Inspection Reports for
Bainbridge Nursing & Rehabilitation Center
3518 Bainbridge Avenue, Bronx, NY, 10467
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
8.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
71% worse than New York average
New York average: 5.1 deficiencies/yearDeficiencies per year
20
15
10
5
0
Inspection Report
Renewal
Deficiencies: 4
Date: Jul 23, 2025
Visit Reason
The inspection was a Recertification Survey conducted from 07/16/2025 to 07/23/2025 to assess compliance with regulatory requirements for nursing home recertification.
Findings
The facility was found deficient in multiple areas including failure to review and revise residents' comprehensive care plans quarterly, improper storage of medications accessible to residents and unlicensed staff, unsafe food storage temperatures in a dairy refrigerator, and failure to provide residents with a 30-day rescind period for binding arbitration agreements.
Deficiencies (4)
F 0657: The facility failed to ensure residents' comprehensive care plans were reviewed and revised quarterly by the interdisciplinary team, as evidenced by Resident #43's dental care plan not being updated after assessments.
F 0761: Medications and biologicals were not stored securely; a box of medications labeled with residents' names was found unsecured and accessible at the nurse's station on the 5th floor.
F 0812: Potentially hazardous foods were not stored at safe temperatures; the dairy refrigerator in Unit 1 was observed above 40°F with items not immediately disposed of despite unsafe temperatures.
F 0847: The Binding Arbitration Agreements did not grant residents or their representatives 30 calendar days to rescind the agreement, contrary to facility policy and regulatory requirements.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 3
Medications observed: 6
Medications observed: 29
Medications observed: 2
Medications observed: 6
Medications observed: 30
Medications observed: 20
Medications observed: 22
Medications observed: 28
Medications observed: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse #4 | Unit Manager | Interviewed regarding care plan review and medication storage deficiencies |
| Registered Nurse #5 | Unit Manager | Interviewed regarding medication storage deficiency |
| Licensed Practical Nurse #3 | Interviewed regarding medication storage deficiency | |
| Director of Nursing | Interviewed regarding care plan review and medication storage deficiencies | |
| Food Service Director | Interviewed regarding food storage deficiency | |
| Administrator | Interviewed regarding food storage and arbitration agreement deficiencies | |
| Assistant Director for Admissions | Interviewed regarding binding arbitration agreement deficiency | |
| Director of Operations | Interviewed regarding binding arbitration agreement deficiency |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 4
Date: Jul 23, 2025
Visit Reason
Inspection identified 4 standard health citations related to quality of care including care plan timing, arbitration agreements, food sanitation, and drug labeling.
Findings
Inspection identified 4 standard health citations related to quality of care including care plan timing, arbitration agreements, food sanitation, and drug labeling.
Deficiencies (4)
Care plan timing and revision
Entering into binding arbitration agreements
Food procurement,store/prepare/serve-sanitary
Label/store drugs and biologicals
Inspection Report
Annual Inspection
Deficiencies: 1
Date: Apr 11, 2023
Visit Reason
The inspection was conducted as a Recertification/Complaint survey to assess compliance with reporting requirements for injuries of unknown origin and abuse allegations.
Complaint Details
The visit was complaint-related, triggered by allegations of abuse involving injuries of unknown source. The complaint was substantiated as the facility failed to timely report the injury.
Findings
The facility failed to report an alleged injury of unknown origin, specifically a right hip fracture of Resident #58, to the New York State Department of Health within the required 2-hour timeframe. The Director of Nursing and Administrator acknowledged the reporting requirements but could not explain the delay in this case.
Deficiencies (1)
F 0609: The facility did not report Resident #58's right hip fracture to the New York State Department of Health within 2 hours as required by policy. This delay violated timely reporting requirements for suspected abuse or injury of unknown origin.
Report Facts
Residents reviewed for abuse: 3
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding reporting of injuries of unknown origin | |
| Administrator | Interviewed regarding awareness of reporting requirements |
Inspection Report
Annual Inspection
Deficiencies: 1
Date: Apr 11, 2023
Visit Reason
The inspection was a Recertification survey conducted from 2023-04-03 through 2023-04-11 to assess compliance with regulatory requirements for the nursing home.
Findings
The facility failed to ensure that Resident #154's Comprehensive Care Plan (CCP) was reviewed and revised by the interdisciplinary team to reflect the resident's self-catheter care. The CCP did not include interventions for self-catheter care despite the resident independently managing their Foley catheter leg bag.
Deficiencies (1)
F 0657: The facility did not develop, review, and revise the complete care plan within 7 days of the comprehensive assessment to reflect changes in Resident #154's needs. The CCP lacked documentation of the resident's self-catheter care despite evidence the resident independently empties and changes the catheter leg bag.
Report Facts
Residents sampled: 38
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Interviewed regarding Resident #154's catheter care |
| Registered Nurse Manager #2 | Registered Nurse Manager | Interviewed regarding Resident #154's catheter care |
| Director of Nursing | Director of Nursing | Interviewed regarding Resident #154's care plan |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 15
Date: Apr 11, 2023
Visit Reason
Inspection identified 2 standard health citations and 14 life safety code citations, all corrected. Issues included care plan timing, reporting violations, cooking facilities, corridor doors, electrical systems, fire alarm, HVAC, means of egress, multiple occupancies, exits, administration, and sprinkler systems.
Findings
Inspection identified 2 standard health citations and 14 life safety code citations, all corrected. Issues included care plan timing, reporting violations, cooking facilities, corridor doors, electrical systems, fire alarm, HVAC, means of egress, multiple occupancies, exits, administration, and sprinkler systems.
Deficiencies (15)
Care plan timing and revision
Reporting of alleged violations
Cooking facilities
Corridor - doors
Electrical systems - essential electric syste
Fire alarm system - testing and maintenance
Hvac
Means of egress - general
Multiple occupancies
Number of exits - corridors
Organization and administration
Sprinkler system - installation
Sprinkler system - maintenance and testing
Sprinkler system - out of service
Subdivision of building spaces - smoke barrie
Inspection Report
Annual Inspection
Deficiencies: 1
Date: Sep 14, 2020
Visit Reason
The inspection was conducted as a Recertification survey to evaluate compliance with physical restraint use policies and procedures at the nursing home.
Findings
The facility failed to ensure that a resident's physical restraint seat belt was released every two hours for 15 minutes as ordered, including during meals, and did not complete periodic re-evaluation of the ongoing need for the restraint. Observations, record reviews, and interviews confirmed noncompliance with restraint release and documentation requirements.
Deficiencies (1)
F 0604: The facility did not ensure a resident's rear buckle restraint seat belt was released every two hours for 15 minutes for range of motion and during meals as ordered. Periodic re-evaluation of the ongoing need for the restraint was not completed.
Report Facts
Residents reviewed for Physical Restraints: 38
Residents affected: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nursing Assistant | Observed not releasing the resident's seat belt restraint during meals and care |
| RN #1 | Registered Nurse | Interviewed regarding restraint release and documentation practices |
| Director of Nursing | Director of Nursing | Interviewed about restraint orders and documentation |
| Attending Physician | Attending Physician | Interviewed about restraint orders and evaluations |
| Rehabilitation Director | Rehabilitation Director | Interviewed about restraint use and care plan decisions |
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