Harlem Center for Nursing and Rehabilitation, L L

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Apr 3, 2025

  Based on observation, record review, and interviews during an abbreviated survey (NY00375711), the facility did not ensure each resident received adequate supervision to prevent an elopement. This was evident for one (1) of four (4) residents (Resident #1),sampled for elopement. Specifically, the facility's video surveillance footage dated 03/19/2025 at 4:04:06 PM showed Resident #1 walked past Security Guard #1, who was sitting at the front desk in the lobby with their head down. Security Guard #1 did not stop Resident #1 from leaving the facility. Resident #1 exited the automatic front doors and left the facility. Staff interviews and the facility's investigative report revealed that the facility was not aware Resident #1 was missing until 7:30 PM. […]

• No harm, potential for more than minimal, widespreadF584Dec 17, 2025

  Based on observations, interviews, and record review during an on-site abbreviated survey (457794), it was determined that for five (Second, Third, Fourth, Fifth, and Sixth Floors) of five resident-occupied floors, the facility did not maintain a comfortable environment. Issues included residents feeling uncomfortable and resident room temperatures ranging from 46 F to 57 F, from approximately 3:00 AM on 12/16/2025 through approximately 4:00 PM on 12/17/2025.Observations in the presence of the Director of Maintenance during an initial tour of the facility on 12/17/2025, between 9:30 AM and 10:30 AM, included but were not limited to the following: Utilizing an infrared temperature gun, the temperatures in resident rooms on the Sixth Floor were recorded at 49.4 F in resident room [ROOM… […]

• No harm, potential for more than minimal, patternF868Feb 12, 2025

  Based on record review and interview conducted during the Recertification Survey from 02/05/2025 to 02/12/2025, the facility did not ensure that the Quality Assurance & Performance Improvement (QAPI) and Quality Assessment & Assurance (QAA) committee consisted at a minimum of the Medical Director, or their designee attended quarterly meetings. Specifically, the Medical Director has not participated in Quality Assurance & Performance Improvement (QAPI) and Quality Assessment & Assurance (QAA) meetings for 4 out of the four meetings as required. […]

• No harm, potential for more than minimal, patternF880Feb 12, 2025

  Based on observation, record review, and interviews conducted during the Recertification Survey from 02/05/2025 - 02/12/2025, the facility did not ensure that infection control practices and procedures were maintained. This was evident for 2 Residents (Resident # 389 and Resident #63) of 12 residents observed for medication administration and 1 Resident (Resident #389) observed for Pressure Ulcer Injury out of a total of 35 sampled residents. Specifically, 1.) Licensed Practical Nurse #2 failed to follow Enhanced Barrier Precautions by not donning a gown while administering intravenous medications for a Resident with a Peripherally Inserted Central Catheter. […]

• No harm, potential for more than minimal, patternF584Mar 16, 2023

  Based on observation, interview, and record review conducted during the Recertification Survey from 3/9/23 to 3/16/23, the facility did not ensure the resident's right to a safe, clean, comfortable, and homelike environment. This was evidenced for 2 of 5 units (Unit 5 and Unit 2). Specifically, 1) Unit 5 had multiple rooms with dirty and stained bathroom disinfectant tanks (DT) in disrepair, a wheelchair in disrepair, and a missing closet door in resident's room, and 2) Unit 3 contained wheelchairs in disrepair, a rusty shower chair, torn mesh on a large shower chair, torn mesh covering the clean linen carts, and heaters in the dining room area littered with dirt and debris. […]