Cycle 1
Health 2024-09-23 · Fire 2024-09-23
5 health deficiencies
Top issue: Infection Control (1 deficiency)
3 fire-safety deficiencies
Top issue: Construction (1 deficiency)
Bronx, NY
Bronx Park Rehabilitation & Nursing Center
4-star overall rating with 4-star inspections with 5 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
3845 Carpenter Ave, Bronx, NY
(718) 798-1100
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
240
Certified beds
Average residents
230
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1972-08-27
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
0.39
Registered nurse staffing · state 0.70 · national 0.68
LPN hours / resident day
0.69
Licensed practical nurse staffing · state 0.78 · national 0.87
Aide hours / resident day
2.06
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
3.14
All reported nurse hours · state 3.65 · national 3.89
Licensed hours
1.08
RN + LPN hours · state 1.47 · national 1.54
Weekend hours
2.91
Weekend nurse staffing · state 3.16 · national 3.43
Weekend RN hours
0.22
Weekend registered nurse coverage · state 0.47 · national 0.47
Physical therapist
0.10
Reported PT staffing · state 0.11 · national 0.07
Adjusted RN hours
0.36
CMS adjusted RN staffing hours
Adjusted total hours
2.88
CMS adjusted total nurse staffing hours
Case-mix index
1.49
Higher values indicate more complex resident acuity
RN turnover
22%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
18%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Value-based purchasing
Program rank
6,571
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
32.40
Composite VBP score used to determine payment impact.
Payment multiplier
0.9871
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
1.19
Baseline 17.88% · Performance 20.88% · Measure score 1.19 · Achievement 1.19 · Improvement 0
Healthcare-associated infections
3.56
Baseline 7.92% · Performance 6.77% · Measure score 3.56 · Achievement 3.56 · Improvement 3.42
Total nurse turnover
8.21
Performance 30.12% · Measure score 8.21 · Achievement 8.21 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
0
Baseline 2.63 hours · Performance 2.50 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.4% |
10.72%
1.3 pts better
|
No Different than the National Rate · Eligible stays 77 · Observed rate 5.19% · Lower 95% interval 6.18% |
| Discharge to community | 28.39% |
50.57%
22.2 pts worse
|
Worse than the National Rate · Eligible stays 37 · Observed rate 10.81% · Lower 95% interval 16.67% |
| Medicare spending per beneficiary | 1.84 |
1.02
0.8 pts worse
|
|
| Drug regimen review with follow-up | 87.67% |
95.27%
7.6 pts worse
|
Numerator 64 · Denominator 73 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 73 |
| Discharge self-care score | 78.05% |
53.69%
24.4 pts better
|
Numerator 32 · Denominator 41 |
| Discharge mobility score | 68.29% |
50.94%
17.4 pts better
|
Numerator 28 · Denominator 41 |
| Pressure ulcers or injuries, new or worsened | 1.37% |
2.29%
0.9 pts better
|
Numerator 1 · Denominator 73 · Adjusted rate 0.7% |
| Healthcare-associated infections requiring hospitalization | 6.77% |
7.12%
0.4 pts better
|
No Different than the National Rate · Eligible stays 55 · Observed rate 7.27% · Lower 95% interval 4.05% |
| Staff COVID-19 vaccination coverage | 4.39% |
8.2%
3.8 pts worse
|
Numerator 10 · Denominator 228 |
| Staff flu vaccination coverage | 99.35% |
42%
57.3 pts better
|
Numerator 305 · Denominator 307 |
| Discharge function score | 73.17% |
56.45%
16.7 pts better
|
Numerator 30 · Denominator 41 |
| Transfer of health information to provider | 67.74% |
95.95%
28.2 pts worse
|
Numerator 21 · Denominator 31 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 7.69% |
25.2%
17.5 pts worse
|
Numerator 4 · Denominator 52 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 3.0 |
1.7
1.3 pts worse
|
1.9
1.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.0 · Observed 2.3 · Expected 1.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.7 |
1.3
0.4 pts worse
|
1.8
0.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.7 · Observed 1.3 · Expected 1.3 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.9% |
91.2%
8.7 pts better
|
93.4%
6.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 99.6% · 4Q avg 99.9% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 99.2% |
95.3%
3.9 pts better
|
95.5%
3.7 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 99.2% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.8% |
3.0%
2.2 pts better
|
3.3%
2.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.5% · Q2 0.4% · Q3 0.9% · Q4 1.3% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 73.5% |
18.5%
55 pts worse
|
11.4%
62.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 88.0% · Q2 86.4% · Q3 60.4% · Q4 59.5% · 4Q avg 73.5% |
| Percentage of long-stay residents who lose too much weight | 4.9% |
6.1%
1.2 pts better
|
5.4%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.2% · Q2 3.7% · Q3 3.2% · Q4 6.5% · 4Q avg 4.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 2.4% |
13.5%
11.1 pts better
|
19.6%
17.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 3.1% · Q3 2.2% · Q4 2.2% · 4Q avg 2.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 13.0% |
14.8%
1.8 pts better
|
16.7%
3.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.8% · Q2 14.6% · Q3 13.9% · Q4 12.9% · 4Q avg 13.0% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.2% |
0.2%
About the same
|
0.1%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.4% · Q3 0.0% · Q4 0.4% · 4Q avg 0.2% |
| Percentage of long-stay residents whose ability to walk independently worsened | 21.3% |
15.1%
6.2 pts worse
|
16.3%
5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.1% · Q2 29.9% · Q3 21.6% · Q4 12.8% · 4Q avg 21.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 20.7% |
15.5%
5.2 pts worse
|
14.9%
5.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.1% · Q2 26.2% · Q3 20.7% · Q4 16.7% · 4Q avg 20.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.9% |
0.6%
0.3 pts worse
|
1.0%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.8% · Q2 1.5% · Q3 1.0% · Q4 0.4% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.0% |
1.4%
0.6 pts worse
|
1.7%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 2.8% · Q3 1.4% · Q4 1.4% · 4Q avg 2.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 3.7% |
20.8%
17.1 pts better
|
19.8%
16.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 1.9% · Q3 3.9% · Q4 4.8% · 4Q avg 3.7% |
| Percentage of long-stay residents with pressure ulcers | 5.7% |
6.9%
1.2 pts better
|
5.1%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.1% · Q2 4.0% · Q3 6.2% · Q4 5.3% · 4Q avg 5.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 95.9% |
76.7%
19.2 pts better
|
81.7%
14.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 94.1% · Q2 96.6% · Q3 98.0% · Q4 95.7% · 4Q avg 95.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 5.8% |
9.7%
3.9 pts better
|
12.0%
6.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 5.8% · Observed 5.9% · Expected 11.3% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.1% |
1.2%
0.9 pts worse
|
1.6%
0.5 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 3.7% · Q3 0.0% · Q4 0.0% · 4Q avg 2.1% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 96.5% |
78.8%
17.7 pts better
|
79.7%
16.8 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 96.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 31.1% |
20.6%
10.5 pts worse
|
23.9%
7.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 31.1% · Observed 33.3% · Expected 25.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-06-21 · Fire 2022-06-21
1 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
4 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Cycle 3
Health 2019-08-29 · Fire 2019-08-29
0 health deficiencies
No concentrated health issue counts in this cycle.
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2024-09-23
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2024-10-23
D · Potential for more than minimal harm
2024-09-23
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2024-10-23
D · Potential for more than minimal harm
2024-09-23
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-10-23
E · Potential for more than minimal harm
2022-06-21
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2022-08-13
E · Potential for more than minimal harm
2022-06-21
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2022-08-13
D · Potential for more than minimal harm
2022-06-21
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2022-08-13
D · Potential for more than minimal harm
2022-06-21
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2022-08-13
D · Potential for more than minimal harm
2019-08-29
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2019-10-25
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-12-09
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-12-10
D · Potential for more than minimal harm
2024-09-23
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2024-11-08
D · Potential for more than minimal harm
2024-09-23
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2024-11-08
D · Potential for more than minimal harm
2024-09-23
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-11-08
D · Potential for more than minimal harm
2024-09-23
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-11-08
D · Potential for more than minimal harm
2022-06-21
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2022-07-29
Penalties and ownership
What sits behind the stars
Ownership
Loren, Miriam
5% Or Greater Direct Ownership Interest · Individual
Chang, Jonathan
Operational/Managerial Control · Individual
Freifeld, Steven
Operational/Managerial Control · Individual
Freifeld, Steven
Corporate Officer · Individual
Loren, Miriam
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
Bainbridge Nursing & Rehabilitation Center
Bronx, NY
5-star overall rating with 4-star inspections with 4 recent health deficiencies with 13 fire-safety deficiencies in the latest cycle
#3
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
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