BronxCare Special Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interviews, the facility failed to ensure that the resident's representative was notified of a change in resident's condition. This was evident in 1 (one) (Resident #143) of 1 resident reviewed out of 35 total sampled residents. Specifically, the facility did not inform Resident #143's family representative that the resident's fourth fingernail on the right hand was detached. The findings include: The facility policy and procedure titled Change in Condition which was last reviewed on 01/2025 documented that the charge nurse/supervisor will notify the resident's family member or designee of any or all change in condition that differs from the resident's baseline. Resident #143 was admitted with diagnoses that included Cerebrovascular Accident and Hypertension. The quarterly Minimum Data Set assessment dated [DATE] documented Resident #143 was severely cognitively impaired. and that resident required substantial assistance with all activities of daily living.On 08/11/2025…

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 report all alleged violations involving neglect, abuse, and/or including injuries of unknown source to the State Survey Agency. This was evident for one (1) (Resident #143) of six (6) residents reviewed for abuse out of 35 total sampled residents. Specifically, on 05/23/2025, Resident #143's fourth finger on the right hand was bleeding and was subsequently noted with a detached fingernail on 05/24/2025. The resident was cognitively impaired and could not explain how the injury had occurred This incident was not reported to the New York State Department of Health. Cross Reference: F580 - Notify of ChangesThe findings include: The facility's policy and procedure titled Abuse Prevention Protocol with a last revised date of 06/2025 documented the investigator is trained to report incidents to the New York State Department of Health when there is reasonable cause for resident abuse. The policy stated that federal regulations require reporting…

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 that a resident received treatment and care in accordance with professional standards of practice. This was evident in one (1) (Resident #238) of one (1) resident reviewed out of 35 total sampled residents. Specifically, on 05/16/2025, Resident #238 was observed with thick, brownish, foul smelling penile discharge. The attending physician was not appropriately notified of Resident #238's change in condition resulting to a delay in medical intervention. The findings include:The facility's policy and procedure titled Change in Condition with a reviewed date of 01/2025 documented at the time a change in condition is identified, the nurse will notify the medical doctor, document all findings in the assessment and evaluation in a progress note, and document the change in condition on the 24-hour report.Resident #238 had diagnoses of Non-Alzheimer's Dementia, Coronary Artery Disease, and Benign Prostatic Hyperplasia without lower…

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 during the Recertification and Complaint (#668295) Survey, the facility failed to ensure that food was served at an appetizing temperature during meals. This was evident in one (1) (Unit 4) of five (5) units. Specifically, food served during meal service were not maintained at palatable and appetizing temperatures.The findings include:The facility's policy and procedure titled Food Temperatures with a reviewed date of 02/2024 documented all food is to be prepared, held, and served within the appropriate ranges to provide the highest quality of food and maintain aesthetic value of food. Minimum temperature for hot food is above 140 degrees Fahrenheit. During the Resident Council meeting on 08/08/2025, Residents #138 and #146 stated that food are often served lukewarm, and at times were served cold during meal service. The residents stated staff should not eat their meals prior to serving meals to the residents because meals are served late, not hot, and sometimes run out. Resident #66 stated food are served cold because meals 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.

Based on record review and staff interviews during the Recertification and Complaint survey, the facility did not ensure that a surety bond or similar protection with the amount equal to at least the current total amount of resident's funds. Specifically, the surety bond held by the facility did not cover the total amount of resident personal funds deposited with the facility. This was evident for 111 residents with personal funds out of 238 residents in the facility. The findings are: On 6/7/23 at 10:16am, the Finance Manager presented a surety bond in the amount of $150,000 with an effective date of 5/4/2009. The finance ledger dated 6/7/2023 with residents funds amount documented the current total amount of resident's funds was $257,687.53. The facility did not ensure that the value of the surety bond covered funds currently held in all residents accounts. On 6/7/23 at 12:54pm, the Finance Manager stated the amount of the surety bond was established in 2007. The Finance Manager stated there is an additional $90,000 in a CD (certificate of deposit), totaling the amount of surety…

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 reviews, and staff interviews conducted during the Recertification survey from 6/1/23 through 6/8/23, the facility did not ensure that Gradual Dose Reduction (GDR) was attempted for a prescribed psychotropic medication. This was evident in 2 (Resident #113 and #82) of 5 residents reviewed for Unnecessary Medication out of a sample of 38 residents. Specifically, 1) Resident #113 had a diagnosis of dementia and was prescribed and administered Risperidone for agitation with no GDR attempted, and 2) Resident # 82 had a diagnosis of dementia and was prescribed Divalproex and Citalopram without a GDR attempt. The findings are: The facility policy titled Psychopharmacological Drugs/Chemical Restraints revised August 2022 documented that the policy is to ensure that all residents maintained on psychopharmacological medication are on the lowest dosage of drug to achieve effects and are reviewed on a regular basis to evaluate need for continued use. 1.) Resident # 113 was admitted to 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 the Recertification survey from 6/1/23 through 6/8/23, the facility did not ensure that each resident or resident representative was offered the opportunity to participate in the review of their Comprehensive Care Plan s (CCP). This was evident for 2 out of 4 residents reviewed for care planning out of a sample of 38 residents. (Resident #54 and Resident #444). Specifically, Resident #54 and Resident # 444 were not invited to participate in their care plan meeting. The findings are: The facility policy titled Comprehensive Care Planning (CCP) with no effective date and last updated in September 2022 documented the CCP will be prepared by the interdisciplinary team that includes the input from the resident when appropriate and the resident's family or legal representative. It also documented the Social Work Department staff will make a phone call and/or mail a letter of invitation to the designated representative prior to the meeting to invite them to…

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 conducted during the Recertification and Complaint survey, the facility did not ensure that residents are informed and provided written information concerning their right to accept or refuse medical or surgical treatment and, at the resident's option, formulate an advance directive. This includes a written description of the facility's policies to implement advance directives and applicable State law. This was evident for 3 of 3 residents reviewed for Advance directive out of 35 sample residents (Residents #23, #121, and #229). Specifically, the facility failed to discuss and provide information concerning the resident's right and option to formulate an advance directive for newly admitted resident. The findings are: The facility Policy and Procedures titled Advance Directives dated June 2009, last revised August 2022, documented that the facility will conform to all applicable laws and regulatory agencies requirement while maintaining a program that ensures…

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 staff interview conducted during the Recertification/Complaint survey from 6/1/23 to 6/8/23, the facility did not ensure that the resident and their representatives were provided with a written summary of the baseline care plan. This was evident for 1 of 3 residents reviewed for Advance Directive out of a sample of 35 residents. (Resident #229). The finding is: The facility policy and procedure titled Comprehensive Care Planning - Baseline Care Plans dated September 2022 documented: .The facility must provide the resident and their representative with a summary of the baseline care plan that includes but not limited to: The initial goals of the resident; A summary of the resident's medication and dietary instructions; Any services and treatments to be administered by the facility and personnel acting on behalf of the facility; Any updated information based on the details of the comprehensive care plan, as necessary. Resident #229 was admitted to the facility with diagnoses 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 observation, interview, and record review conducted during the Recertification Survey from 6/1/23 to 6/8/23, the facility did not ensure a comprehensive care plan (CCP) was reviewed and revised to reflect changes in the resident's care. This was evident for 1 (Resident #444) of 2 residents reviewed for Respiratory out of 38 total sampled residents. Specifically, Resident #444's CCP was not reviewed and revised to reflect that Resident #444 was receiving oxygen therapy. The findings are: The facility policy titled Comprehensive Care Planning (CCP) with no effective date and last updated in September 2022 documented the CCP will be kept current by all disciplines on an ongoing basis. It also documented each discipline will be responsible for updating the care plan and alerting the team that a new problem has been identified. Resident #444 was admitted to the facility with diagnosis including Respiratory failure with hypoxia, Heart failure, and Chronic Obstructive Pulmonary Disease) The admission Minimum…

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 conducted during the Recertification survey from 6/1/23 through 6/8/23, the facility did not ensure a resident with an indwelling Foley catheter was provided care consistent with professional standards of practice. Specifically, a resident was observed several times with an indwelling Foley catheter without a Medical Doctor's Order (MDO). This was evident in 1 of the 1 residents reviewed for urinary catheter out of 38 sample residents. (Residents # 105). The findings include: The facility policy and procedure titled Urinary Catheterization dated 9/2022 documented that urinary catheter should be placed under the direction of a physician's order-catheter change monthly and as needed by a licensed nurse. Resident #105 was admitted to the facility with a diagnosis of Urinary Tract Infection and Manic Depression. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented that the resident had an indwelling catheter. On 6/1/23 at 10:38 AM, 6/2/23 at…

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 staff interviews conducted during re-certification survey, the facility did not report an alleged incident of resident-to-resident sexual abuse was reported to the New York State Department of Health (NYSDOH) within 2 hours. Specifically, the Certified Nursing Assistant (CNA #1) reported that she observed Resident #23 and Resident #38 (a cognitively impaired resident) engaged in inappropriate sexual behavior in the dining room. The facility did not report this allegation of resident-to-resident abuse to NYSDOH. This was evident for 2 of 3 residents sampled for abuse (Resident #23 and Resident # 38). The findings include: The facility's policy and procedure titled Abuse Prevention Protocol with a revised date 01/22/2020 states that an investigator is trained to report incident to NYSDOH Long Term Care bureau when there is reasonable cause for patient abuse without necessarily completing internal investigation. The policy further states that the federal regulations require reporting of…

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 staff interviews conducted during a recertification survey, the facility did not ensure that an allegations of abuse were thoroughly investigated and corrective actions were implemented. Specifically, (1) an allegation of potential resident-to-resident sexual abuse reported by a Certified Nursing Assistant (CNA #1) who observed Resident #23 and Resident #38 (a cognitively impaired resident) engaged in sexually inappropriate behavior was not thoroughly investigated; and (2) a resident's allegations of abuse and neglect were not thoroughly investigated, and the corrective action of having male CNA's assigned was not implemented (Resident #63). This was evident for 3 of 3 residents reviewed for Abuse (Resident #s 23, 38, and 63) for 2 abuse allegations reviewed. The findings include: The facility's policy and procedure titled Abuse Prevention Protocol with a revised date 01/22/2020 documented that the nursing supervisor, department heads or designees are trained to make the initial…

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.