Above 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 Williamsbridge Center For Rehabilitation And Nrsg during CMS and state inspections, most recent first.
The facility failed to maintain infection control practices during medication administration and resident hygiene. An LPN placed medical equipment on a resident's blanket instead of a sanitized surface. Additionally, staff did not assist residents with hand hygiene before meals, and a resident's urinary drainage bag was observed touching the floor, breaching infection control guidelines.
The facility failed to adhere to food storage and labeling standards, with undated items found in the walk-in and unit refrigerators. The Dietary Director and nursing staff acknowledged the need for proper labeling and disposal within 48-72 hours, as per facility policy.
The facility failed to review and revise comprehensive care plans for two residents as required. One resident's smoking-related care plan was not updated quarterly, and another resident's care plan was not revised after a fall. Staff interviews revealed a lack of clarity and responsibility in updating care plans.
The facility did not include the actual hours worked by nursing staff in the daily nurse staffing information, as required by policy. Observations showed that postings only included the facility name, current date, number of nursing staff, and resident census. Interviews with the Staffing Coordinator and DON revealed a lack of awareness of the requirement to list actual hours worked.
The facility failed to ensure that the Criminal History Record Check Form for a CNA was completed and signed by the Authorized Person before submission. The form was incomplete as Section #3 was not signed or dated, which was overlooked because the employee was hired through a staffing agency. The Human Resources Director admitted the oversight, and the Administrator confirmed the responsibility for ensuring the form's accuracy.
Infection Control Deficiencies in Medication Administration and Resident Hygiene
Penalty
Summary
The facility failed to maintain proper infection control practices during medication administration, as observed with one of the nurses. During the administration of medication to a resident, the nurse placed a glucometer and insulin pen on the resident's blanket instead of using a sanitized surface. The nurse admitted to usually using a table with a barrier but did not do so because the resident was using the table to eat. The Director of Nursing confirmed that the nurse should not have placed the medical equipment on the bed. Additionally, the facility did not ensure that residents were assisted with hand hygiene before meals. During meal observations on two units, several Certified Nursing Assistants failed to provide sanitizing wipes or assist residents with washing their hands before eating. Interviews with the staff revealed that they either forgot to provide the wipes or assumed someone else was responsible for the task. The Director of Nursing Services acknowledged that the staff should have provided sanitizing wipes or assisted with hand hygiene. Furthermore, a resident's urinary drainage bag was observed touching the floor, which is against the facility's urinary catheter guidelines. The resident, who was cognitively impaired and dependent on all activities of daily living, had a urinary catheter. Staff interviews confirmed that the catheter bag touching the floor is an infection control issue, as it could lead to backflow and introduce bacteria. The Director of Nursing stated that the incident was unintentional and resulted from the bed being in the lowest position, acknowledging it as a breach in infection control.
Plan Of Correction
Plan of Correction: Approved January 29, 2025 Element 1 - Facility policy titled Infection Prevention and Control Program was reviewed by DNS; no revisions needed. Licensed Practical Nurse # 1 was in-serviced by DNS on facility Infection Prevention and Control program. Licensed Practical Nurse # 1 was in-serviced by DNS on glucometer check process. Resident # 3 was assessed by DNS; no ill effects from deficient practice; resident stable. The facility policy titled Hand Hygiene was reviewed by DNS; no revisions needed. Certified Nurses Aides # 2, #3, #4, and #5 were in-serviced by DNS on Hand hygiene policy, specifically residents' hand hygiene prior to meals. Resident # 41, # 37, #72, #17, #54, and # 24 were assessed by DNS; no ill effects from deficient practice. The facility policy titled Urinary Catheter Guidelines was reviewed by DNS; no revisions needed. Resident # 4 was assessed by DNS; no ill effects from deficient practice. Licensed Practical Nurse # 3 was in-serviced on Urinary Catheter Guidelines policy. Element 2 - All residents had potential to be affected by the deficient practice. Element 3 - In-service for all Registered Nurses and Licensed Practical Nurses on facility Infection Prevention and Control program. In-service for all Registered Nurses and Licensed Practical Nurses on Urinary Catheter Guidelines policy. In-service for all Certified Nurse’s Aides on Hand hygiene policy, specifically residents' hand hygiene prior to meals. Audit tool was created and in place to monitor resident hand hygiene before meals weekly for 4 weeks, then monthly for 3 months, then quarterly. Audit tool was created and in place to monitor Licensed Practical Nurse process during resident fingerstick weekly for 4 weeks, then monthly for 3 months, then quarterly. Audit tool was created and in place to monitor resident catheter tubing and bag placement weekly for 4 weeks, then monthly for 3 months, then quarterly. Any deficient findings will be addressed immediately. Element 4 - The DNS/Designee will report all findings to the QAPI committee monthly for 3 months. Responsible Party: DNS/Designee.
Deficiency in Food Storage and Labeling
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 a kitchen observation, it was found that the walk-in refrigerator contained undated items, including five trays of unpackaged eggs, four undated bologna and cheese sandwiches, and an open, undated 5-pound container of peanut butter with an unreadable expiration date. The Dietary Director acknowledged that all refrigerated items should have been labeled with dates to ensure they are discarded within 48-72 hours, as per the facility's policy. Additionally, a unit refrigerator was observed with spilled liquid and undated food items, including two cups of facility-prepared peaches and an open, undated cranberry juice. A Registered Nurse confirmed that all food should be dated with the resident's name and date before being placed in the refrigerator, and that the refrigerator should be free of standing liquids. The Associate Administrator and Director of Nursing Services also confirmed that food should be dated and discarded within 48 hours, and that nursing staff are responsible for ensuring proper labeling and disposal of food items.
Plan Of Correction
Plan of Correction: Approved January 30, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Element 1 All food items stored in the refrigerators without proper labeling, opened food items without dates, and the expired food items were discarded on [DATE]. And the refrigerators were cleaned on [DATE]. Element 2 All residents had potential to be affected by the deficient practice. Element 3 The policy and procedures titled Food storage, Food from outside, and Unit Food Storage was reviewed, with no revisions needed. The Ass Administrator or designee will inservice dietary and RN's, LPN's & CNA's on managing and maintaining proper food storage areas. Focus on ensuring food is labeled, dated, and discarded upon expiration. And that the refrigerators are cleaned regularly. The Asst administrator or designee will Round 2x’s per week x4 weeks, then monthly x3mths. Any issues will be immediately addressed. An Audit tool developed on this issue. Element 4 The Ass. Administrator or designee will report findings to QA committee Monthly X 3 Months. Audit will include monitoring of shelving units to ensure they are free from dirt and that all food is labeled and discarded according to facility policy. Responsible party: Administrator/designee.
Failure to Update Comprehensive Care Plans
Penalty
Summary
The facility failed to ensure that residents' comprehensive care plans were reviewed and revised by the interdisciplinary team after each assessment and as needed. This deficiency was identified during a recertification survey, affecting two residents. Resident #35, who has a history of smoking, had a care plan related to smoking that was not reviewed and revised quarterly after each assessment. Despite the facility's policy requiring quarterly updates, there was no documented evidence of review or revision for several quarters. Interviews with staff, including a Registered Nurse, the Recreation Director, and the Director of Nursing, revealed a lack of clarity and responsibility regarding the updating of care plans. Resident #18, who was admitted with a history of falls and required assistance for most activities of daily living, experienced a fall in the facility. Despite this incident, there was no documented evidence that the resident's care plan was reviewed and revised following the fall. Interviews with a Licensed Practical Nurse and the Director of Nursing confirmed that the fall should have been documented and the care plan updated. The Minimum Data Set Coordinator also indicated that Registered Nurse Managers are responsible for initiating and updating care plans, but there was a failure to ensure this process was followed.
Plan Of Correction
Plan of Correction: Approved January 30, 2025 Element 1 - Resident #35 care plan was reviewed by DNS; all appropriate care plans reviewed and revised as needed. - Resident #18 care plan was reviewed by DNS; all appropriate care plans reviewed and revised as needed. - An audit was completed on all residents with smoking care plans to ensure they were reviewed and revised as needed. - An audit was completed on all residents with recent falls within the last 30 days to ensure fall care plan was reviewed and revised as needed. Element 2 All residents had potential to be affected by the deficient practice. Element 3 - The facility's policy titled Care Plans Comprehensive was reviewed; no revisions at this time. - In-service to all Registered Nurses and Licensed Practical Nurses on resident care plan timing and revision process is ongoing. - Audit tools in place to ensure smoking and fall care plans are reviewed and revised as needed, minimum quarterly for all residents. Bi-weekly for 2 weeks, monthly for 3 months. Element 4 - Audit tools in place to ensure care plans are reviewed and revised as needed, minimum quarterly for all residents. - Any deficient findings will be addressed immediately. - All audit findings will be reported to QAPI committee monthly for 3 months. Responsible Party: DNS/Designee
Deficiency in Nurse Staffing Information Posting
Penalty
Summary
The facility failed to ensure that the daily nurse staffing information included all required details, specifically the actual number of hours worked by licensed and unlicensed nursing staff directly responsible for resident care. This deficiency was identified during the Recertification Survey conducted from January 2, 2025, to January 8, 2025. The facility's policy, last revised in October 2022, mandates that staffing postings should include the facility name, current date, resident census, facility-specific shift schedule, and the number and actual hours worked by Registered Nurses, Licensed Practical Nurses, and Certified Nurse's Aides. However, during multiple observations from January 2 to January 7, 2025, the posted nurse staffing information in the lobby only included the facility name, current date, number of nursing staff working, and resident census, omitting the actual hours worked. Interviews with the Staffing Coordinator and the Director of Nursing revealed a lack of awareness and adherence to the requirement to list actual hours worked by nursing staff.
Plan Of Correction
Plan of Correction: Approved January 29, 2025 Element 1: The staffing template was corrected to reflect work hours. Updated sheet posted. Element 2: All residents had potential to be affected by the deficient practice. Element 3: The policy & procedure for STAFFING – POSTING OF HOURS, PAYROLL BASED JOURNAL SUBMISSION was reviewed and no revisions were necessary. HR was inserviced on STAFFING – POSTING OF HOURS, PAYROLL BASED JOURNAL SUBMISSION policy. An audit tool was developed. Weekly rounds x4, Monthly x3 to ensure proper staffing posting. Element 4: Audit to be done by Administrator/designee to review the findings of the weekly and Monthly Rounds. Findings of audit to be brought to QA committee monthly x3. Responsible party Administrator/designee.
Incomplete Criminal History Record Check Form
Penalty
Summary
The facility failed to ensure that the Acknowledgement and Consent form for Fingerprinting and Disclosure of Criminal History Record Information (Form 102) was accurately completed and signed by the Authorized Person before submitting a request for a Criminal History Record Check. This deficiency was identified in the record of an employee hired as a Certified Nursing Assistant. The form, which is a requirement for all direct caregivers and staff with access to residents or their property, was incomplete as Section #3 was neither signed nor dated by the Authorized Person. The Human Resources Director, who was responsible for completing and signing the form, admitted during an interview that the oversight occurred because the employee was hired through a staffing agency. The Director acknowledged that the form was signed by the employee in May 2023, but the request for the background check was not submitted until September 2024. The Administrator confirmed that it is the responsibility of the Authorized Person to ensure the form is correctly filled out and signed, indicating that the oversight was an error in the facility's process.
Plan Of Correction
Plan of Correction: Approved January 30, 2025 Element 1: The employee is no longer active. Employee has been terminated on CHRC. Facility is now in compliance. Element 2: All residents had potential to be affected by the deficient practice. Element 3: The policy for CHRC / FINGERPRINTING – NY was reviewed and no revisions were necessary. The CHRC authorized Users were inserviced on CHRC / FINGERPRINTING – NY policy. An audit tool was developed. Weekly rounds x4, Monthly x3 to ensure proper CHRC process is performed. Element 4: Audit to be done by Administrator/designee to review the findings of the weekly and Monthly Rounds. Findings of audit to be brought to QA committee monthly x3. Responsible party Administrator/designee.
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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 | 0.9 mi | ★★★★★ | 5 | 1 |
| Morningside Nursing And Rehabilitation Center | 0.9 mi | ★★★★★ | 1 | 0 |
| East Haven Nursing & Rehabilitation Center | 1 mi | ★★★★★ | 0 | 0 |
| Rebekah Rehab And Extended Care Center | 1.1 mi | ★★★★★ | 2 | 0 |
| Pelham Parkway Nursing Care & Rehab Facility L L C | 1.1 mi | ★★★★★ | 9 | 0 |
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