Bronx Gardens Rehabilitation and Nursing Center

Inspectors wroteBased on observation, record review, and interviews conducted during an abbreviated survey (Incident # 2646947), the facility did not ensure residents received adequate assistance consistent with resident's needs to prevent accidents. This was evident in one (1) out three (3) residents (Resident #1) sampled. Specifically, on 10/18/2025 at 8:30 AM, Resident #1, who required two (2) person assistance for bed mobility, fell off the bed onto the floor while Certified Nursing Assistant #1 was turning the resident by themself. Resident #1 was assessed with cuts and bleeding to their chin and forehead. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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)

Inspectors wroteBased 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.

Inspectors wroteBased 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. [...]