Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Triboro Center For Rehabilitation And Nursing during CMS and state inspections, most recent first.
A resident with dementia and depression received Seroquel and later Trazodone without adequate documentation of target behaviors, diagnostic justification, or monitoring for effectiveness and side effects. The MDS showed severe cognitive impairment, no psychosis, and no behavioral symptoms, yet antipsychotic therapy continued without a documented GDR attempt or physician rationale for contraindication. Care plans for behavior, dementia, and psychoactive meds required behavior tracking and evaluation of interventions, but monitoring notes were essentially absent. Psychiatric consults referenced major depressive disorder and dementia without behavioral disturbance and instructed staff to document mood and behavior, but the facility record did not contain behavior data to support reported aggression or poor sleep. CNAs and an LPN reported only occasional shower refusal and mild agitation, while the family stated they had not seen aggressive behavior, questioned the bipolar diagnosis, and said they were not informed about initiation of psychotropic meds. Leadership interviews acknowledged incorrect indications on orders and poor behavior documentation, yet the resident continued on psychotropics without the required supporting documentation.
The facility failed to report an alleged violation involving possible abuse to the state as required by its abuse prevention policy and regulations. A resident with Alzheimer's disease, cognitive communication deficit, and depression, and with severely impaired cognition, was found by a CNA with redness and a bump on the right upper eyelid after an unwitnessed event. The resident first stated they had fallen but later said they did not know what happened, and an LPN documented that the resident could not state how or when they fell. Despite the unclear cause of the injury and the resident’s confusion, the DON concluded the injury was from a fall and did not report the incident as an injury of unknown source to the Department of Health.
A resident with dementia and depression was receiving antipsychotic and other psychoactive medications, but the facility failed to update the comprehensive care plan after multiple psychiatric evaluations and medication adjustments. Although care plans for dementia and psychoactive medications listed interventions such as administering meds as ordered and monitoring cognition, behavior, and medication effectiveness, there was no documented evidence in the monitoring/evaluation sections that behavior, mood, or medication effectiveness were actually being tracked. Physician and psychiatric consults changed Seroquel dosing, added Trazodone, and directed staff to monitor and document mood and behavior, yet the care plan was not revised to reflect these new orders or required monitoring, contrary to facility policy and expectations stated by the DON.
A resident with hemiplegia, aphasia, and significant mobility impairments, documented as totally dependent for rolling in bed, was assessed by PT to require at least two-person assistance and verbal cues for safe rolling. Despite this, the bedside task list continued to show only one-person assist for rolling, and communication of the updated PT recommendation from Rehab to nursing relied on a hard copy process that left no documented evidence of an update. During incontinence care, a CNA attempted to turn the resident with only one-person assistance, at which time the resident reached for the bed frame, overextended, and rolled off the bed, sustaining a head hematoma with laceration and facial skin excoriation.
Failure to Justify and Monitor Psychotropic Medication Use
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from chemical restraints and unnecessary psychotropic medications, as required by regulation and facility policy. One resident with diagnoses including non-Alzheimer’s dementia, depression, and bipolar disorder received Seroquel and later Trazodone without adequate documentation of an appropriate diagnosis for the specific psychotropic use, without documented target behaviors to justify ongoing use, and without evidence of monitoring for effectiveness or side effects. The facility’s psychotropic medication policy required use in accordance with standards of practice and regulations to promote the resident’s highest practicable well-being, but the clinical record did not contain behavior monitoring or evaluation notes to support the continued administration of these medications. The resident’s MDS assessment documented severe cognitive impairment, no indicators of psychosis, and no documented behavioral symptoms, while also noting that the resident was taking an antipsychotic with an indication, that no gradual dose reduction (GDR) had been attempted, and that the physician had not documented GDR as clinically contraindicated. Physician orders included Seroquel 125 mg at bedtime for dementia with behavioral disturbance, later increased to 150 mg at bedtime, and Trazodone 25 mg every 12 hours. Care plans for behavior, dementia, and psychoactive medications listed non-pharmacological interventions and required monitoring and documentation of behaviors, cognitive changes, and medication side effects and effectiveness. However, the monitoring/evaluation sections of these care plans lacked documentation of behavior escalation, target behaviors, or the effectiveness and side effects of the psychotropic medications, aside from a note about adding extra snacks. Psychiatric consults documented diagnoses of major depressive disorder and dementia without behavioral disturbance, and noted that staff were to monitor mood and behavior and document accordingly, with follow-up every three months and as needed. Subsequent consults recorded that the resident was doing well and calm, leading to a dose reduction of Seroquel, and later that the resident was irritable with disorganized behaviors and poor sleep, prompting an increase in Seroquel and initiation of Trazodone. Despite these notes, there was no corresponding behavior documentation in the facility record to substantiate the reported behaviors or to show monitoring of medication response. Interviews with CNAs and an LPN indicated they did not observe aggressive behaviors, aside from occasional agitation and refusal of showers that could be managed with encouragement or additional assistance. The psychiatrist, medical director, and DON acknowledged issues such as incorrect or incomplete indications on orders, lack of staff behavior documentation, and reliance on hospital records and prior use of Seroquel, but there remained no documented evidence in the resident’s record of behaviors supporting ongoing psychotropic use or of systematic monitoring for effectiveness and side effects. A family complaint further described concerns that the resident had never been diagnosed with bipolar disorder, was receiving psychotropic medications despite a dementia diagnosis, and that the family had not observed aggressive or violent behaviors during frequent visits. The family also reported that a community psychiatrist had not prescribed medication for behavior and that they were not informed when the facility started the resident on Seroquel. The complainant stated they had been asking the primary physician to stop certain medications due to increased risk in dementia and that the medications were not discontinued until they called 911 and had the resident transferred to the hospital and then to another nursing home. These documented concerns, combined with the lack of behavior monitoring, absence of clear diagnostic justification for the psychotropic regimen, and failure to document effectiveness and side effects, formed the basis for the cited deficiency related to unnecessary psychotropic medication use and chemical restraint.
Failure to Report Injury of Unknown Source as Alleged Abuse
Penalty
Summary
The facility failed to ensure that an alleged violation involving possible abuse was reported to the New York State Department of Health within the required timeframe. Facility policy on Abuse Prevention required that all alleged violations related to mistreatment, exploitation, neglect, or abuse, including injuries of unknown source, be reported to proper authorities, and that alleged violations involving abuse, neglect, exploitation, or mistreatment be reported immediately, but not later than 2 hours after the allegation is made if the events involve abuse or result in serious bodily injury. For one resident, an unwitnessed injury to the upper right eyelid was not reported to the Department of Health as required. Resident #426 had diagnoses including Alzheimer's disease, cognitive communication deficit, and depression, and was documented as having severely impaired cognition and requiring partial assistance of one person for ADLs. On the date of the incident, a CNA observed redness on the resident’s right upper eyelid at 8:15 AM; when interviewed, the resident initially stated they had fallen, but later stated they did not know what had happened. An LPN documented that the resident had a bump over the right eye and that the resident could not state how or when they fell. The DON stated that an investigation was conducted and, based on the resident’s initial statement that they had fallen, the facility concluded the injury was from a fall. The DON also acknowledged that the resident was confused and could not fully state what happened, and that the injury to the resident’s right eye was not reported to the Department of Health because the facility had already completed its investigation.
Failure to Revise Psychoactive Medication Care Plan After Medication Changes
Penalty
Summary
The deficiency involves the facility’s failure to review and revise a resident’s comprehensive care plan to reflect changes in psychoactive medication orders and required monitoring. The resident had diagnoses including non-Alzheimer’s dementia, depression, and bipolar disorder, and a Quarterly MDS documented severe cognitive impairment, use of an antipsychotic with an indication, and no documented gradual dose reduction or physician documentation that a gradual dose reduction was clinically contraindicated. The facility’s policy required ongoing assessment and revision of care plans as residents’ conditions changed, but this was not carried out for this resident’s psychoactive medication management. The resident had a care plan for dementia initiated on 09/19/2025 that identified impaired cognition and included interventions such as engaging the resident in simple, structured activities, maintaining a consistent routine and caregivers, and monitoring, documenting, and reporting changes in cognitive function. However, the monitoring/evaluation section did not contain documented evidence of the effectiveness of these interventions. A separate psychoactive medications care plan dated the same day identified use of psychoactive medications related to depression, with interventions to administer medications as ordered, monitor and document side effects and effectiveness, and monitor and record target behavior symptoms per facility protocol. The monitoring/evaluation notes for this care plan also lacked documented evidence that behavior and psychotropic medication effectiveness were being monitored. Physician and psychiatric consult documentation showed multiple medication management decisions that were not reflected in the care plan. A physician’s order dated 12/23/2025 documented Seroquel 125 mg at bedtime for dementia with behavioral disturbance. Psychiatric consults on 09/26/2025 and 11/07/2025 documented the resident as alert, awake, doing well, calm, and recommended continuation of Seroquel 125 mg at bedtime with non-pharmacological interventions, along with instructions for staff to monitor mood and behavior and document accordingly. A subsequent psychiatric consult on 12/29/2025 documented the resident as not doing well on current medication, irritable with disorganized behaviors, with staff reporting poor sleep; the psychiatrist ordered initiation of Trazodone 25 mg every 12 hours, an increase of Seroquel to 150 mg at bedtime, and continued non-pharmacological interventions, again directing staff to monitor mood and behavior and document accordingly. Despite these changes and instructions, there was no documented evidence that the comprehensive care plans were revised to include monitoring for medication effectiveness or mood and behavior problems after the medication adjustments. Interviews with nursing staff and the DON confirmed that care plans were expected to be updated with such changes, and that this had not occurred for this resident.
Failure to Update and Follow Two-Person Assist Requirement for Bed Mobility Leading to Fall
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and appropriate assistance during bed mobility for a resident, resulting in a fall from bed and head injury. The resident had diagnoses including hemiplegia, aphasia, and diabetes mellitus, and the Quarterly MDS documented moderate cognitive impairment, impaired upper and lower extremities, dependence on staff for toileting and dressing, substantial assistance for rolling left and right, and frequent bowel and bladder incontinence. Despite this, the Visual/Bedside Kardex reports on multiple dates, including the day of the incident, listed the resident as requiring substantial assist of one staff for rolling left and right. On the date of the incident, a CNA provided one-person assistance while attempting to turn the resident onto the right side during care. According to the nursing progress note, the CNA reported that the resident tried to hold onto the metal part of the bed with the left side, reached out too far, and rolled off the bed headfirst onto the floor. The resident was found face down on the floor with a left parietal hematoma with laceration and right upper face skin excoriation, and the CNA was at the bedside. Interviews with the resident’s sibling and the complainant indicated that the resident had a history of multiple strokes, paralysis from the waist down, limited mobility in the left arm and leg, and that concerns had previously been raised with the facility that the resident required two-person assistance for care, but the resident continued to receive one-person assistance at the time of the fall. Therapy documentation prior to the incident showed that the resident’s bed mobility needs had been assessed as requiring more than one staff member. Physical therapy progress reports and recertification documents dated from late July through early September recorded that the resident was totally dependent for rolling left and right in bed, with attempts to initiate movement, and specifically commented that the resident was able to initiate rolling but required at least two persons to complete rolling. These notes also recommended continued verbal cues for task sequencing to reduce the risk of falls and injury. Occupational Therapist #1 confirmed that as of early September, rolling left and right required two-person assistance for safety and that this should have been carried over because it posed a safety and fall risk. Interviews with the DON, Director of Rehabilitation, and Assistant DON revealed that the mechanism for communicating therapy recommendations to nursing at the time relied on hard copy documents passed from therapists to nurse managers, who would then update resident tasks. The DON stated that the incident had been investigated and that the resident was noted as one-person assist for bed mobility, and therefore they believed there was no care plan violation at that time. However, when the surveyor reviewed the PT progress note from early September documenting the need for two-person assistance for rolling, the DON could not explain why this recommendation was not followed and could not locate documentation of any updated communication after a prior May recommendation to change from two-person to one-person assistance. The Director of Rehabilitation stated that the PT note indicating the need for two-person assistance for rolling was current as of early September and that the task list should have been updated to two-person assistance, but there was no documented evidence that this occurred or that nursing was made aware. The Assistant DON confirmed that resident task lists can and should be updated during therapy if a decline is noted and that nursing should be notified so tasks can be adjusted accordingly.
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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) |
|---|---|---|---|---|
| Concourse Rehabilitation And Nursing Center Inc | 0.4 mi | — | 0 | 0 |
| Bronxcare Special Care Center | 0.4 mi | — | 0 | 0 |
| Highbridge Woodycrest Center | 0.9 mi | — | 0 | 0 |
| Hope Center For H I V And Nursing Care | 1 mi | — | 0 | 0 |
| Casa Promesa | 1.1 mi | — | 0 | 0 |
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