Inspection Reports for
Mosholu Parkway Nursing & Rehabilitation Center
3356 Perry Avenue, Bronx, NY, 10467
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
16.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
229% worse than New York average
New York average: 5.1 deficiencies/yearDeficiencies per year
80
60
40
20
0
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 2
Date: Jul 17, 2025
Visit Reason
Two standard health citations related to quality of care and reporting of alleged violations, both Level 2 severity and isolated scope.
Findings
Two standard health citations related to quality of care and reporting of alleged violations, both Level 2 severity and isolated scope.
Deficiencies (2)
Quality of care
Reporting of alleged violations
Inspection Report
Abbreviated Survey
Deficiencies: 3
Date: Jul 17, 2025
Visit Reason
The inspection was conducted as an abbreviated survey to evaluate compliance with regulations regarding timely reporting of suspected abuse, neglect, and provision of appropriate treatment and care according to orders and resident needs.
Findings
The facility failed to report an injury of unknown origin (fracture) within the required 2-hour window and did not ensure timely and appropriate care for two residents, including delayed transfer and delayed STAT x-ray orders. The investigation concluded no abuse or neglect occurred, but deficiencies in reporting and care coordination were identified.
Deficiencies (3)
F 0609: The facility did not report an injury of unknown origin (fracture of Resident #2's left femur) within 2 hours to the New York State Department of Health as required by policy and regulation.
F 0684: The facility did not ensure Resident #1 received timely and appropriate treatment for a second degree burn to the right hand, including failure to notify nursing staff promptly and delayed hospital transfer.
F 0684: The facility did not ensure timely ordering and completion of STAT x-rays for Resident #2 after a fall, resulting in delayed diagnosis and transfer for a femur fracture.
Report Facts
Residents affected: 2
Fall risk score: 15
Tylenol dosage: 650
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant #1 | Observed Resident #1's hand injury and failed to report promptly. | |
| Certified Nursing Assistant #2 | Observed Resident #1's hand injury and delayed reporting to Licensed Practical Nurse #1. | |
| Registered Nurse Supervisor #1 | Assessed Resident #1's injury and communicated with Medical Doctor #1. | |
| Registered Nurse Supervisor #2 | Observed Resident #2's grimacing and notified Medical Doctor #1 about delayed x-ray. | |
| Assistant Director of Nursing | Conducted investigations and interviews regarding incidents involving Residents #1 and #2. | |
| Medical Doctor #1 | Ordered x-rays and hospital transfers for Residents #1 and #2; no longer employed at facility. | |
| Director of Nursing | Provided information on investigation and facility policies. | |
| Occupational Therapist #1 | Performed range of motion screening on Resident #2 post-fall. |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 1
Date: Nov 15, 2024
Visit Reason
One standard health citation for right to be free from physical restraints, Level 2 severity and isolated scope, corrected as of March 14, 2023.
Findings
One standard health citation for right to be free from physical restraints, Level 2 severity and isolated scope, corrected as of March 14, 2023.
Deficiencies (1)
Right to be free from physical restraints
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Nov 15, 2024
Visit Reason
The abbreviated survey was conducted to assess compliance with regulations regarding the use of physical restraints and resident dignity following a reported incident involving Resident #1.
Findings
The facility failed to ensure that Resident #1 was free from physical restraints, as a bedsheet was tied around the resident's waist and wheelchair, which is against facility policy. The incident was investigated, corrective actions were implemented, and staff were re-trained on restraint policies.
Deficiencies (1)
10 NYCRR 415.4(a) (2-7) The facility failed to ensure that Resident #1 was free from physical restraints, as a bedsheet was tied around the resident's waist and wheelchair without medical necessity.
Report Facts
Residents Affected: Few
Staff in-service completion: 100
Audit frequency: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Applied restraint on Resident #1 and was disciplined, re-in-serviced, and terminated |
| Physical Therapist #1 | Physical Therapist | Observed and removed the restraint from Resident #1 |
| Registered Nurse Supervisor #1 | Registered Nurse Supervisor | Assessed Resident #1 after restraint incident |
| Certified Nursing Assistant #1 | Certified Nursing Assistant | Witnessed Resident #1 agitated and reported concerns about restraint use |
| Assistant Director of Nursing | Assistant Director of Nursing | Oversaw investigation and confirmed no injuries to Resident #1 |
| Director of Nursing | Director of Nursing | Reported on facility compliance and staff training post-incident |
Inspection Report
Annual Inspection
Deficiencies: 9
Date: Aug 16, 2024
Visit Reason
The inspection was a Recertification survey conducted from 08/12/2024 to 08/16/2024 to assess compliance with regulatory standards for nursing home operations and resident care.
Findings
The facility was found deficient in multiple areas including failure to honor resident bathing preferences, delayed reporting of suspected abuse, inadequate care to maintain range of motion, improper food storage and handling, unsanitary garbage disposal, incomplete medical record documentation, inadequate infection control practices, unsecured handrails, and ineffective pest control.
Deficiencies (9)
F 0561: The facility did not promote resident self-determination by supporting bathing preferences. Resident #76 was scheduled for showers twice weekly but was usually given bed baths without documented refusals.
F 0609: The facility failed to timely report suspected abuse. Resident #12 sustained a scratch and possible bruise that were not reported to the Department of Health within required timeframes.
F 0688: Resident #16 with limited range of motion did not consistently receive ordered bilateral hand gauze to prevent contractures, observed without the device on multiple occasions.
F 0812: Food was improperly stored with opened, undated, expired items in refrigerators and freezers. Thermometers were missing and food temperatures were not consistently monitored. Staff handled food with bare hands during meal service.
F 0814: Garbage storage areas were unsanitary. Outside dumpsters were uncovered and overflowing, and kitchen trash cans were uncovered. Food service worker was observed not wearing gloves during garbage disposal.
F 0842: Resident #42's medical records inaccurately documented dialysis access. The resident had a right chest catheter but progress notes documented use of a non-functioning AV fistula.
F 0880: Infection control practices were inadequate. Enhanced Barrier Precautions were not implemented for residents with wounds or indwelling devices. Staff failed to wear gowns and gloves appropriately during wound care, catheter care, and care of residents with central venous catheters.
F 0924: Handrails in Unit 2 hallways were loose and not firmly secured. Maintenance was unable to repair due to staffing shortages, and no repair was documented.
F 0925: The facility did not maintain an effective pest control program. Multiple dead cockroaches, water bugs, spiders, and silverfish were found in the food storage room. Pest control logs were incomplete or unavailable.
Report Facts
Residents sampled: 27
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Food storage observations: 50
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant #3 | Interviewed regarding Resident #76 shower schedule and care | |
| Assistant Director of Nursing | Interviewed regarding shower documentation and abuse reporting | |
| Director of Nursing | Interviewed regarding shower schedule, abuse reporting, infection control, and medical record documentation | |
| Licensed Practical Nurse #3 | Interviewed regarding application of hand gauze for Resident #16 | |
| Occupational Therapist #1 | Interviewed regarding orders for hand gauze for Resident #16 | |
| Rehab Supervisor #1 | Interviewed regarding application and monitoring of hand devices | |
| Director of Food Service | Interviewed regarding food storage, temperature monitoring, and pest control | |
| Certified Nursing Assistant #5 | Observed and interviewed regarding food handling without gloves | |
| Certified Nursing Assistant #6 | Observed and interviewed regarding food handling without gloves | |
| Licensed Practical Nurse #2 | Interviewed regarding dialysis care documentation for Resident #42 | |
| Licensed Practical Nurse #4 | Interviewed regarding wound care for Resident #36 | |
| Certified Nursing Assistant #8 | Interviewed and observed providing catheter care for Resident #218 | |
| Licensed Practical Nurse #5 | Interviewed regarding catheter care oversight | |
| Certified Nursing Assistant #9 | Interviewed regarding catheter care training | |
| Maintenance Worker | Interviewed regarding handrail repairs and maintenance rounds | |
| Administrator | Interviewed regarding pest control, handrail repairs, and food service oversight |
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Aug 16, 2024
Visit Reason
The inspection was conducted as a Recertification and Complaint Survey from 08/12/2024 to 08/16/2024 to investigate alleged abuse, care planning deficiencies, supervision failures, and other compliance issues at Mosholu Parkway Nursing & Rehabilitation Center.
Complaint Details
The complaint investigation revealed failures in abuse investigation, care planning, and supervision. The alleged abuse of Resident #12 was not properly investigated. Care plans were incomplete or not updated for Residents #76, #85, and #12. Resident #99 eloped due to inadequate supervision and unlocked facility doors.
Findings
The facility failed to thoroughly investigate an alleged abuse incident involving Resident #12, did not develop or implement comprehensive care plans for residents following incidents or for specific medical needs, and did not provide adequate supervision to prevent accidents, including an elopement by Resident #99.
Deficiencies (4)
F 0610: The facility did not ensure that an alleged abuse of Resident #12 was thoroughly investigated, with only one staff statement and no written investigation summary documented.
F 0656: The facility failed to develop and implement a comprehensive care plan for Resident #76 following a resident-to-resident altercation and for Resident #85 to address insulin use.
F 0657: The facility did not review and revise Resident #12's Skin Integrity Care Plan to reflect a new skin break observed on 01/01/2024.
F 0689: The facility did not ensure adequate supervision to prevent accidents, resulting in Resident #99 eloping from the facility on 10/18/2023 due to unlocked doors and inadequate front desk monitoring.
Report Facts
Residents reviewed for care planning: 27
Residents with care planning deficiencies: 2
Date of resident elopement: Oct 18, 2023
Medication doses: 50
Medication doses: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding abuse investigation, care plan deficiencies, and supervision issues | |
| Assistant Director of Nursing | Interviewed regarding abuse investigation, care plan responsibilities, and supervision | |
| Certified Nursing Assistant #7 | Certified Nursing Assistant | Interviewed about Resident #99 elopement and search efforts |
| Licensed Practical Nurse #5 | Licensed Practical Nurse | Charge nurse on duty during Resident #99 elopement |
| Occupational Therapist | Interviewed about Resident #99 ambulation and elopement |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 35
Date: Aug 16, 2024
Visit Reason
Multiple standard health and life safety code citations including care plan revisions, handrails, food safety, infection control, electrical systems, fire safety, and sprinkler systems. Most deficiencies Level 2 severity with isolated, pattern, or widespread scope. Many corrected by October 2024.
Findings
Multiple standard health and life safety code citations including care plan revisions, handrails, food safety, infection control, electrical systems, fire safety, and sprinkler systems. Most deficiencies Level 2 severity with isolated, pattern, or widespread scope. Many corrected by October 2024.
Deficiencies (35)
Care plan timing and revision
Corridors have firmly secured handrails
Develop/implement comprehensive care plan
Dispose garbage and refuse properly
Food procurement,store/prepare/serve-sanitary
Free of accident hazards/supervision/devices
Increase/prevent decrease in rom/mobility
Infection prevention & control
Investigate/prevent/correct alleged violation
Maintains effective pest control program
Reporting of alleged violations
Resident records - identifiable information
Self-determination
Cooking facilities
Corridors - construction of walls
Electrical equipment - testing and maintenanc
Electrical systems - essential electric syste
Electrical systems - maintenance and testing
Electrical systems - other
Elevators
Emergency lighting
Emergency officials contact information
Ep testing requirements
Fire alarm system - testing and maintenance
Fire drills
Fundamentals - building system categories
Illumination of means of egress
Maintenance, inspection & testing - doors
Names and contact information
Physical environment
Policies/procedures for sheltering in place
Procedures for tracking of staff and patients
Sprinkler system - installation
Sprinkler system - maintenance and testing
Subdivision of building spaces - smoke barrie
Inspection Report
Capacity: 60
Deficiencies: 1
Date: May 2, 2023
Visit Reason
One standard health citation for reporting to national health safety network, Level 2 severity and widespread scope.
Findings
One standard health citation for reporting to national health safety network, Level 2 severity and widespread scope.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Capacity: 60
Deficiencies: 1
Date: Apr 24, 2023
Visit Reason
One standard health citation for reporting to national health safety network, Level 2 severity and widespread scope.
Findings
One standard health citation for reporting to national health safety network, Level 2 severity and widespread scope.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Capacity: 60
Deficiencies: 1
Date: Apr 17, 2023
Visit Reason
One standard health citation for reporting to national health safety network, Level 2 severity and widespread scope.
Findings
One standard health citation for reporting to national health safety network, Level 2 severity and widespread scope.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Capacity: 60
Deficiencies: 1
Date: Apr 3, 2023
Visit Reason
One standard health citation for reporting to national health safety network, Level 2 severity and widespread scope.
Findings
One standard health citation for reporting to national health safety network, Level 2 severity and widespread scope.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 16
Date: Sep 1, 2022
Visit Reason
Multiple standard health and life safety code citations including care plan revisions, drug regimen, reporting of alleged violations, resident records, corridor doors, electrical systems, fire alarm system, gas equipment storage, means of egress, sprinkler system, stairways, and smoke barriers. Most deficiencies Level 2 severity with isolated or pattern scope. All corrected as of late 2022.
Findings
Multiple standard health and life safety code citations including care plan revisions, drug regimen, reporting of alleged violations, resident records, corridor doors, electrical systems, fire alarm system, gas equipment storage, means of egress, sprinkler system, stairways, and smoke barriers. Most deficiencies Level 2 severity with isolated or pattern scope. All corrected as of late 2022.
Deficiencies (16)
Care plan timing and revision
Drug regimen is free from unnecessary drugs
Drug regimen review, report irregular, act on
Investigate/prevent/correct alleged violation
Medicaid/medicare coverage/liability notice
Reporting of alleged violations
Resident records - identifiable information
Corridor - doors
Electrical systems - essential electric syste
Fire alarm system - installation
Gas equipment - cylinder and container storag
Illumination of means of egress
Means of egress - general
Sprinkler system - installation
Stairways and smokeproof enclosures
Subdivision of building spaces - smoke barrie
Inspection Report
Annual Inspection
Deficiencies: 7
Date: Sep 1, 2022
Visit Reason
The inspection was conducted as a recertification and complaint survey to assess compliance with Medicare/Medicaid regulations and investigate specific complaints.
Complaint Details
The complaint investigation revealed failures in timely reporting of injuries of unknown origin, conducting thorough investigations of alleged abuse, and revising care plans following resident injuries.
Findings
The facility was found deficient in providing Skilled Nursing Facility Advanced Beneficiary Notices (SNFABN) at Medicare Part A termination, timely reporting and investigating injuries of unknown origin, revising comprehensive care plans after condition changes, monitoring blood pressure for residents on antihypertensive medication, and maintaining accurate medical records including documentation of ordered nutritional supplements and wandering guard placement.
Deficiencies (7)
F 0582: The facility failed to provide SNFABN to residents discharged from skilled rehabilitation services as required by Medicare Part A regulations.
F 0609: The facility did not report an injury of unknown origin to the state health department within the required 2-hour timeframe.
F 0610: The facility failed to conduct a thorough investigation of an injury of unknown origin to rule out abuse.
F 0657: The facility did not revise comprehensive care plans to reflect changes in resident conditions, including Foley catheter use and injury incidents.
F 0756: The facility did not ensure the attending physician documented and acted upon pharmacy recommendations regarding blood pressure monitoring for a resident on Metoprolol.
F 0757: The facility failed to adequately monitor a resident for efficacy and adverse effects of blood pressure medication due to lack of documented blood pressure monitoring.
F 0842: The facility did not maintain complete and accurate medical records, including failure to document administration of ordered nutritional supplements and inaccurate documentation of wandering guard placement.
Report Facts
Residents reviewed: 27
Residents with SNFABN deficiency: 2
Residents with injury reporting deficiency: 1
Residents with care plan revision deficiency: 2
Residents with medication monitoring deficiency: 1
Residents with medical record documentation deficiency: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #2 | Registered Nurse | Interviewed regarding injury assessment and reporting for Resident #264. |
| DON | Director of Nursing | Interviewed regarding reporting, investigation, and care plan revision deficiencies. |
| Administrator | Interviewed regarding injury reporting and investigation decisions. | |
| RN #1 | Registered Nurse | Interviewed regarding care plan revisions and medication administration documentation. |
| LPN #1 | Licensed Practical Nurse | Interviewed regarding blood pressure monitoring and medication administration documentation. |
| LPN #2 | Licensed Practical Nurse | Interviewed regarding blood pressure monitoring and medication administration documentation. |
| MD | Medical Doctor | Interviewed regarding pharmacy consultant recommendations and medication orders. |
| Medical Director | Interviewed regarding responsibility for reviewing pharmacy consultant recommendations. |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Nov 6, 2019
Visit Reason
The inspection was conducted as a recertification survey and complaint investigation related to the facility's failure to thoroughly investigate an incident involving a resident found with a foreign object in his anal cavity.
Complaint Details
The complaint involved an incident where Resident #73 was found with a spoon in his anal cavity. The facility did not conduct an investigation to rule out abuse. Interviews with staff and administration confirmed lack of awareness and failure to initiate required investigation procedures.
Findings
The facility failed to initiate an investigation after Resident #73 was found with a spoon in his anal cavity. The resident's care plans documented behavioral issues, but no investigation or updated care plan was initiated following the incident. Additionally, the facility failed to timely submit a Minimum Data Set (MDS) for Resident #1, which was submitted 8 days late.
Deficiencies (2)
F 0610: The facility did not initiate an investigation after Resident #73 was found with a spoon in his anal cavity. No evidence of an Accident/Incident Investigation was documented, and staff were unaware of the policy for such incidents.
F 0640: The facility failed to timely transmit the Minimum Data Set (MDS) for Resident #1 within 14 days of assessment completion. The MDS was submitted 8 days late.
Report Facts
Days late for MDS submission: 8
Residents reviewed for Resident Assessment task: 27
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nursing Assistant | Interviewed regarding Resident #73's behavior and incident with spoon. |
| RN #1 | Registered Nurse, Charge Nurse | Interviewed about incident with Resident #73 and lack of investigation. |
| Director of Nursing | Director of Nursing | Interviewed about facility policy and lack of investigation for Resident #73 incident. |
| Administrator | Administrator | Interviewed about incident and facility response regarding Resident #73. |
| MDS Coordinator | Registered Nurse | Interviewed regarding late submission of Resident #1's MDS. |
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