Inspection Reports for Bronxcare Special Care Center
1265 Fulton Avenue, Bronx, NY, 10456
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
8.4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
65% worse than New York average
New York average: 5.1 deficiencies/yearDeficiencies per year
20
15
10
5
0
Inspection Report
Recertification
Deficiencies: 1
Date: Aug 14, 2025
Visit Reason
The inspection was conducted as part of a Recertification and Complaint (#668295) Survey to evaluate compliance with food service standards, specifically regarding food temperature during meal service.
Complaint Details
The visit included a complaint investigation (#668295) related to food temperature issues raised by residents during council meetings and interviews.
Findings
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.
Deficiencies (1)
Food served during meal service were not maintained at palatable and appetizing temperatures, with several hot foods below the minimum temperature of 140 degrees Fahrenheit.
Report Facts
Food temperature readings: 142.2
Food temperature readings: 144
Food temperature readings: 150
Food temperature readings: 126
Food temperature readings: 116
Food temperature readings: 132.6
Food temperature readings: 128
Food temperature readings: 134
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Food Service Director | Interviewed regarding food temperature issues and test tray results | |
| Administrator | Interviewed and stated unawareness of resident concerns about food temperature and intention to address the issue |
Inspection Report
Complaint Investigation
Deficiencies: 5
Date: Aug 14, 2025
Visit Reason
The inspection was conducted based on complaints and recertification survey to investigate allegations of failure to notify family of resident condition changes, failure to provide required Medicare beneficiary notices, failure to report suspected abuse, failure to provide appropriate treatment, and food temperature concerns.
Complaint Details
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.
Findings
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.
Deficiencies (5)
Failure to notify Resident #143's family representative of the detached fingernail on the right hand.
Failure to provide Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) to residents at termination of Medicare Part A benefits for Residents #187, #212, and #222.
Failure to timely report suspected abuse and injuries of unknown origin involving Resident #143 to the State Survey Agency.
Failure to timely notify physician and document abnormal penile discharge for Resident #238 resulting in delayed medical intervention.
Failure to serve food at palatable and appetizing temperatures; several hot foods served below minimum temperature of 140°F.
Report Facts
Residents reviewed: 35
Residents affected: 1
Residents affected: 3
Residents affected: 1
Residents affected: 1
Units affected: 1
Temperature readings: 126
Temperature readings: 116
Temperature readings: 132.6
Temperature readings: 128
Temperature readings: 134
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse #4 | Charge Nurse | Interviewed regarding notification of Resident #143's fingernail detachment |
| Registered Nurse #5 | Nurse Manager | Interviewed regarding notification of Resident #143's fingernail detachment and investigation |
| Attending Physician #1 | Physician | Interviewed regarding Resident #143's fingernail injury and Resident #238's penile discharge |
| Assistant Director of Nursing | Interviewed regarding notification failures and investigation follow-up | |
| Director of Nursing | Interviewed regarding notification responsibilities and family communication | |
| Director of Social Services | Interviewed regarding Medicare Non-Coverage notices | |
| Minimum Data Set Coordinator | Interviewed regarding Medicare Non-Coverage notices and forms | |
| Administrator | Interviewed regarding Medicare Non-Coverage notices and food temperature concerns | |
| Certified Nursing Assistant #3 | Interviewed regarding observation of Resident #238's penile discharge | |
| Registered Nurse #1 | Unit Charge Nurse | Interviewed regarding observation and notification of Resident #238's penile discharge |
| Food Service Director | Interviewed regarding food temperature issues and resident complaints |
Inspection Report
Covid-19 Survey
Capacity: 60
Deficiencies: 1
Date: Aug 7, 2023
Visit Reason
One standard health citation related to reporting to the national health safety network with Level 2 severity and widespread scope.
Findings
One standard health citation related to reporting to the national health safety network with Level 2 severity and widespread scope.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jun 8, 2023
Visit Reason
The inspection was conducted as a recertification and complaint survey to investigate allegations of abuse involving residents at Bronxcare Special Care Center.
Complaint Details
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.
Findings
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.
Deficiencies (1)
Failure to protect residents from physical abuse by staff and other residents, including inappropriate touching by a CNA and resident-to-resident assaults.
Report Facts
Residents reviewed for abuse: 9
Incident dates: 2
Cut size: 1.5
BIMS scores: 12
BIMS scores: 15
Q15 minute monitoring: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #7 | Certified Nursing Assistant | Named in inappropriate touching allegation and abuse investigation |
| RN #4 | Registered Nurse | Interviewed regarding resident altercation and monitoring |
| SW #2 | Social Worker | Interviewed regarding resident altercation and family notifications |
| RN #5 | Registered Nurse | Interviewed regarding monitoring and incident response |
| DON | Director of Nursing | Interviewed regarding monitoring, room changes, and incident management |
| MD #2 | Attending Physician | Assessed resident #222 after alleged inappropriate touching incident |
| ADN | Assistant Director of Nursing | Conducted investigation and provided training related to CNA #7 |
| RN Supervisor #1 | RN Supervisor | Interviewed regarding CNA #7 and resident #222 incident |
Inspection Report
Annual Inspection
Deficiencies: 7
Date: Jun 8, 2023
Visit Reason
The inspection was conducted as a Recertification and Complaint survey to assess compliance with federal regulations regarding resident care, advance directives, care planning, medication management, and other regulatory requirements.
Findings
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.
Deficiencies (7)
Failure to ensure residents or their representatives were offered the opportunity to participate in the review of their Comprehensive Care Plans.
Failure to ensure surety bond coverage equaled or exceeded the total amount of resident personal funds deposited with the facility.
Failure to inform residents and provide written information concerning their right to accept or refuse medical or surgical treatment and to formulate an advance directive.
Failure to provide a written summary of the baseline care plan to residents or their representatives within 48 hours of admission.
Failure to develop and revise a comprehensive care plan to reflect changes in the resident's care, specifically failure to update care plan to reflect oxygen therapy.
Failure to provide appropriate care for a resident with an indwelling Foley catheter, including lack of a medical doctor's order for catheter insertion or care.
Failure to implement gradual dose reductions (GDR) for prescribed psychotropic medications and failure to limit PRN orders to necessary use only.
Report Facts
Residents with personal funds: 111
Surety bond amount: 150000
Resident personal funds total: 257687.53
Additional surety in CD: 90000
Residents reviewed for care planning: 38
Residents reviewed for advance directives: 35
Residents reviewed for urinary catheter: 38
Residents reviewed for unnecessary medication: 38
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Social Worker #3 | Social Worker | Interviewed regarding care plan meeting invitations for Resident #54 |
| Director of Social Services | Director of Social Services | Interviewed regarding care plan meeting invitations and documentation |
| Director of Nursing | Director of Nursing | Interviewed regarding care plan meeting invitations and documentation |
| Social Worker #2 | Social Worker | Interviewed regarding care plan meeting invitations and documentation for Resident #444 |
| Finance Manager | Finance Manager | Interviewed regarding surety bond and resident funds |
| RN #1 | Registered Nurse | Interviewed regarding advance directives discussion and documentation |
| Registered Nurse Supervisor (RNS #3) | Registered Nurse Supervisor | Interviewed regarding advance directives responsibilities |
| Social Worker (SW#1) | Social Worker | Interviewed regarding advance directives discussion and documentation |
| Clinical Nurse Manager (CNM) #1 | Clinical Nurse Manager | Interviewed regarding care plan updates and oxygen therapy for Resident #444 |
| Certified Nursing Assistant (CNA) #5 | Certified Nursing Assistant | Interviewed regarding Resident #444 oxygen use |
| Licensed Practical Nurse (LPN) #1 | Licensed Practical Nurse | Interviewed regarding Foley catheter care for Resident #105 |
| Clinical Nurse Manager (CNM) #1 | Clinical Nurse Manager | Interviewed regarding Foley catheter care for Resident #105 |
| Director of Nursing (DNS) | Director of Nursing | Interviewed regarding Foley catheter care for Resident #105 |
| Certified Nursing Assistant (CNA) #3 | Certified Nursing Assistant | Interviewed regarding Resident #113 behavior |
| Licensed Practical Nurse (LPN) #2 | Licensed Practical Nurse | Interviewed regarding Resident #113 behavior |
| Attending Physician (AP) #1 | Attending Physician | Interviewed regarding psychotropic medication use for Residents #113 and #82 |
| Psychiatrist | Psychiatrist | Interviewed regarding psychotropic medication use and GDR for Resident #113 |
| Medical Director | Medical Director | Interviewed regarding facility commitment to GDR for psychotropic medications |
| Pharmacy Director | Pharmacy Director | Interviewed regarding pharmacist role in recommending GDR |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 18
Date: Jun 8, 2023
Visit Reason
Multiple standard health and life safety code citations with Level 2 severity, mostly isolated or pattern scope, all corrected by June/August 2023.
Findings
Multiple standard health and life safety code citations with Level 2 severity, mostly isolated or pattern scope, all corrected by June/August 2023.
Deficiencies (18)
Baseline care plan
Bowel/bladder incontinence, catheter, uti
Care plan timing and revision
Free from abuse and neglect
Free from unnec psychotropic meds/prn use
Request/refuse/dscntnue trmnt;formlte adv dir
Right to participate in planning care
Surety bond-security of personal funds
Discharge from exits
Electrical equipment - power cords and extens
Electrical equipment - testing and maintenanc
Electrical systems - essential electric syste
Fire alarm system - testing and maintenance
Fire drills
Interior wall and ceiling finish
Maintenance, inspection & testing - doors
Organization and administration
Sprinkler system - maintenance and testing
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 2
Date: Dec 19, 2022
Visit Reason
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.
Findings
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.
Deficiencies (2)
Free from abuse and neglect
Reporting of alleged violations
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 1
Date: Dec 1, 2022
Visit Reason
One standard health citation for free of accident hazards/supervision/devices, Level 2 severity and isolated scope, corrected by January 2023.
Findings
One standard health citation for free of accident hazards/supervision/devices, Level 2 severity and isolated scope, corrected by January 2023.
Deficiencies (1)
Free of accident hazards/supervision/devices
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 1
Date: Aug 8, 2022
Visit Reason
One standard health citation for free of accident hazards/supervision/devices, Level 2 severity and isolated scope, corrected by October 2022.
Findings
One standard health citation for free of accident hazards/supervision/devices, Level 2 severity and isolated scope, corrected by October 2022.
Deficiencies (1)
Free of accident hazards/supervision/devices
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 2
Date: Dec 6, 2021
Visit Reason
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.
Findings
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.
Deficiencies (2)
Cardio-pulmonary resuscitation (cpr)
Care plan timing and revision
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Oct 28, 2020
Visit Reason
The inspection was conducted due to complaints regarding the facility's failure to timely report suspected resident-to-resident sexual abuse and failure to thoroughly investigate allegations of abuse and implement corrective actions.
Complaint Details
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.
Findings
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.
Deficiencies (3)
Failure to timely report suspected resident-to-resident sexual abuse to the New York State Department of Health within 2 hours.
Failure to thoroughly investigate allegations of resident-to-resident sexual abuse, including incomplete occurrence reports and lack of documentation of residents' decision-making capacity.
Failure to thoroughly investigate and implement corrective actions regarding a resident's allegations of abuse and neglect, including failure to assign male CNAs as corrective action.
Report Facts
BIMS score: 13
BIMS score: 8
BIMS score: 13
Date of incident report: 2020
Date of survey completion: 2020
Timeframe for investigation completion: 24
Timeframe for complaint investigation: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nursing Assistant | Reported observation of resident-to-resident sexual abuse and interviewed regarding the incident |
| Social Worker #1 | Social Worker | Interviewed regarding resident inappropriate behavior and admitted touching |
| Social Worker #2 | Social Worker | Interviewed Resident #23 and Resident #63, documented statements regarding abuse allegations |
| Registered Nurse Supervisor | RN Supervisor | Assessed residents after incident, did not initiate incident report |
| Director of Nursing | Director of Nursing | Interviewed regarding incident awareness and investigation process |
| RN #1 | Registered Nurse Charge Nurse | Responsible for CNA assignments and interviewed regarding abuse allegations |
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