Inspection Reports for
Morris Park Rehabilitation and Nursing Center
1235 Pelham Parkway North, Bronx, NY, 10469
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
10.2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
100% worse than New York average
New York average: 5.1 deficiencies/year
Deficiencies per year
28
21
14
7
0
Inspection Report
Abbreviated Survey
Census: 175
Deficiencies: 1
Date: Jan 31, 2025
Visit Reason
The survey was conducted to assess compliance with nursing staff sufficiency requirements, triggered by concerns about low staffing levels, particularly on weekends, as documented in the Payroll Based Journal Staffing Data Report for the 4th Quarter of 2024.
Findings
The facility failed to provide sufficient nursing staff consistently to meet residents' needs, resulting in delayed care and unmet resident needs. Staffing levels were repeatedly below facility-assessed levels, with excessively low weekend staffing documented. Multiple residents and staff reported staffing shortages impacting care delivery.
Deficiencies (1)
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Report Facts
Average daily census: 175
Certified Nursing Assistants needed: 20
Certified Nursing Assistants needed: 10
Certified Nursing Assistants scheduled: 3
Certified Nursing Assistants working: 17
Certified Nursing Assistants working: 8
Certified Nursing Assistants hired: 90
Certified Nursing Assistants remaining: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant #8 | Interviewed about staffing shortages and workload on weekends | |
| Certified Nursing Assistant #7 | Interviewed about short staffing on weekends and efforts to call in colleagues | |
| Certified Nursing Assistant #2 | Interviewed about staffing challenges and resident care needs on 12/16/2024 | |
| Certified Nursing Assistant #4 | Interviewed about delayed incontinent care and shower rescheduling due to short staffing | |
| Registered Nurse #2 | Interviewed about stress due to short staffing and supervisory tasks | |
| Staffing Coordinator | Interviewed about staffing strategies and use of home health aides | |
| Director of Nursing | Interviewed about hiring efforts, agency staff use, and staffing challenges | |
| Administrator | Interviewed about recruitment strategies and staff retention |
Inspection Report
Annual Inspection
Census: 175
Deficiencies: 3
Date: Jan 31, 2025
Visit Reason
The inspection was conducted as a Recertification and Abbreviated Survey to assess compliance with nursing staff sufficiency, medication storage, emergency drug box management, and food safety standards.
Findings
The facility was found to have insufficient nursing staff, particularly Certified Nursing Assistants, resulting in delayed resident care and unmet needs. Medication storage practices were deficient, including unlabeled and expired medications and improperly stored insulin pens. Emergency drug boxes contained expired medications. Food safety violations included unlabeled and undated food items in kitchen and unit refrigerators.
Deficiencies (3)
Insufficient nursing staff on weekends and other shifts, leading to delayed resident care and unmet needs.
Drugs and biologicals not stored in accordance with professional standards; insulin pens unlabeled and improperly stored; expired medications in emergency drug box.
Food items in kitchen walk-in refrigerator, freezer, and unit refrigerators were unlabeled and undated, violating food safety standards.
Report Facts
Average daily census: 175
Certified Nursing Assistants staffing levels: 3
Certified Nursing Assistants staffing levels: 17
Certified Nursing Assistants staffing levels: 8
Certified Nursing Assistants hired: 90
Expired medications: 3
Insulin pens: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant #8 | Certified Nursing Assistant | Interviewed about staffing shortages and workload stress on weekends. |
| Certified Nursing Assistant #7 | Certified Nursing Assistant | Interviewed about short staffing on weekends and efforts to call in colleagues. |
| Certified Nursing Assistant #2 | Certified Nursing Assistant | Interviewed about staffing levels on 12/16/2024 and resident care challenges. |
| Certified Nursing Assistant #4 | Certified Nursing Assistant | Interviewed about delayed incontinent care and shower rescheduling due to staffing shortages. |
| Registered Nurse #2 | Registered Nurse | Interviewed about stress assisting aides due to short staffing on weekends. |
| Director of Nursing | Director of Nursing | Interviewed about staffing challenges, agency staff use, and medication cart responsibilities. |
| Administrator | Administrator | Interviewed about staffing recruitment strategies and turnover. |
| Licensed Practical Nurse #2 | Licensed Practical Nurse | Interviewed about medication cart observations and insulin pen storage. |
| Registered Nurse #1 | Registered Nurse | Interviewed about medication cart checks and food safety monitoring. |
| Assistant Director of Nursing | Assistant Director of Nursing | Interviewed about emergency drug box checks and expired medications. |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Interviewed about charge nurse responsibilities for emergency drug box. |
| Food Service Director | Food Service Director | Interviewed about food labeling and storage practices. |
| Licensed Practical Nurse #4 | Licensed Practical Nurse | Interviewed about food labeling responsibilities on unit. |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 7
Date: Jan 31, 2025
Visit Reason
Multiple standard health and life safety code citations including food procurement, drug labeling, nursing staff sufficiency, and HVAC issues. All deficiencies were corrected by March or April 2025.
Findings
Multiple standard health and life safety code citations including food procurement, drug labeling, nursing staff sufficiency, and HVAC issues. All deficiencies were corrected by March or April 2025.
Deficiencies (7)
Food procurement,store/prepare/serve-sanitary
Label/store drugs and biologicals
Sufficient nursing staff
Hvac
Means of egress - general
Sprinkler system - maintenance and testing
Stairways and smokeproof enclosures
Inspection Report
Annual Inspection
Capacity: 60
Deficiencies: 1
Date: Jul 10, 2024
Visit Reason
One deficiency related to abuse reporting documentation.
Findings
One deficiency related to abuse reporting documentation.
Deficiencies (1)
R9-10-803.J — Abuse reporting documentation
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: May 8, 2024
Visit Reason
The abbreviated survey was conducted due to a failure to ensure adequate supervision to prevent a resident elopement from the facility.
Findings
The facility failed to prevent Resident #1 from eloping undetected on 05/01/24, despite policies on wandering and elopement risk management. Resident #1 was found several days later without injury. The investigation concluded no abuse or neglect occurred. Corrective actions included staff re-education, policy revisions, implementation of an elopement care plan, and termination of the security guard involved.
Deficiencies (1)
Failure to ensure adequate supervision to prevent resident elopement.
Report Facts
Staff in-serviced: 179
Security Guards in-serviced: 4
Certified Nursing Assistants in-serviced: 62
Home Health Aides in-serviced: 4
Licensed Practical Nurses in-serviced: 20
Registered Nurse Supervisors in-serviced: 15
Recreation Staff in-serviced: 7
Housekeeping and Maintenance Staff in-serviced: 20
Dietary Staff in-serviced: 17
Social Services Staff in-serviced: 2
Administration Staff in-serviced: 6
Physical Therapist/Occupational Therapist in-serviced: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse Supervisor #1 | Registered Nurse Supervisor | Notified at 7:10 pm that Resident #1 was missing and activated Code E. |
| Security Guard #1 | Security Guard | Buzzed out pharmacy delivery person allowing Resident #1 to elope; was terminated on 05/03/24. |
| Certified Nurse Assistant #1 | Certified Nurse Assistant | Last saw Resident #1 between 3:40 pm and 4:00 pm; stated Resident #1 was not at risk for elopement. |
| Certified Nurse Assistant #2 | Certified Nurse Assistant | Handed out trays on 05/01/24 but did not verify Resident #1 was in dining room. |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Notified Registered Nurse Supervisor #1 about missing Resident #1 and activated Code E. |
| Director of Nursing | Director of Nursing | Investigated elopement incident and oversaw corrective actions. |
| Administrator | Administrator | Reviewed surveillance footage and questioned Security Guard #1. |
| Recreation Leader | Recreation Leader | Assisted with collecting dinner trays on 05/01/24 but did not verify Resident #1's tray. |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 1
Date: May 8, 2024
Visit Reason
One standard health citation for accident hazards and supervision, corrected shortly after inspection.
Findings
One standard health citation for accident hazards and supervision, corrected shortly after inspection.
Deficiencies (1)
Free of accident hazards/supervision/devices
Inspection Report
Annual Inspection
Deficiencies: 1
Date: Jul 3, 2023
Visit Reason
The inspection was conducted as part of the Recertification and Complaint survey from 6/26/2023 to 7/3/2023 to evaluate compliance with care planning requirements.
Findings
The facility failed to develop and implement a person-centered Comprehensive Care Plan (CCP) for Resident #108's right thumb skin lesion, despite medical orders and treatments. This deficiency was identified through observations, record reviews, and interviews.
Deficiencies (1)
Failure to develop and implement a complete care plan that meets all the resident's needs, specifically related to Resident #108's right thumb skin lesion.
Report Facts
Residents sampled: 38
Treatment duration: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse (RN) #3 | Interviewed regarding Resident #108's wart and care plan oversight | |
| Director of Nursing Services (DNS) | Interviewed regarding responsibility for CCP oversight and timelines |
Inspection Report
Annual Inspection
Deficiencies: 7
Date: Jul 3, 2023
Visit Reason
The inspection was a Recertification survey conducted from 6/26/23 to 7/3/23 to assess compliance with federal and state regulations for nursing home operations.
Findings
The facility was found deficient in multiple areas including failure to ensure residents were treated with dignity, timely completion of Minimum Data Set (MDS) assessments, inadequate supervision leading to resident falls, improper food storage temperatures, infection control lapses, unsecured handrails, and ineffective pest control.
Deficiencies (7)
Resident #123 was observed wearing the same blood-stained shirt for three consecutive days, indicating failure to provide dignified care.
MDS assessments for 16 residents were not completed within 14 days of the Assessment Reference Date, indicating failure to update resident assessments quarterly.
Resident #284 fell while on 1:1 observation due to inadequate supervision, resulting in a left hip fracture and actual harm.
Cold sandwiches and milk were stored above the proper temperature of 41°F due to a malfunctioning walk-in refrigerator.
A Certified Nursing Assistant was observed touching the inside of cups being served to residents, violating infection control practices.
Handrails on Unit 1 and Unit 4 hallways were not firmly affixed to the wall.
Fruit flies were observed in the kitchen, Food Service Director's office, and conference room, indicating ineffective pest control.
Report Facts
Residents reviewed for dignity: 38
Residents reviewed for Resident Assessment: 17
Residents affected by late MDS assessments: 16
Residents reviewed for accidents: 38
Residents affected by inadequate supervision: 1
Temperature of turkey sandwiches: 52
Temperature of milk: 53.1
Units with loose handrails: 2
Pest control visits: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant #4 | CNA | Named in dignity deficiency related to Resident #123's care |
| Registered Nurse Supervisor #3 | RNS | Interviewed regarding Resident #123's care and supervision |
| Director of Nursing Services | DNS | Interviewed regarding ADL care and supervision policies |
| Certified Home Health Aide #1 | HHA | Assigned 1:1 observation for Resident #284 and involved in fall incident |
| Certified Nursing Assistant #1 | CNA | Witnessed fall incident of Resident #284 |
| Licensed Practical Nurse #1 | LPN | Supervised HHA #1 and responded to Resident #284 fall |
| Registered Nurse Supervisor #1 | RNS | Provided oversight and in-service to HHA #1 |
| Assistant Director of Nursing | ADON | Responsible for orienting HHAs and in-service training |
| Food Service Director | FSD | Interviewed regarding food storage and pest control |
| Dietary [NAME] #2 | DC | Observed food temperatures and pest issues |
| Certified Nursing Assistant #3 | CNA | Observed touching inside cups during lunch service |
| Registered Nurse #2 | RN | Observed CNA #3's infection control breach |
| Maintenance Director | DM | Interviewed regarding handrails and pest control |
| Pest Company Supervisor | PCS | Interviewed regarding pest control visits |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 13
Date: Jul 3, 2023
Visit Reason
Multiple standard health and life safety code citations including accident hazards, infection prevention, care plan development, and HVAC issues. Some citations involved actual harm. All corrected by August or September 2023.
Findings
Multiple standard health and life safety code citations including accident hazards, infection prevention, care plan development, and HVAC issues. Some citations involved actual harm. All corrected by August or September 2023.
Deficiencies (13)
Free of accident hazards/supervision/devices
Infection prevention & control
Develop/implement comprehensive care plan
Maintains effective pest control program
Qrtly assessment at least every 3 months
Resident rights/exercise of rights
Corridors have firmly secured handrails
Hvac
Illumination of means of egress
Maintenance, inspection & testing - doors
Portable fire extinguishers
Sprinkler system - installation
Stairways and smokeproof enclosures
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 2
Date: Mar 20, 2023
Visit Reason
Two standard health citations related to abuse and neglect and reporting of alleged violations, corrected by April 2023.
Findings
Two standard health citations related to abuse and neglect and reporting of alleged violations, corrected by April 2023.
Deficiencies (2)
Free from abuse and neglect
Reporting of alleged violations
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Mar 6, 2023
Visit Reason
The inspection was conducted as an abbreviated survey following a complaint alleging physical abuse of Resident #1 by Licensed Practical Nurse #1 (LPN #1) on 03/06/2023.
Complaint Details
The complaint investigation was triggered by an incident on 03/06/2023 where LPN #1 was observed on surveillance footage and by staff forcefully pushing Resident #1's wheelchair causing it to tilt and Resident #1 to fall partially to the floor. Resident #1 complained of pain and was sent to the hospital. The investigation concluded there was evidence to suspect abuse, neglect, or mistreatment. Additionally, a separate abuse allegation reported on 06/21/2022 involving Resident #1's roommate was not reported timely to the state.
Findings
The facility failed to ensure Resident #1's right to be free from physical abuse. Surveillance footage and multiple staff interviews confirmed that LPN #1 forcefully pushed Resident #1's wheelchair causing it to tilt and Resident #1 to fall partially to the floor. Resident #1 was evaluated at the hospital with no fractures found. LPN #1 was suspended and terminated. The facility also failed to timely report an abuse allegation involving Resident #1's roommate, which was reported late to the state.
Deficiencies (2)
Failure to protect Resident #1 from physical abuse by LPN #1 who forcefully pushed the resident's wheelchair causing a fall.
Failure to timely report suspected abuse involving Resident #1 to the New York State Department of Health within required timeframes.
Report Facts
Residents reviewed: 4
Date of incident: Mar 6, 2023
Date of late report: Jun 24, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Named in physical abuse incident involving Resident #1; suspended and terminated |
| Director of Nursing | Director of Nursing (DON) | Conducted investigation, suspended involved staff, notified authorities |
| Recreation Staff #1 | Recreation Staff | Witnessed the abuse incident and reported it to the DON |
| Certified Nurse Assistant #2 | Certified Nurse Assistant | Involved in incident response and suspended for failure to report fall |
| Nurse Manager #1 | Nurse Manager | Assessed Resident #1 post-incident and reviewed surveillance footage |
| Registered Nurse #1 | Registered Nurse | Assessed Resident #1 after incident |
| Nurse Manager #2 | Registered Nurse Manager | Followed up on abuse allegation involving Resident #1's roommate |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 1
Date: Jan 9, 2023
Visit Reason
One standard health citation for reporting to national health safety network, widespread scope, not corrected at time of report.
Findings
One standard health citation for reporting to national health safety network, widespread scope, not corrected at time of report.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 1
Date: Dec 5, 2022
Visit Reason
One standard health citation for reporting to national health safety network, widespread scope, not corrected at time of report.
Findings
One standard health citation for reporting to national health safety network, widespread scope, not corrected at time of report.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 1
Date: Sep 22, 2022
Visit Reason
One standard health citation for accident hazards and supervision with actual harm, corrected by November 2022.
Findings
One standard health citation for accident hazards and supervision with actual harm, corrected by November 2022.
Deficiencies (1)
Free of accident hazards/supervision/devices
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 1
Date: Jul 7, 2022
Visit Reason
One standard health citation for abuse and neglect, corrected by September 2022.
Findings
One standard health citation for abuse and neglect, corrected by September 2022.
Deficiencies (1)
Free from abuse and neglect
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 3
Date: May 6, 2022
Visit Reason
Three standard health citations related to care plan development, investigation of alleged violations, and reporting of alleged violations, corrected by June 2022.
Findings
Three standard health citations related to care plan development, investigation of alleged violations, and reporting of alleged violations, corrected by June 2022.
Deficiencies (3)
Develop/implement comprehensive care plan
Investigate/prevent/correct alleged violation
Reporting of alleged violations
Inspection Report
Annual Inspection
Deficiencies: 5
Date: Jun 10, 2021
Visit Reason
The inspection was a Recertification survey conducted to assess compliance with regulatory requirements for Morris Park Rehabilitation and Nursing Center.
Findings
The facility was found deficient in multiple areas including failure to notify a resident's physician of significantly elevated blood sugar levels, inadequate sanitation of a resident's hand splint, lack of medical follow-up for a resident with consistently elevated blood sugars, failure to review and adjust care plans and medications appropriately, and improper infection control practices during wound care.
Deficiencies (5)
Failure to notify resident's medical provider when blood sugar increased to 409 on two occasions.
Resident's hand splint was worn and caked with dirt on multiple occasions without cleaning or replacement.
No evidence of medical follow-up to address consistently elevated blood sugars for a resident with Diabetes Mellitus.
No documented evidence that the facility reviewed the resident's total program of care, including medications and treatments, at each required visit.
Staff did not change gloves during wound care observation, violating infection control practices.
Report Facts
Blood sugar readings: 409
Hemoglobin A1C: 11.7
Blood sugar readings range: 592
Blood sugar readings range: 41
Deficiency count: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Interviewed regarding notification of physician about elevated blood sugar. |
| RN #1 | Registered Nurse | Interviewed regarding blood sugar checks and documentation. |
| Primary Care Physician | Interviewed and stated not informed of elevated blood sugar on 05/14/2021. | |
| Director of Nursing Services | DNS | Interviewed regarding policy on notification of medical provider and documentation. |
| CNA #1 | Certified Nursing Assistant | Interviewed about care and cleaning of resident's hand splint. |
| RN Supervisor #3 | Registered Nurse Supervisor | Interviewed about awareness and reporting of hand splint cleanliness. |
| Director of Rehabilitation | DOR | Interviewed about responsibilities for splint evaluation and replacement. |
| NP #1 | Nurse Practitioner | Interviewed about review of resident's diabetes care and documentation. |
| PMD #1 | Primary Medical Doctor | Interviewed about workload and oversight of diabetes care and documentation. |
| Assistant Director of Nursing Services | ADNS / Inservice Coordinator | Interviewed about staff in-service training and competency on medication administration and protocols. |
| LPN #2 | Licensed Practical Nurse | Observed performing wound care and interviewed about infection control practices. |
| Unit RNS | Registered Nurse Supervisor | Interviewed about follow-up on blood work orders and audit responsibilities. |
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