Above average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at University Center For Rehabilitation And Nursing during CMS and state inspections, most recent first.
A resident with dementia, DVT, and bipolar disorder had a Quarterly MDS that did not document continuous O2 use, even though the physician's order required O2 via NC at 2 L/min with monitoring every shift and the care plan note stated the resident was on continuous O2. The MDS Coordinator said the omission should have been coded and was an oversight.
Incorrect Oxygen Flow Rate and Missing O2 Monitoring: A resident with severe cognitive impairment and orders for O2 via NC at 2 L/min was observed receiving 4 L/min instead. The chart lacked O2 saturation documentation even though the order called for monitoring every shift. Staff interviews showed the LPN did not know who changed the flow rate, the CNA was not trained to adjust or monitor O2, and the DON acknowledged there was no O2 sat order in place.
A resident with dementia, depression, HF, and DM was transferred to the hospital after worsening SOB and never returned, yet BH notes later appeared in the facility record documenting in-person encounters, alert orientation, stable mood, and ongoing psych services. Interviews with the LMHC, BH regional manager, and DON confirmed the resident was not back at the facility and they could not explain why documentation from another facility was reflected in the resident’s chart.
The facility failed to follow resident menus and honor food preferences, affecting four residents. Discrepancies were noted between the menu, meal tickets, and actual food served. Residents reported receiving meals that did not match their meal tickets or preferences, and staff interviews revealed issues with menu creation and meal accuracy, particularly during the Passover holiday.
The facility was found deficient in food storage and safety practices during a survey. Observations revealed unlabeled, undated, and expired food items in refrigerators, along with structural issues and debris. Interviews with staff indicated unclear responsibilities and oversight regarding food safety, contributing to these deficiencies.
The facility did not ensure survey results were accessible to residents and visitors, as they were placed in the basement, contrary to policy. A resident was unaware of the location, and signage was inadequate, failing to direct individuals properly.
The facility did not properly dispose of garbage, as observed during a survey. Five trash containers were uncovered, and a dumpster had exposed trash bags, attracting flies. The Maintenance Director stated it was their responsibility to ensure covers were on and to clean the area weekly.
MDS Did Not Accurately Reflect Continuous Oxygen Use
Penalty
Summary
The facility did not ensure that assessments accurately reflected resident status when the Quarterly MDS for Resident #3 failed to document continuous oxygen use. Resident #3 had diagnoses including Non-Alzheimer's Dementia, DVT, and bipolar disorder, and the Quarterly MDS documented severely impaired cognitive status. However, the assessment did not indicate that the resident was receiving oxygen via nasal cannula at 2 liters per minute, even though the physician's order dated 11/12/2025 and renewed 03/01/2026 directed oxygen use and oxygen monitoring every shift, and the Nursing Quarterly Care Plan Note dated 01/28/2026 stated that the resident was on continuous oxygen. During interview on 03/24/2026, the MDS Coordinator stated that a physical assessment and medical record review are completed before the MDS is finalized, that continuous oxygen should have been coded, and that the omission for Resident #3 was an oversight.
Incorrect Oxygen Flow Rate and Missing Oxygen Saturation Monitoring
Penalty
Summary
Safe and appropriate respiratory care was not provided for one resident who had diagnoses including non-Alzheimer's dementia, deep venous thrombosis, and bipolar disorder, and whose cognitive status was documented as severely impaired. The resident was observed sitting in the day room receiving oxygen via nasal cannula at 4 liters per minute, even though the physician's order written and renewed for the resident specified oxygen at 2 liters per minute. The resident's quarterly care plan note stated the resident was on continuous oxygen, and the comprehensive care plan directed staff to provide oxygen per physician orders and maintain or change tubing per protocol. The medical record did not show documentation of oxygen saturation monitoring, despite the physician's order stating to monitor oxygen every shift. During interview, an LPN stated the 4-liter setting was an error and adjusted the oxygen to 2 liters per minute, but could not explain how or who changed the flow rate. The LPN also stated there was no order to monitor oxygen saturation. A CNA assigned to the resident stated they were not trained to adjust oxygen flow or monitor oxygen saturation, and an RN stated medication nurses were responsible for ensuring residents received the proper oxygen flow rates. The DON stated that if a resident requires oxygen, there should be an oxygen saturation order in place, and acknowledged there was no documentation of oxygen saturation levels in the record.
Inaccurate Behavioral Health Documentation in Closed Record
Penalty
Summary
The facility did not ensure that resident medical records were accurately documented in accordance with professional standards of practice for one resident reviewed for closed records. Resident #50, who had diagnoses including non-Alzheimer's dementia, depression, heart failure, and diabetes mellitus, had impaired cognition and required assistance with dressing and personal hygiene, with dependence for lower body dressing and footwear. On 02/07/2026, the resident developed increased shortness of breath and labored breathing, the NP was notified, and staff transferred the resident to the hospital emergency department at 5:30 PM. The record review showed the resident never returned to the facility after leaving for the hospital. Despite the resident not returning, behavioral health documentation remained in the facility record. A note dated 03/12/2026 documented the resident as alert and oriented to person, place, time, and situation, with stable affect, euthymic mood, logical and organized thought processes, and no psychotic symptoms, and stated the resident would continue to receive psychological services. Another note dated 03/19/2026 documented an encounter with the resident from 12:04 PM to 12:20 PM. Interviews with the LMHC, Behavioral Health Regional Manager, and DON confirmed that the resident never returned to the facility after transfer and that they could not explain why documentation from the sister facility appeared in the resident's medical record at University Center for Rehabilitation and Nursing.
Failure to Follow Resident Menus and Honor Food Preferences
Penalty
Summary
The facility failed to ensure that resident menus were followed and food preferences were honored, as observed during a recertification survey. This deficiency was evident for four residents out of a total of twelve sampled. Specifically, residents did not receive the food items listed on their meal tickets, and one resident did not receive their preferred food items as requested. The facility's policy requires that meal tickets are used to identify correct items for resident diets and that food service staff check trays for accuracy before they are delivered. However, discrepancies were noted between the menu, meal tickets, and the actual food served. Resident #95, who was cognitively intact, reported not receiving the food listed on their meal ticket or the menu. They were served Matzah crackers for multiple meals, which did not match the menu or meal ticket. Similarly, Resident #38, also cognitively intact, did not receive the food items listed on their meal ticket and expressed dissatisfaction with the repetitive meals. Resident #4, with multiple diagnoses including anemia and diabetes, also received meals that did not match their meal ticket and expressed dissatisfaction with the quality and variety of food. Interviews with facility staff revealed that the menus were created at the corporate level, and the Registered Dietitian claimed to have addressed resident complaints. However, the Food Services Supervisor acknowledged discrepancies during the Passover holiday, and the Assistant Administrator stated it was the Kitchen Supervisor's responsibility to ensure meal accuracy. Despite these acknowledgments, the facility failed to provide meals that matched the residents' meal tickets and preferences, leading to the identified deficiency.
Deficiencies in Food Storage and Safety Practices
Penalty
Summary
The facility failed to ensure food was stored, prepared, and distributed in accordance with professional standards for food service safety during a recertification survey. Observations in the kitchen revealed multiple deficiencies, including food items in refrigerators without proper labeling, opened food items not dated, expired food items, and food stored near rust or soiled surfaces. Specifically, hamburger meat and green string beans were found on the counter without dates, and various items in multiple refrigerators were either unlabeled, undated, or expired. Additionally, refrigerators were found with structural issues and debris, contributing to unsanitary conditions. Interviews with facility staff highlighted a lack of clear responsibility and oversight regarding food safety practices. The Food Services Supervisor indicated that refrigerators were cleaned every evening, but discrepancies in labeling and dating persisted. The Assistant Administrator was unsure about procedures for checking expired food or the duration food should remain in the refrigerator before disposal. The Maintenance Supervisor noted that the Dietary Department was responsible for reporting refrigerator issues, but the Administration decided on replacements. These findings indicate systemic issues in food storage and safety management within the facility.
Inaccessible Survey Results
Penalty
Summary
The facility failed to ensure that the most recent survey results were posted in a location that was readily accessible to residents, family members, and legal representatives. During the recertification survey, it was observed that the survey results were placed in the facility's basement, which was not in plain view and not easily accessible for review. Signage indicating the location of the survey results was inadequate, with no signs posted on the second floor, and the existing signs directed individuals to the basement, which was not frequented by residents. A resident attending the Resident Council meeting expressed that they were unaware of where to find the survey results, highlighting the inaccessibility of the information. The facility's policy required that survey results be maintained in an area frequented by most residents, such as the main lobby or resident activity room, and be readily accessible without requiring residents or visitors to ask for them. However, the survey results were stored in a file box in a low position in the basement, contrary to the facility's policy.
Improper Garbage Disposal
Penalty
Summary
The facility failed to ensure proper disposal of garbage and refuse, as observed during the Recertification Survey. The facility's policy requires all garbage and rubbish containing food wastes to be kept in containers with tight-fitting lids or covers, which must remain covered when not in continuous use. However, during an observation on 5/1/2024, five large green trash containers were found uncovered, and a dumpster had exposed white trash bags, attracting flies in the area. The Maintenance Director acknowledged that it was the responsibility of the Maintenance Department to ensure trash container covers were on and to maintain cleanliness by hosing down the garbage area weekly.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Bronx
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Plaza Rehab And Nursing Center | 0.3 mi | ★★★★★ | 1 | 0 |
| Fordham Nursing And Rehabilitation Center | 0.4 mi | ★★★★★ | 0 | 0 |
| Bronx Gardens Rehabilitation And Nursing Center | 1 mi | ★★★★★ | 1 | 0 |
| Manhattanville Health Care Center | 1.2 mi | ★★★★★ | 0 | 0 |
| Prestige Nursing Care & Rehab Center | 1.2 mi | ★★★★★ | 11 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.