Cycle 1
Health 2025-07-23 · Fire 2023-04-11
4 health deficiencies
Top issue: Administration (1 deficiency)
13 fire-safety deficiencies
Top issue: Smoke (8 deficiencies)
Bronx, NY
Bainbridge Nursing & Rehabilitation Center
5-star overall rating with 4-star inspections with 4 recent health deficiencies with 13 fire-safety deficiencies in the latest cycle
3518 Bainbridge Avenue, Bronx, NY
(718) 655-1991
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
200
Certified beds
Average residents
193
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1979-07-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.55
Registered nurse staffing · state 0.70 · national 0.68
LPN hours / resident day
0.58
Licensed practical nurse staffing · state 0.78 · national 0.87
Aide hours / resident day
1.99
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
3.12
All reported nurse hours · state 3.65 · national 3.89
Licensed hours
1.13
RN + LPN hours · state 1.47 · national 1.54
Weekend hours
2.55
Weekend nurse staffing · state 3.16 · national 3.43
Weekend RN hours
0.27
Weekend registered nurse coverage · state 0.47 · national 0.47
Physical therapist
0.15
Reported PT staffing · state 0.11 · national 0.07
Adjusted RN hours
0.59
CMS adjusted RN staffing hours
Adjusted total hours
3.36
CMS adjusted total nurse staffing hours
Case-mix index
1.27
Higher values indicate more complex resident acuity
RN turnover
27%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
37%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Value-based purchasing
Program rank
2,118
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
51.64
Composite VBP score used to determine payment impact.
Payment multiplier
1.0060
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
7.32
Baseline 20.31% · Performance 18.04% · Measure score 7.32 · Achievement 7.32 · Improvement 6.41
Healthcare-associated infections
6.19
Baseline 6.82% · Performance 5.99% · Measure score 6.19 · Achievement 6.19 · Improvement 4.06
Total nurse turnover
7.15
Baseline 30.34% · Performance 34.44% · Measure score 7.15 · Achievement 7.15 · Improvement 0
Adjusted total nurse staffing
0
Baseline 3.14 hours · Performance 3.20 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.11% |
10.72%
1.6 pts better
|
No Different than the National Rate · Eligible stays 108 · Observed rate 6.48% · Lower 95% interval 5.83% |
| Discharge to community | 46.59% |
50.57%
4 pts worse
|
No Different than the National Rate · Eligible stays 78 · Observed rate 33.33% · Lower 95% interval 35.41% |
| Medicare spending per beneficiary | 1.07 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 99.17% |
95.27%
3.9 pts better
|
Numerator 120 · Denominator 121 |
| Falls with major injury | 0.83% |
0.77%
0.1 pts worse
|
Numerator 1 · Denominator 121 |
| Discharge self-care score | 51.25% |
53.69%
2.4 pts worse
|
Numerator 41 · Denominator 80 |
| Discharge mobility score | 52.5% |
50.94%
1.6 pts better
|
Numerator 42 · Denominator 80 |
| Pressure ulcers or injuries, new or worsened | 2.5% |
2.29%
0.2 pts worse
|
Numerator 3 · Denominator 120 · Adjusted rate 1.72% |
| Healthcare-associated infections requiring hospitalization | 5.99% |
7.12%
1.1 pts better
|
No Different than the National Rate · Eligible stays 72 · Observed rate 5.56% · Lower 95% interval 3.45% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 140 |
| Staff flu vaccination coverage | 90.4% |
42%
48.4 pts better
|
Numerator 160 · Denominator 177 |
| Discharge function score | 57.5% |
56.45%
1 pts better
|
Numerator 46 · Denominator 80 |
| Transfer of health information to provider | 97.14% |
95.95%
1.2 pts better
|
Numerator 34 · Denominator 35 |
| Transfer of health information to patient | 72.73% |
96.28%
23.5 pts worse
|
Numerator 16 · Denominator 22 |
| Resident COVID-19 vaccinations up to date | 17.91% |
25.2%
7.3 pts worse
|
Numerator 12 · Denominator 67 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.9 |
1.7
0.2 pts worse
|
1.9
About the same
|
Long Stay · 20240701-20250630 · Adjusted 1.9 · Observed 1.8 · Expected 1.9 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.6 |
1.3
0.7 pts better
|
1.8
1.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.6 · Observed 0.6 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.7% |
91.2%
6.5 pts better
|
93.4%
4.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 96.6% · Q2 98.3% · Q3 98.2% · Q4 97.6% · 4Q avg 97.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 95.8% |
95.3%
0.5 pts better
|
95.5%
0.3 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 95.8% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.9% |
3.0%
1.1 pts better
|
3.3%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 1.7% · Q3 2.4% · Q4 2.4% · 4Q avg 1.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 7.0% |
18.5%
11.5 pts better
|
11.4%
4.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.5% · Q2 9.0% · Q3 6.4% · Q4 7.0% · 4Q avg 7.0% |
| Percentage of long-stay residents who lose too much weight | 1.2% |
6.1%
4.9 pts better
|
5.4%
4.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 0.0% · Q3 1.3% · Q4 1.9% · 4Q avg 1.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 4.1% |
13.5%
9.4 pts better
|
19.6%
15.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.1% · Q2 4.1% · Q3 3.7% · Q4 4.3% · 4Q avg 4.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 11.9% |
14.8%
2.9 pts better
|
16.7%
4.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.7% · Q2 12.3% · Q3 10.2% · Q4 12.6% · 4Q avg 11.9% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.2%
0.2 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 16.9% |
15.1%
1.8 pts worse
|
16.3%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.5% · Q2 12.5% · Q3 11.6% · Q4 22.0% · 4Q avg 16.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 22.3% |
15.5%
6.8 pts worse
|
14.9%
7.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.7% · Q2 17.7% · Q3 16.0% · Q4 28.9% · 4Q avg 22.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.2% |
0.6%
0.6 pts worse
|
1.0%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 0.4% · Q3 1.2% · Q4 1.6% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 4.2% |
1.4%
2.8 pts worse
|
1.7%
2.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.6% · Q2 6.5% · Q3 4.9% · Q4 1.9% · 4Q avg 4.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 19.1% |
20.8%
1.7 pts better
|
19.8%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.4% · Q2 20.1% · Q3 19.7% · Q4 19.2% · 4Q avg 19.1% |
| Percentage of long-stay residents with pressure ulcers | 8.2% |
6.9%
1.3 pts worse
|
5.1%
3.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.1% · Q2 9.3% · Q3 6.3% · Q4 7.8% · 4Q avg 8.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 94.5% |
76.7%
17.8 pts better
|
81.7%
12.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 91.0% · Q2 92.6% · Q3 97.0% · Q4 96.2% · 4Q avg 94.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 1.7% |
9.7%
8 pts better
|
12.0%
10.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 1.7% · Observed 2.1% · Expected 13.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.8% |
1.2%
0.4 pts better
|
1.6%
0.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 0.0% · Q3 0.0% · Q4 0.9% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 95.2% |
78.8%
16.4 pts better
|
79.7%
15.5 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 95.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 15.6% |
20.6%
5 pts better
|
23.9%
8.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 15.6% · Observed 19.8% · Expected 30.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-04-11 · Fire 2020-09-14
1 health deficiencies
Top issue: Resident Assessment and Care Planning (1 deficiency)
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Cycle 3
Health 2020-09-14 · Fire 2018-11-01
2 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
1 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2023-04-11
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-06-22
E · Potential for more than minimal harm
2023-04-11
K252 · Egress Deficiencies
Fire Safety
Provide at least two remote exits on each floor or fire section of the building.
Corrected 2023-06-16
E · Potential for more than minimal harm
2023-04-11
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2023-06-16
E · Potential for more than minimal harm
2023-04-11
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-06-16
D · Potential for more than minimal harm
2023-04-11
K131 · Construction Deficiencies
Fire Safety
Meet requirements for sections of health care facilities separated by fire resistive construction.
Corrected 2023-06-16
D · Potential for more than minimal harm
2023-04-11
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-06-16
D · Potential for more than minimal harm
2023-04-11
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2023-06-16
C · Minimal harm
2023-04-11
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-06-16
C · Minimal harm
2023-04-11
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-06-16
C · Minimal harm
2023-04-11
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-06-16
C · Minimal harm
2023-04-11
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2023-06-16
C · Minimal harm
2023-04-11
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-06-16
C · Minimal harm
2023-04-11
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-06-16
D · Potential for more than minimal harm
2020-09-14
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2020-10-12
D · Potential for more than minimal harm
2018-11-01
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2018-11-15
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-07-23
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2025-09-22
D · Potential for more than minimal harm
2025-07-23
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2025-09-22
D · Potential for more than minimal harm
2025-07-23
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-10-01
B · Minimal harm
2025-07-23
F847 · Administration Deficiencies
Health
Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
Corrected 2025-09-22
D · Potential for more than minimal harm
2023-04-11
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-05-08
D · Potential for more than minimal harm
2023-04-11
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2023-05-08
D · Potential for more than minimal harm
2020-09-14
F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2020-11-14
Penalties and ownership
What sits behind the stars
Ownership
Brachfeld, Joseph
5% Or Greater Direct Ownership Interest · Individual
Hartman, Israel
5% Or Greater Direct Ownership Interest · Individual
Isaac E Goldbrenner Estate
5% Or Greater Direct Ownership Interest · Organization
Daniel, David
Operational/Managerial Control · Individual
Feldman, Benjamin
Operational/Managerial Control · Individual
Gross, Avrohom
Operational/Managerial Control · Individual
Hartman, Israel
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Wayne Center For Nursing & Rehabilitation
Bronx, NY
3-star overall rating with 3-star inspections with 7 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#2
Mosholu Parkway Nursing & Rehabilitation Center
Bronx, NY
2-star overall rating with 1-star inspections with $3,174 in total fines with 11 recent health deficiencies with 21 fire-safety deficiencies in the latest cycle
#3
St Patricks Home
Bronx, NY
4-star overall rating with 3-star inspections with $51,500 in total fines with 4 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
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