Prestige Nursing Care & Rehab Center

In the surveyor’s words

From the most serious findings on record at Prestige Nursing Care & Rehab Center, in the surveyor’s own words.

• Immediate jeopardy, widespreadF689Feb 25, 2021

  F689- S/S = L Free of Accident Hazards/Supervision/Devices The Citadel Rehab and Nursing Center at Kingsbridge NY 906 Based on observation, interviews and record review conducted during an abbreviated survey (Complaint # NY 906) from [DATE] to [DATE], the facility staff failed to provide adequate supervision and an environment free from accident hazards. Specifically, new windows were installed in the resident's fourth floor room during a project completed from [DATE] to [DATE]. The facility failed to ensure the window's safety latch was in place to prevent the window from tilting into the room and fully opening. […]

• Actual harm, isolatedF689Feb 5, 2025

  Based on observation, record review, and interviews conducted during an Abbreviated Survey (NY00335650), the facility failed to provide adequate supervision to a resident to prevent accidents. This was evident for one (1) of three (3) residents (Resident #1) sampled. Specifically, on [DATE] at 11:00 AM, Resident #1 fell off their bed onto the floor while Certified Nursing Assistant #1 was providing bed mobility care by themself. Registered Nurse Supervisor #1 assessed Resident #1 to have swelling of their right elbow, and complaints of pain to their head, right arm, elbow, and back. Resident #1 was transferred to the hospital on [DATE] at 2:55 PM and was admitted to the hospital with diagnoses of right arm and pelvis fracture. […]

• No harm, potential for more than minimal, patternF584Apr 16, 2026

  Based on observation, record review, and interviews, the facility failed to ensure that residents' right to a safe, homelike environment was maintained. This was evident in two (2) shower rooms observed during the Environmental Task. Specifically, two (2) clear overhead lighting fixture coverings in the Six (6) [NAME] unit shower room were observed to be cracked or had broken circular areas, and the faucet on a sink in the Four (4) East unit was loose and became partially detached from the sink's base when used. The findings include:The facility policy and procedure titled, Homelike Environment, reviewed 01/2026, documented it is the policy of the facility to create and sustain a home-like environment that supports each residents' physical, emotional, and psychosocial well-being. […]

• No harm, potential for more than minimal, patternF812Apr 16, 2026

  Based on observations and interviews, the facility failed to ensure that food was stored in accordance with professional standards for food service safety. This was evident for three (3) of five (5) kitchen refrigerators that were observed during the initial kitchen tour. Specifically, walk-in refrigerator #1 was observed to contain unlabeled and undated cups of almond milk, walk-in refrigerator #2 was observed to contain outdated cooked food and undated defrosting food, and the kitchen pantry refrigerator contained four (4) ounce fruit and pudding cups that were undated and/or outdated.The findings include: The facility policy and procedure titled, Food Storage, with review date of 10/2025, documented that all use by dates will function as safety dates and all frozen food will be stored… […]

• No harm, potential for more than minimal, patternF609Mar 8, 2024

  Based on record review and interviews conducted during the recertification and complaint (NY00324696 and NY00318663) survey from 3/3/2024 to 3/8/2024, the facility did not ensure that all alleged violations involving abuse were immediately reported to the New York State Department of Health, but not later than 2 hours after the allegation was made. This was evident for 3 (Resident #265, #181, and #66) of 38 total sampled residents. Specifically, 1) Resident #265's abrasion and bruise to their face and head of unknown origin were not reported to the New York State Department of Health, and 2) a resident-to-resident altercation between Resident #181 and #66 was not reported to the New York State Department of Health within 2 hours of occurrence. […]