Bronx Gardens Rehabilitation and Nursing Center

In the surveyor’s words

From the most serious findings on record at Bronx Gardens Rehabilitation and Nursing Center, in the surveyor’s own words.

• Actual harm, isolatedF689Dec 9, 2025

  Based 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. […]

• No harm, potential for more than minimal, patternF584Jun 24, 2025

  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. […]

• No harm, potential for more than minimal, patternF684Jun 24, 2025

  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. […]

• No harm, potential for more than minimal, patternF725Jun 24, 2025

  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. […]

• No harm, potential for more than minimal, isolatedF695Jun 24, 2025

  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. […]