Inspection Reports for Bronxcare Special Care Center

The visit included a complaint investigation (#668295) related to food temperature issues raised by residents during council meetings and interviews.

The facility failed to ensure that food was served at an appetizing temperature during meals in one of five units. Food temperatures for several hot items were below the minimum required 140 degrees Fahrenheit, as confirmed by resident complaints and temperature testing.

The complaint investigation revealed failures related to notification of family about resident condition changes, failure to provide required Medicare notices, failure to report suspected abuse, failure to provide timely treatment, and food temperature issues affecting resident care and safety.

The facility was found deficient in multiple areas including failure to notify a resident's family of a detached fingernail, failure to provide Skilled Nursing Facility Advance Beneficiary Notice at Medicare Part A termination, failure to report suspected abuse of a resident with injury of unknown origin, failure to timely notify physician and document abnormal penile discharge leading to delayed treatment, and failure to serve food at appropriate hot temperatures.

One standard health citation related to reporting to the national health safety network with Level 2 severity and widespread scope.

The complaint investigation revealed that on 3/7/23, resident #222 was inappropriately touched by CNA #7. On 5/23/23, resident #129 was struck by resident #238 with a plastic hanger, and later that evening resident #129 retaliated by hitting resident #238, causing injury. Both residents were involved in altercations resulting in police involvement and arrests. The facility failed to adequately monitor and protect residents, including failure to implement proper Q15 minute monitoring after the incidents.

The facility failed to ensure residents were free from abuse, neglect, and corporal punishment. Two incidents of resident-to-resident physical abuse were documented, involving residents #129 and #238, including hitting with a plastic hanger and resulting injuries. Additionally, an allegation of inappropriate touching by a CNA (#7) toward resident #222 was substantiated. The facility's response and monitoring were inadequate, leading to repeated incidents and arrests.

The facility was found deficient in multiple areas including failure to ensure resident participation in care plan meetings, inadequate surety bond coverage for resident funds, failure to provide residents with information on advance directives, failure to provide baseline care plan summaries to residents or their representatives, incomplete care plans not reflecting current treatments such as oxygen therapy, lack of medical orders for Foley catheter care, and failure to attempt gradual dose reductions for psychotropic medications as required.

Multiple standard health and life safety code citations with Level 2 severity, mostly isolated or pattern scope, all corrected by June/August 2023.

Two standard health citations related to abuse and neglect and reporting of alleged violations, both Level 2 severity and isolated scope, corrected by February 2023.

One standard health citation for free of accident hazards/supervision/devices, Level 2 severity and isolated scope, corrected by January 2023.

One standard health citation for free of accident hazards/supervision/devices, Level 2 severity and isolated scope, corrected by October 2022.

Two standard health citations for cardio-pulmonary resuscitation (CPR) and care plan timing and revision, Level 2 severity and isolated scope, corrected by February 2022.

The complaint investigation revealed that the facility did not report an alleged incident of resident-to-resident sexual abuse within the required timeframe. The investigation into the abuse allegations was incomplete and lacked proper documentation and follow-up. A resident also alleged verbal and physical abuse by a female CNA, but the facility failed to conduct a thorough investigation or implement corrective actions such as assigning male caregivers as requested.

The facility failed to report an alleged resident-to-resident sexual abuse incident to the New York State Department of Health within the required 2 hours. Investigations into the abuse allegations were incomplete, lacking thorough documentation, witness statements, and evaluation of residents' capacity to consent. Additionally, a resident's allegations of abuse and neglect were not thoroughly investigated, and corrective actions such as assigning male CNAs were not implemented.