Inspection Reports for
Bronx Center for Rehabilitation & Health Care
1010 Underhill Ave, Bronx, NY, 10472
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
7.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
51% worse than New York average
New York average: 5.1 deficiencies/yearDeficiencies per year
20
15
10
5
0
Inspection Report
Abbreviated Survey
Deficiencies: 2
Date: Jul 14, 2023
Visit Reason
The survey was conducted as a recertification and complaint investigation survey from 7/10/2023 to 7/14/2023, including an abbreviated survey component.
Complaint Details
The complaint investigation involved Resident #77 regarding lack of translation services during treatment education and Resident #338 regarding delayed reporting of an alleged abuse incident. The complaint was substantiated based on observations, interviews, and record reviews.
Findings
The facility failed to ensure that residents were fully informed and understood their health status and treatments in their preferred language, and did not timely report alleged abuse to the state authorities as required.
Deficiencies (2)
F 0552: The facility did not ensure Resident #77 was provided translation services when offered a tuberculosis test, resulting in the resident not understanding the treatment in their preferred language, Spanish.
F 0609: The facility failed to timely report an alleged abuse incident involving Resident #338 to the New York State Department of Health within 2 hours as required by policy.
Report Facts
Total sampled residents reviewed: 35
Residents affected: 1
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide (CNA #4) | Interviewed and stated they did not assist with translating for Resident #77 on 5/17/2023 | |
| Certified Nurse Aide (CNA #5) | Interviewed and stated they were not asked to translate or educate Resident #77 in Spanish on 5/17/2023 | |
| Licensed Practical Nurse (LPN #4) | Interviewed and stated they used gestures instead of an interpreter to explain PPD injection to Resident #77 on 5/17/2023 | |
| Director of Nursing (DON) | Interviewed and stated Resident #77 should have been provided translation services and abuse reporting training includes timely reporting |
Inspection Report
Annual Inspection
Deficiencies: 4
Date: Jul 14, 2023
Visit Reason
The inspection was conducted as a recertification survey to assess compliance with regulatory requirements for the nursing home.
Findings
The facility was found deficient in multiple areas including resident dignity during meal assistance, physician oversight of resident care and medication orders, proper storage and labeling of medications, and maintenance of a safe and sanitary environment.
Deficiencies (4)
F 0550: The facility did not ensure residents were treated with respect and dignity during meal assistance. Staff were observed standing over residents while feeding them, contrary to facility policy.
F 0711: The resident's physician did not review and order insulin coverage as required for a diabetic resident, resulting in lack of appropriate medication orders and treatment.
F 0761: The facility did not ensure biologicals were stored according to professional principles. An emergency medication box with expired medication was found in the 2nd floor medication room.
F 0921: The facility failed to maintain a safe, functional, sanitary, and comfortable environment. Missing cove base and non-functional lighting were observed in soiled utility rooms on multiple floors.
Report Facts
Residents sampled: 35
Residents affected: 2
Residents affected: 1
Medication storage rooms observed: 5
Floors with environmental issues: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #3 | Licensed Practical Nurse | Observed standing over residents while feeding and interviewed about meal assistance practices |
| CNA #3 | Certified Nursing Assistant | Observed standing over resident while feeding and interviewed about meal assistance practices |
| LPN #4 | Charge Nurse for 3rd Floor | Interviewed regarding feeding practices and instructing staff to sit while feeding residents |
| LPN #5 | Licensed Practical Nurse | Interviewed about resident medication orders and insulin coverage |
| RNM #2 | Registered Nurse Manager | Interviewed about medication order management and physician order review process |
| MD #1 | Physician | Interviewed regarding insulin orders and medication review for resident |
| RNM #1 | Registered Nurse Manager | Interviewed about emergency medication box monitoring and storage |
| DON | Director of Nursing | Interviewed about medication storage and emergency medication box inspection |
| Director of Maintenance | Interviewed about environmental maintenance issues in soiled utility rooms |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 11
Date: Jul 14, 2023
Visit Reason
Inspection identified multiple standard health and life safety code deficiencies related to drug labeling, physician visits, abuse reporting, resident rights, and building safety features. All deficiencies were corrected by August 25, 2023.
Findings
Inspection identified multiple standard health and life safety code deficiencies related to drug labeling, physician visits, abuse reporting, resident rights, and building safety features. All deficiencies were corrected by August 25, 2023.
Deficiencies (11)
Label/store drugs and biologicals
Physician visits - review care/notes/order
Reporting of alleged violations
Resident rights/exercise of rights
Right to be informed/make treatment decisions
Safe/functional/sanitary/comfortable environ
Building construction type and height
Cooking facilities
Electrical systems - essential electric syste
Sprinkler system - maintenance and testing
Subdivision of building spaces - smoke barrie
Inspection Report
Annual Inspection
Deficiencies: 2
Date: May 20, 2021
Visit Reason
The inspection was conducted as a Recertification Survey to assess compliance with regulatory requirements for nursing home care.
Findings
The facility failed to ensure residents' dignity and privacy, particularly regarding uncovered Foley catheter bags and residents wearing hospital gowns without proper clothing. Additionally, the facility did not timely review and revise the comprehensive care plan to address a resident's missing dentures.
Deficiencies (2)
F 0550: The facility did not maintain residents' dignity and privacy; Foley catheter bags were left uncovered and visible, and residents were observed wearing hospital gowns without appropriate clothing in public areas.
F 0657: The facility failed to review and revise the comprehensive care plan timely to address a resident's missing dentures and related care needs.
Report Facts
Residents affected: 3
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN supervisor #4 | RN Supervisor | Interviewed regarding catheter bag privacy and staff supervision. |
| Director of Nursing | Director of Nursing (DON) | Interviewed about catheter bag coverage policy and staff training. |
| CNA #6 | Certified Nursing Assistant | Interviewed about catheter bag privacy practices. |
| LPN #6 | Licensed Practical Nurse | Interviewed about catheter bag privacy and staff responsibilities. |
| CNA #2 | Certified Nursing Assistant | Interviewed about resident clothing availability and gown use. |
| CNA #3 | Certified Nursing Assistant | Interviewed about resident clothing preferences and gown use. |
| LPN #1 | Licensed Practical Nurse | Interviewed about resident clothing and gown use. |
| RN #1 | Registered Nurse, Unit Manager | Interviewed about clothing reporting and resident dignity. |
| CNA #5 | Certified Nursing Assistant | Interviewed about resident clothing and catheter bag privacy. |
| LPN #4 | Licensed Practical Nurse | Interviewed about catheter bag privacy and leg bag use. |
| RN #2 | Registered Nurse | Interviewed about catheter bag privacy and clothing supply. |
| Speech Therapist | Speech Therapist | Interviewed about resident's dental status and swallowing therapy. |
Inspection Report
Annual Inspection
Deficiencies: 4
Date: Jan 10, 2019
Visit Reason
The survey was a recertification annual inspection to assess compliance with federal regulations including care planning, medication use, dietary services, and infection control.
Findings
The facility failed to ensure resident participation in care planning and proper documentation of psychotropic medication use. An antipsychotic medication was prescribed off-label without documented non-pharmacological interventions. Dietary services failed to follow a resident's renal diet restrictions. Infection control practices were deficient, including oxygen tubing touching the floor and outdated infection control policies.
Deficiencies (4)
F 0657: The facility did not ensure resident or representative participation in care planning and failed to revise care plans before initiating psychotropic medication. Non-pharmacological interventions were not documented prior to prescribing Risperdal for a resident with dementia.
F 0756: The consultant pharmacist failed to timely identify and report irregularities related to off-label antipsychotic medication use for a resident with dementia. The resident was prescribed Risperdal without an FDA-approved diagnosis and without appropriate gradual dose reduction attempts.
F 0803: The facility failed to ensure menus met nutritional needs and followed dietary restrictions. A resident on a renal diet was served potatoes despite explicit diet orders prohibiting them.
F 0880: Infection control practices were deficient. Oxygen tubing was observed touching the floor for a resident on oxygen. Infection control policies were not reviewed or updated annually as required.
Report Facts
Residents reviewed for unnecessary medications: 5
Residents reviewed for dietary care: 38
Residents reviewed for infection control: 38
Resident age: 96
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN Manager #3 | 4th Floor Registered Nurse Unit Manager | Interviewed regarding care plan updates and monitoring of resident behavior |
| Psychiatrist | Consultant psychiatrist prescribing Risperdal and discussing medication rationale | |
| Attending Physician | Prescribed Risperdal and discussed medication appropriateness and Black Box Warning | |
| Director of Nursing | Interviewed about care planning, non-pharmacological interventions, and medication management | |
| Pharmacy Consultant | Reviewed medication regimen and identified irregularities late | |
| Dietitian #1 | Interviewed about dietary compliance and in-service plans | |
| CNA #1 | Certified Nursing Assistant | Observed serving food and interviewed about dietary procedures |
| LPN #3 | Licensed Practical Nurse | Interviewed about resident behavior and medication |
| CNA #2 | Certified Nursing Assistant | Interviewed about resident behavior and dietary procedures |
| RN Manager #1 | Interviewed about dietary and infection control practices | |
| LPN #1 | Licensed Practical Nurse | Interviewed about oxygen use and infection control |
| CNA #1 | Certified Nursing Assistant | Interviewed about oxygen use and infection control |
| ADON | Assistant Director of Nursing | Interviewed about infection control policy updates |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 0
Visit Reason
Two additional inspections were conducted during the reporting period but resulted in no citations.
Findings
Two additional inspections were conducted during the reporting period but resulted in no citations.
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 0
Visit Reason
Additional inspections related to complaints were conducted during the reporting period with no citations issued.
Findings
Additional inspections related to complaints were conducted during the reporting period with no citations issued.
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