Bronx Center for Rehabilitation & Health Care

Inspectors wroteBased on observation, record review, and interviews conducted during survey, the facility failed to ensure a resident was free from physical abuse. This was evident for one out of five residents (Resident #1) sampled. Specifically, on 05/12/2026 at 2:20 PM, Licensed Practical Nurse #1 was called to Resident #1's room and the resident indicated Certified Nursing Assistant #1 hit them after they spit on them (unwitnessed). Certified Nursing Assistant #1 refused to leave the room and continued providing care, and then Resident #1 spat and kicked Certified Nursing Assistant #1 who in turn hit the resident on the right side of the face and covered their mouth with a washcloth. Resident #1 was assessed by Registered Nurse Unit Manager #1 with redness on their right cheek and complaints of pain and was transferred to the emergency room for evaluation on 05/12/2026. [...]

Inspectors wroteBased on observation, record review, and interviews during the Recertification Survey, the facility did not ensure residents receive treatment and care in accordance with professional standards of practice, and comprehensive person-centered care plan. This was evident for one (1) of five (5) residents reviewed for Unnecessary Medications (Resident #4), out of a sample of 37 residents investigated. Specifically, Resident #4 had a physician's order to notify the physician when Resident's finger stick blood sugar (method of drawing drops of blood from the finger for testing the blood glucose level) result is less than 80 milligrams per deciliter or more than 300 milligrams per deciliter. Licensed Practical Nurse #3 failed to notify the physician when Resident #4's finger stick blood sugar was higher than 300 milligrams per deciliter on 12/02/2025, 12/11/2025, 12/12/2025, and 12/13/2025.

Inspectors wroteBased on observation, record review, and interviews, the facility failed to ensure that drugs and biologicals were stored in accordance with professional standards. This was evident for two (2) (4th and 5th Floor) of five (5) units observed during medication administration. Specifically, 1.) An expired one (1) liter bag of dextrose intravenous solution and an open undated bottle of liquid hydromorphone was found in the 4th Floor medication storage room. 2.) The 5th Floor medication cart contained expired arginine powder. 3.) The 4th Floor medication cart contained multiple open and undated eye drops and liquid medications.

Inspectors wroteBased on observation, record review, and interviews, the facility failed to ensure infection control practices and procedures were maintained to provide a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infections. Specifically, 1.) Infection prevention and control practices were not maintained during residents' meal service. This was evident for one (1) of five (5) units observed during dining. 2.) The resident's clean laundry was observed hanging in a cart without a cover in the lobby and on the 3rd Floor unit.

Inspectors wroteBased on observation, record review, and interviews, the facility failed to maintain an effective pest control program so that the facility is free of pests and rodents. This was evident on the 4th Floor dining room. Specifically, a live cockroach was sighted crawling on the pantry counter near the ice machine where food and beverages were placed during lunch. In addition, the facility's pest control service record documented numerous cockroach sightings on the 4th Floor Unit.

Inspectors wroteBased on observation, record review, and interviews, the facility failed to ensure that all alleged violations involving abuse, neglect, including injuries of unknown source were reported immediately, but not later than 2 (two) hours after the allegation was made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the New York State Department of Health. This was evident for 1 (one) (Resident #11) of 2 (two) residents reviewed for abuse out of 37 total sampled residents. Specifically, on 10/20/2025, Resident #11 alleged that Certified Nursing Assistant #2 told them I heard you like to have your balls rubbed. Resident #11 felt that this was inappropriate. [...]

Inspectors wroteBased on observation, record review, and interviews the facility failed to ensure that all alleged violations involving abuse were thoroughly investigated. This was evident for 1 (one) (Resident #11) of two (2) residents reviewed for abuse out of 37 total sampled residents. Specifically, on 10/20/2025, Resident #11's family member alleged that on 10/19/2025, Certified Nursing Assistant #2 allegedly made an inappropriate remark towards Resident #11 that offended the resident. The facility initiated the investigation but did not thoroughly investigate the allegation. The facility failed to interview other staff on the unit who may have potentially witnessed the alleged incident.

Inspectors wroteBased on observation, record review, and interviews, the facility failed to ensure that a resident with limited range of motion received appropriate treatment and services to prevent further decrease in range of motion. This was evident for one (1) (Resident #9) of two (2) residents reviewed for position and mobility out of 35 total sampled residents. Specifically, Resident #9 who had a right-hand contracture, was not provided with a right palm guard as per rehabilitation recommendations.

Inspectors wroteBased on observation, record review, and interviews the facility failed to ensure that a resident received necessary respiratory care in accordance with professional standards of practice. This was evident for one (1) (Resident #159) of one (1) resident reviewed for respiratory care out of 37 total sampled residents. Specifically, Resident #159 was observed receiving oxygen via nasal cannula without a physician's order.

Inspectors wroteBased on observation, record review, and interviews the facility failed to ensure that a physician reviewed the resident's total program of care, including treatments at each visit. This was evident for one (1) (Resident #159) of one (1) resident reviewed for respiratory care out of 37 total sampled residents. Specifically, Resident #159 was observed receiving oxygen via nasal cannula. A review of interdisciplinary progress notes revealed that Resident #159 was receiving oxygen via nasal cannula, however, there was no attending practitioner's orders and indication for oxygen use.

Inspectors wroteBased on observation, record review, and interviews conducted during the Recertification Survey from 12/15/2025 to 12/22/2025, the facility did not ensure that the results of the most recent health survey were posted in a place readily accessible to residents, visitors, or legal representatives of residents, where individuals wishing to examine survey results do not have to ask to see them. Specifically, the facility stored a copy of their health survey results on the inner side of the reception desk that required those wishing to examine the results to ask the Receptionist to hand them the results.

Inspectors wroteBased on observation, record review, and interviews, the facility failed that nurse staffing information was consistently posted in a prominent place readily accessible to residents and visitors. Specifically, staffing information was not consistently posted daily; and the posting of staffing did not indicate the daily resident census.

Inspectors wroteBased on observation, interview, and record review conducted during the recertification survey from 7/10/2023 to 07/14/2023, the facility did not ensure each resident was treated with respect and dignity. This was evident for 2 (Resident #21 and #107) of 35 total sampled resident. Specifically, staff were observed standing over Resident #21 and Resident #107 while feeding them.

Inspectors wroteBased on observation, record review, and interviews conducted during the recertification survey from 7/10/2023 to 7/14/2023, the facility did not ensure that the Physician (MD) reviewed the resident's total program of care, including medications and treatments, at each visit. This was evidenced for 1 (Resident #176) of 35 total sampled residents. Specifically, the MD did not order insulin coverage for Resident #176, a resident with a diagnosis of Diabetes Mellitus (DM).

Inspectors wroteBased on observation, interviews, and record review conducted during the recertification survey from [DATE] to [DATE], the facility did not ensure biologicals were stored in accordance with professional principles. This was evident for 1 (2nd floor) of 5 medication storage rooms observed during the Medication Storage Task. Specifically, an emergency medication box (EMB) with expired medication was not removed the 2nd Floor medication room.

Inspectors wrote42 CFR 483.90(i) Other environmental conditions. The facility must provide a safe, functional, sanitary, and comfortable environment for the residents, staff and the public. 10NYCRR 415.29 Physical environment. The nursing home shall be designed, constructed, equipped, and maintained to provide a safe, health, functional, sanitary, and comfortable environment for residents, personnel, and the public. Based on observations and staff interview conducted during a Life Safety Code Recertification survey, the facility did not ensure to maintain a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. Specifically, a) missing cove base within the soiled utility room and b) lights in soiled utility room not functional. This occurred on 2 of 7 floors, including basement.

Inspectors wroteBased on observations and interviews during the Recertification Survey, the facility did not ensure that residents were cared for in a manner that maintained or enhanced his or her dignity. Specifically, two resident's Foley catheter bag and tubing were left uncovered and exposed to public view. Two residents were observed in the dining room with a gown on without any pants and the resident back was exposed. This was evident for 3 of 3 residents reviewed for Dignity (Residents# 157, Resident #484 and Resident #142).

Inspectors wroteBased on observations, record review, and interviews, during the re-certification survey, the facility did not ensure that each resident's person-centered, comprehensive care plan, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment was reviewed and revised timely to address resident's change in dental and Activities of daily Living (ADL) status. Specifically, the Comprehensive Care Plan (CCP) for Dental Care and Oral/Dental Health problems was not reviewed and revised to include the loss of the resident's dentures. This was evident of 1 of 2 residents investigated for dental status out of an Investigative sample of 35 residents (Resident #142). The finding is: [...]