skilled needs. A resident reported missing rehab therapy sessions and experiencing delays in dressing and bathing, while another resident described times when only one nurse covered an entire floor and morning medications were given an hour late. Staff, including an LPN, CNAs, the staffing coordinator, the floor RN supervisor, the DON, and the administrator, all acknowledged ongoing nurse and aide shortages, frequent call-outs, floating of staff from the 6th floor to other units, and an inability to consistently meet the established staffing par levels.
A resident with dementia, Alzheimer’s disease, and a femur fracture was observed in bed with bilateral upper side rails raised and bed bolsters placed under the sheet on both sides of the lower bed. The record showed an order for side rails as enablers, but there was no restraint assessment, MD order, or representative consent for the bed bolsters. Staff stated the bolsters were used to prevent the resident from rolling out of bed, and the DON confirmed the rails plus bolsters would be a physical restraint.
Failure to Report Injury of Unknown Origin: The facility did not ensure an alleged injury of unknown source was reported to DOH within the required timeframe after a cognitively impaired resident was found on the floor with a large hematoma, temple laceration, and elbow abrasion. The resident had dementia, a hx of falls, and acute ischemic heart disease, and could not explain how the injury occurred; the DON determined the event was not reportable, while the Administrator stated unexplained injuries of unknown origin must be reported.
A resident with CAD, HF, and renal insufficiency was readmitted after hospitalization, and the facility did not reactivate the resident’s activities/recreation care plan at that time. The resident’s MDS showed moderate cognitive impairment and noted that customary routine and activity preferences were very important; the recreation assessment listed preferences such as arts and crafts, beauty hours, sewing and knitting, and watching TV. The care plan was not initiated until later, despite staff stating that activity care plans are started on admission, readmission, and with changes in health status.
Failure to post survey results notice: Survey results were kept in a binder in the lobby, but no notices were posted on any resident floor to tell residents or visitors where to find them. During a Resident Council meeting, all attending residents said they did not know where the survey results were located and had not seen any notice. The DON/Administrator stated they believed the notices were posted on all resident floors but had not paid attention to the posting during rounds.
Late MDS Submission: The facility failed to ensure MDS assessments were electronically transmitted to CMS within the required timeframe for multiple residents. Record review showed several quarterly and annual MDS assessments were submitted more than 14 days after completion. The MDS Director stated they were the only staff able to submit assessments and had not trained the MDS assessor before going on vacation, and the Administrator was unaware the submissions were late.
The facility did not submit required five-day investigation findings to state authorities after incidents involving alleged rough handling of a resident with impaired cognition and a separate altercation between two residents, despite completing internal investigations and immediate reporting of the events. Previous DONs were unable to recall the incidents or clarify reporting requirements, leading to noncompliance with state regulations.
Persistent Understaffing Below Facility Assessment Par Levels
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient nursing staff on a consistent basis to meet residents’ needs as determined by the facility assessment, staffing plan, and residents’ care needs. The facility’s own Facility Assessment, last updated in January 2025, established par levels for LPNs and CNAs on each of five units (Floors 2–6) with a total capacity of 213 beds, including higher-acuity units on the 2nd and 6th floors that required more staff. Despite these defined staffing requirements, review of Payroll Based Journal (PBJ) data for Quarter 4 of 2025 and actual staffing schedules from July 1, 2025 through September 30, 2025 showed that weekend staffing was consistently low and that staffing assignments were frequently below the par levels identified in the Facility Assessment. The PBJ data and weekend staffing schedules documented repeated shortages of LPNs and CNAs across multiple floors and shifts, particularly on weekends. On numerous Saturdays and Sundays during July, August, and September 2025, there were documented shortages of one LPN on the 3rd, 4th, and 5th floors during the day shift, and at times on the 2nd and 6th floors as well. There were also documented shortages of CNAs on several dates, including on the 2nd, 4th, and 6th floors during day or night shifts. The 6th floor, which was designated for short-term rehab residents with fractures, joint replacements, IV therapy needs, and LTC residents requiring skilled nursing, had a documented requirement of two LPNs on all shifts and five CNAs on the day shift, but this par level was often not met. These documented shortages triggered low weekend staffing in the PBJ report and showed that actual staffing was consistently less than the projected needs in the Facility Assessment. Interviews with residents and staff further described the impact of these staffing shortages on daily care and services. One resident reported missing therapy sessions because staff were delayed in providing dressing and bathing assistance, stating that aides sometimes did not help them until after breakfast, causing them to be late for rehabilitation therapy and to miss appointments. The same resident stated that staffing was short at night, in the morning, and generally all the time, with people waiting for care and aides being rushed. Another resident reported that there were times when there was only one nurse for an entire floor and that morning medications were sometimes given an hour later than scheduled. Staff interviews corroborated the pattern of inadequate staffing and its effect on resident care. An LPN stated that the facility had been short of nurses since 2024 and that the 6th floor rehab unit was inadequately staffed, noting that two-person transfers could not be performed timely with only three aides on the day shift when five were required. A CNA reported that the 6th floor was short staffed and that aides were sometimes floated to other units, leaving the 6th floor short; they stated that residents requiring two-person assistance and Hoyer lift transfers sometimes remained in bed and that day showers were pushed to the evening shift. Another CNA stated that even on weekdays the 6th floor often had only four aides for 43 residents and that residents needing Hoyer lift transfers were showered on different days because one aide might be floated to another floor. The staffing coordinator acknowledged awareness of short staffing, especially on day shift and on the higher-acuity 2nd and 6th floors, and stated that call-outs and only partial success in filling shifts contributed to not reaching par levels. The 6th floor RN supervisor and the Director of Nursing both acknowledged that staff from the 6th floor were often floated to other units, and the Administrator confirmed awareness of low weekend staffing and ongoing staffing complaints, stating that the facility could not recruit enough staff to meet the par levels.
Physical Restraint Used Without Order or Consent
Penalty
Summary
The facility failed to ensure a resident remained free from physical restraints when bed bolsters were used without a restraint assessment, physician order, or consent from the resident’s representative. The resident had diagnoses of unspecified dementia, Alzheimer’s disease, and a fracture of the unspecified part of the neck of the left femur, and the admission MDS documented severe cognitive impairment. The MDS also documented that no physical restraint or alarm was used and that only the resident’s representative participated in the assessment. Between 01/15/2026 and 01/21/2026, multiple observations showed the resident lying in bed with bilateral upper side rails raised and bed bolsters placed beneath the sheet on both sides of the lower half of the bed. The resident’s representative stated this was the first time they observed the bed bolsters and said the facility did not notify them about their use. The medical record contained a physician’s order for bilateral one-half side rails/enablers to promote increased bed mobility, and a side rail assessment documented the rails as enablers and to avoid the resident from rolling out of bed. The record also showed a fall-related care plan intervention adding bilateral bed bolsters and floor mats because the resident tried to come out of bed and was at risk of falling, but there was no physician’s order, assessment, or notification to the representative for the bed bolsters. Staff interviews confirmed the bolsters were placed under nurse instruction to prevent the resident from rolling out of bed, and multiple staff stated the resident could not get out of bed when the upper side rails were raised and the bed bolsters were in use. The DON stated the use of upper side rails and bed bolsters together would be a physical restraint for the resident.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to ensure that an alleged injury of unknown source involving Resident #180 was reported immediately, and no later than 2 hours after the allegation was made, to the New York State Department of Health. On 01/09/2026 at approximately 9:07 PM, Resident #180 was observed sitting on the floor in the hallway with a large hematoma, an open laceration on the temple, and an abrasion to the left elbow. There was no witness to how the resident sustained the injury, and the resident could not explain the source of the injury. Resident #180 had diagnoses of acute ischemic heart disease, a history of falling, and dementia, and the quarterly MDS documented severely impaired cognition with partial to moderate assistance needed for activities of daily living. The Accident/Incident Report documented the resident was found on the floor outside the room and was transferred to the emergency room. The DON’s Summary of Investigation concluded the incident did not meet the elements needed to be reportable to the Department of Health, while the Administrator later stated that injuries of unknown origin that cannot be explained must be reported to the Department of Health.
Failure to Initiate Activities Care Plan on Readmission
Penalty
Summary
The facility failed to develop a person-centered comprehensive care plan to meet Resident #8’s preferences and goals and address the resident’s medical, physical, mental, and psychosocial needs. Resident #8 was re-admitted to the facility after hospitalization with diagnoses including coronary artery disease, heart failure, and renal insufficiency. The Significant Change MDS documented that the resident was moderately impaired in cognition and that preferences for customary routine and activities were very important. The Activities-Recreation assessment identified preferences for arts and crafts, beauty hours, sewing and knitting, and watching television. Resident #8’s comprehensive care plan did not include an activities/recreation care plan when the resident was re-admitted to the facility. The record showed that the therapeutic recreation care plan was not initiated until 01/23/2026. The Recreation Director stated that activity care plans are initiated on admission, readmission, and with changes in health status, and that Resident #8’s activities care plan had been discontinued when the resident was transferred to the hospital and was not reactivated upon readmission. The DON stated that the Recreation Department is responsible for initiating each resident’s activities care plan.
Failure to Post Survey Results Notice
Penalty
Summary
The facility failed to ensure that notice of the availability of survey results was posted in prominent and accessible areas for residents and the public. Survey results were found in a binder inside a plastic container on the wall across from the security station in the lobby, but there were no posted notices on any of the five resident floors directing residents or visitors to where the survey results could be viewed. The facility policy stated that residents have the right to examine the results of the most recent federal or state survey, including any statement of deficiencies, plan of correction, and enforcement actions, and that the results must be made available in a readily accessible place. During multiple observations, no notices were seen on the resident units informing people where to locate the survey results. At the Resident Council meeting, seven residents attended and all seven stated they did not know where to find the survey results and had not seen any notice about their location. The minutes from prior Resident Council meetings also did not document that residents were informed where to locate the survey results. The Administrator stated they made rounds on the floors daily, but did not pay attention to the posting and believed the notices were posted on all resident floors; the Administrator also stated the facility should post throughout the building to inform residents and the public where to find the survey results on the units.
Late MDS Submission
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments were electronically transmitted to the Centers for Medicare/Medicaid Services Data System within 14 days of completion for 9 of 9 residents reviewed: Residents #5, #15, #69, #124, #8, #180, #166, #155, and #144. Record review showed that the Quarterly MDS for Resident #5 had a target date of 11/26/2025 and was submitted on 01/19/2026, and the Quarterly MDS for Resident #15 had a target date of 12/08/2025 and was also submitted on 01/19/2026. The Annual MDS for Resident #69 had a target date of 12/01/2025 and was submitted on 01/19/2026. The submission reports documented that these records were submitted late because the submission date was more than 14 days after the assessment completion dates. The facility policy titled Minimum Data Set, effective 12/2024, did not include a procedure for when completed MDS assessments were to be submitted to CMS. During interview, the MDS Director stated they were responsible for completion and submission of MDS assessments and were the only staff able to submit them to the Internet Quality Improvement and Evaluation System. The MDS Director stated they were on vacation from 12/09/2025 to 01/06/2026 and failed to train the MDS assessor to submit the MDS before leaving. The Administrator stated they were not aware the MDS assessments were submitted late.
Failure to Timely Submit Investigation Findings for Alleged Abuse and Resident Altercations
Penalty
Summary
The facility failed to report the results of all investigations of alleged abuse, neglect, or mistreatment to the administrator or their designated representative and to the appropriate state authorities within the required five working days. In one instance, a family member reported to an LPN that two CNAs were rough with a resident who had severely impaired cognition and multiple diagnoses, including depression and diabetes. The resident reported being held by the neck and having their feet pulled. The facility completed an investigation and determined the allegation was unsubstantiated, but the findings were not submitted to the New York State Department of Health within the mandated timeframe. In another case, two residents with intact cognition were involved in a verbal altercation in the dining room, during which one resident picked up a fork and threatened the other. Staff intervened immediately, and the incident was reported to the state health department. However, the facility did not submit the five-day investigation findings as required by regulation. Interviews with previous DONs revealed a lack of recall regarding the incidents and uncertainty about the reporting requirements for follow-up submissions. The facility's own policy required reporting to the Department of Health within two hours of any suspected abuse, neglect, or mistreatment, and completion of the investigation with findings reported within five days. Despite this, the required five-day reports were either delayed or not submitted for the incidents involving the three residents, resulting in noncompliance with state regulations.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 1,315 citations issued within 25 miles in the last 12 months — including the 22 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
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) |
|---|---|---|---|---|
| Bronx Center For Rehabilitation & Health Care | 0.7 mi | ★★★★★ | 17 | 0 |
| Grand Manor Nursing & Rehabilitation Center | 0.9 mi | — | 34 | 2 |
| Williamsbridge Center For Rehabilitation And Nrsg | 1.1 mi | ★★★★★ | 0 | 0 |
| Throgs Neck Rehabilitation & Nursing Center | 1.3 mi | ★★★★★ | 3 | 0 |
| Archcare At Providence Rest | 1.6 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Rebekah Rehabilitation And Extended Care Center.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.