Bronx Gardens Rehabilitation and Nursing Center

Based on observation, record review, and interview the facility failed to provide maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. This was evident for 1 (2nd floor) of 2 units. Specifically, residents' rooms in 2nd floor had mismatched paints and the dirty linen room had chipped paint. The findings include: The facility's undated policy titled Environmental Services documented it is the policy of the facility to provide homelike environment for all residents. On 06/16/2025 to 06/23/2025 between 10:00 AM and 2:00 PM, the following observations were made on the 2nd Floor: a.) Rooms 201, 202 and 203 had mismatched paint on the walls. b.) The paints were chipped on the clean and dirty linen room doors. The Maintenance and Housekeeping logs showed no evidence of repair requested for the above concerns. On 06/24/2025 at 11:23 AM, the Director of Maintenance was interviewed stated they are busy on the other units and have not been able to address the mismatched and chipped paint on the 2nd Floor. On 06/24/2025 at 12:20 PM, the Administrator was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interviews, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice. Specifically, 1. The facility failed to ensure that a physician-ordered pulmonology consultation for 1 (Resident #41) of 3 residents was completed or appropriately followed up. 2. During wound care observation, Registered Nurse #4 did not apply the correct treatment ordered by the physician to treat Resident #116's arterial ulcers. Additionally, Resident #116 was not provided pressure relieving devices as ordered by the physician. This was evident for 1 (Resident #116) of 3 residents reviewed for pressure ulcer injury. The findings include: 1. The facility's policy titled Onsite/Offsite Consultant Services with a last reviewed date of 02/2025 stated Our facility may use as needed outside resources for consults to furnish specific services to residents and to the facility. Such personnel are employed on a consultant basis. The facility's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, and interviews, the facility failed to ensure sufficient nursing staff were available to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial wellbeing of each resident. Specifically, review of the weekend staffing and the Payroll Based Journal Staffing Data Report showed low weekend staffing. The findings include but are not limited to: The Payroll Based Journal Staffing Data Report for the 2nd quarter of 2025 (01/01/2025 - 03/31/2025) documented that low weekend staffing was triggered. The facility's policy and procedure titled Nursing Staffing, last reviewed on 02/2025, stated that the Staffing Coordinator maintains the master staffing schedule. Anyone needing a change in the schedule must place the request in writing and date it, then present it to the Staffing Coordinator to review and approve or deny the request. In the event of an unexpected illness or event, the employee must notify the facility a minimum of at least 2 hours before the shift…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interviews, the facility failed to provide appropriate respiratory equipment at the resident's bedside for immediate access , such as for unplanned extubation. This was evident for 1 (Resident # 89) out of 3 residents reviewed for Respiratory Care out of 38 sampled residents. Specifically, Resident #89, who had a tracheostomy, was observed without an ambu bag immediately available at bedside. The findings include: The undated facility's policy titled Tracheostomy Tube Change Procedure stated that ambu bag shall be readily available for emergency use for residents who has tracheostomy. Resident #89 had diagnoses that included Chronic Obstructive Pulmonary Disease, Chronic Respiratory Failure with Hypoxia and Chronic Lung Disease. The annual Minimum Data Set assessment dated [DATE] documented that Resident #89 had severed impaired cognition and received tracheostomy care and suctioning while residing in the facility. The interdisciplinary Care Plan on respiratory /…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, and interviews, the facility failed to ensure food was stored in accordance with professional standards for food service safety. This was evident for 1 of 3 kitchen refrigerators that were observed during the initial kitchen tour. Specifically, the kitchen snack/nourishment refrigerator was observed to contain staff food. The findings include: The facility's policy and procedure titled Food Storage reviewed on 02/2025 documented that it is the policy of the facility that food brought into the facility ensures proper storage and infection control practices. Staff food is not to be stored in patient food refrigerators. On 06/16/2025 at 9:34 AM, an initial kitchen observation was conducted with the Food Service Director. The Snack/ Nourishment Refrigerator was observed with a plastic bag that contained an unlabeled and undated quart sized bowl of spaghetti and meatballs. On 06/16/2025 at 9:39 AM, the Food Service Director was interviewed and stated that the undated, unlabeled quart sized bowl of spaghetti and meatballs that was observed in the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews conducted during an Abbreviated Survey (NY00368174), the facility did not ensure that the alleged violations involving abuse, neglect, exploitation or mistreatment, were reported immediately, but not later that two (2) hours after the allegation is made, if the events that caused the allegation involved or resulted in serious bodily injury, or not later than 24 hours if the events that caused the allegation do not involved abuse and do not result in serious bodily injury, to the administrator of the facility of the facility and to other officials (including to the State Agency and adult protective services where state law provides for judications in long term care facilities). This was evident for one (1) out of four (4) (Resident #2) residents sampled. Specifically, on 01/03/2025 at around 10:00 AM Resident #2 reported to the Physician Assistant that Resident #3 grabbed their hands then held them by the throat on the morning of 01/02/2025 while they were in their room. The…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews and interviews, conducted during the recertification and abbreviated survey (# NY00303337, NY00305634) from 4/13/23 to 4/24/23, the facility did not ensure all alleged violations involving abuse were reported to the New York State Department of Health (NYSDOH) immediately, but not later than 2 hours after the allegation was made, if the events that cause the allegation result in serious bodily injury. This was evident for 2 (Residents #145 and #88) of 5 residents reviewed for Accidents of 38 total sampled residents. Specifically, 1.) the facility did not report Resident #145's left hip fracture from an unwitnessed fall to the NYSDOH within 2 hours of occurrence, and 2) the facility did not report Resident #88's unwitnessed fall resulting in hospitalization and left tibia fracture to the NYSDOH within 2 hours of occurrence. The findings are: The facility policy titled Reporting Requirements to Local State & Federal Authority last revised 10/2022, documented incidents…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and record review conducted during the Recertification and Abbreviated survey (NY00305634) from 4/17/23 through 4/24/23, the facility did not ensure that person-centered care plans (CCP) with measurable goals, time frames and interventions were developed to address a resident's concerns. This was evident for 1 (Resident #88) of 5 residents reviewed for accidents out of a sample of 38 residents. Specifically, a CCP was not developed to address Resident #88's left tibia fracture. The findings are: A facility policy titled Resident Assessment with effective date 8/21/2019, last reviewed 8/10/22 documented a comprehensive assessment includes development of the comprehensive care plan. Resident #88 has a diagnosis of respiratory failure/ventilator dependence and quadriplegia. The Minimum Data Set 3.0 (MDS) dated [DATE] documented Resident #88 was severely cognitively impaired, and the resident had no fractures. The facility Incident Investigation initiated 11/1/22 and completed on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review conducted during a recertification survey, the facility did not ensure that its medication error rate did not exceed 5% or greater. Specifically, the Registered Nurse did not administer Vitamin B12 as ordered, and the resident's first name on the medication labels for two medications administered was incorrect (Resident #490). This resulted in a total medication error rate of 11.54 %. This was observed during the Medication Administration task. The findings are: The facility Policy and Procedure titled Medication/Treatment Administration last revised on 2/10/23 documented residents shall receive all medications as ordered by the physician. Nurses will safely administer medications with knowledge of the therapeutic effects, contraindications, side effects and drug interactions that may occur. The nurse will review the Medication Administration Record and pour all medications for the individual resident observing the five rights of medication administration that…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews conducted during the Recertification survey from 4/17/23 to 4/24/23, the facility did not ensure the safe and secure storage of medications in accordance with currently accepted professional standards. Specifically, Lumigan 0.01 % eye drops and Brimonidine 0.2 %-Timolol 0.5 % eye drops were kept in the resident's bedside table. This was observed during the Medication Administration Task. (Resident #490) The findings are: The facility policy titled Medication Storage dated 2/10/23 documented the facility will store medications in a manner that maintains the integrity of the product, ensure the safety of the residents. The policy also documented that the medications are to be stored and locked in medication rooms, providing security standards. Resident #490 was admitted to the facility with diagnoses which included Bipolar disorder and Vitamin B12 deficiency anemia. The Minimum Data Set (MDS) assessment dated [DATE] documented that Resident #490 had a moderately impaired…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review and interviews, conducted during the Recertification survey from 4/17/23 - 4/24/23, the facility did not ensure that garbage was properly disposed. Specifically, the garbage receptacle was not covered while garbage was being transported to the dumpster area. This was evident during the Kitchen facility task. The findings are: The Nutrition Service policy titled Waste Disposal effective date 1/2019, review date 2/2023, states to handle dispose waste efficiently, safely and in a sanitary manner, containers must be non-porous, durable, rust free, and chip free with a cover. The procedure states that all garbage containers must be covered with a tight-fitting lid or cover. Trash bags are sealed and transported to the garbage dumpster. On 4/21/23 at 11:08 AM, Dietary Aide (DA) #1 was observed doing trash disposal. DA #1 took the lid off of the large garbage receptacle housed just outside of the kitchen. DA #1 then transported the uncovered garbage receptacle through a long tunnel that leads into the adjacent hospital where the dumpster area was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview conducted during the recertification survey, the facility did not ensure that the assessment accurately reflected the resident's status. Specifically, the resident's dental status reflected on the Minimum Data Set (MDS) did not include broken and carious teeth. This was evident of 1 out of 1 resident reviewed for Dental Care out of a sample of 38 residents (Resident #435). The finding is: The facility policy titled Processing of Consultation policy dated 8/22/10 and last reviewed dated 9/18/20 documented under the section titled policy All residents will receive consultant services per written request of attending Physician. These services are provided in the Nursing Home except in circumstances where needed equipment to render service is not available in the Nursing Home. The facility policy titled MDS 3.0 dated 12/94 and last reviewed 3/2020 documented under the section titled Purpose: the facility shall conduct initial and periodical assessments that are…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.