Harlem Center for Nursing and Rehabilitation, L L

Inspectors wroteBased 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 NUMBER], with the highest temperature 54.6 F in resident room [ROOM NUMBER]. [...]

Inspectors wroteBased on record review and interviews conducted during the Abbreviated Survey (Complaint #2634618) the facility failed to ensure that one (1) (Resident #1) of three (3) residents reviewed for quality of care, received treatment and care in accordance with professional standards of practice. Specifically, an order for comprehensive metabolic panel and complete blood count was made for Resident #1 but was not carried out. There was no documentation available in the medical record to explain why the test was not completed.

Inspectors wroteBased 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. To date, Resident #1 has not been located. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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. 2.) Licensed Practical Nurse #3 failed to follow Enhanced Barrier Precautions by not donning a gown while administering medications for a Resident with a Gastrostomy tube. [...]

Inspectors wroteBased on observations, record reviews, and staff interviews conducted during the Recertification survey from 02/05/2025 to 02/12/2025, the facility did not ensure that care and services were provided according to accepted standards of clinical quality and practice. This was evident for 1 (Resident #389) of 2 residents reviewed for Intravenous medication administration out of a total of 35 sampled residents. Specifically, Intravenous antibiotics for Resident #389 were administered through a Peripherally Inserted Central Catheter by a Licensed Practical Nurse.

Inspectors wroteBased on observation, interview and record review conducted during a Recertification survey from 02/5/2025 to 02/12/2025, the facility did not ensure a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote wound healing. This was evident for 1 of 4 residents (Resident #389) reviewed for Pressure Ulcer Injury out of a total of 35 sampled residents. Specifically, Resident #389 did not receive pressure relieving devices and preventative measures to promote wound healing.

Inspectors wroteBased on the observations and staff interviews conducted during the Recertification survey from 2/5/2025 to 2/12/2025, the facility did not ensure garbage and refuse were disposed properly. This was evident during kitchen observation. Specifically, the facility garbage bins did not have a lid or cover to prevent the harborage and potential feeding of pests.

Inspectors wroteBased on observation, record review and staff interviews conducted during the Complaint (NY#00347998) and Recertification Survey from 2/5/2025 to 2/12/2025, the facility did not ensure that the resident records were accurately documented in accordance with professional standards of practice. This was evident for 1 (Resident #66) of 2 residents reviewed for Limited Range of Motion out of 37 total sampled residents. Specifically, Resident #66 was not provided with Range of Motion exercises, but documentation reflected that resident was provided with Range of Motion exercises.

Inspectors wroteBased on observations, record reviews, and interviews conducted during the Recertification Survey from 02/05/2025 to 02/12/2025, the facility did not ensure the daily nurse staffing was posted. Specifically, there was no indication of the daily nurse staffing information with the total number of staff and total number of hours posted. This was evident during the review of the Staffing task.

Inspectors wroteBased on observation, record review and staff interviews conducted during the Complaint (NY#00347998) and Recertification survey from 2/5/2025 to 2/12/2025, the facility did not ensure a resident with limited range of motion received treatment and services to maintain and/or to prevent further decrease in range of motion. This was evident for 1 (Resident #66) of 2 residents reviewed for Limited Range of Motion out of 37 total sampled residents. Specifically, Resident #66 was not provided with range of motion exercises in accordance with a Physician's Order.

Inspectors wroteBased 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.

Inspectors wroteBased on observations, interview, and record review conducted during the Recertification Survey from 3/9/23 to 3/16/23, the facility did not ensure a resident remained free of physical restraints. This was evidenced for 1 (Resident #94) of 1 resident(s) reviewed for Physical Restraints out of 40 total sampled residents. Specifically, Resident #94 was observed with bilateral upper 1/3 siderails (SR) in place on multiple occasions.

Inspectors wroteBased on record review and staff interviews conducted during a recertification and complaint survey (NY00298773, NY00295726), the facility did not ensure an alleged violation involving resident to resident physical abuse was and allegations that did not involve serious bodily injury to the New York State Department of Health (NYSDOH) within a timely manner. This was evident for 2 (Resident #246 and #119) of 3 residents reviewed for Abuse and 1 (Resident #25) of 7 resident reviewed for Accidents out of 40 total sampled residents. Specifically, the facility did not report a resident-to-resident altercation involving Resident #246 and Resident #119 to the NYSDOH within 2 hours of occurrence, and 2) the facility did not report an incident resulting in Resident #25 sustaining a leg laceration requiring 11 staples and hospital intervention within 24 hours of occurrence.

Inspectors wroteBased on observation, interview, and record review conducted during the Recertification and Complaint (NY00295726) Survey from 3/9/23 to 3/16/23, the facility did not ensure a comprehensive person-centered care plan (CCP) was developed and implemented for each resident to meet the resident's needs. This was evident for 1 ( Resident #25) of 7 residents reviewed for Accidents out of 40 total sampled residents. Specifically, a CCP was not developed to address Resident #25's right leg laceration requiring 11 staples.

Inspectors wroteBased on record review and interviews conducted during the Recertification survey from 3/09/2023 through 03/16/2023, the facility did not ensure that each resident's person-centered comprehensive care plan (CCP) was reviewed and revised. This was evident for 1 (Resident #68) of 1 resident reviewed for Behavior out of a sample of 40 residents. Specifically, the Resident #68's CCP related to hoarding behavior was reviewed and revised to include person-centered interventions to address clutter in the resident's room.

Inspectors wroteBased on observation, interviews, and record review during the Recertification Survey initiated on 3/9/23 and completed on 3/16/23, the facility failed to ensure residents who had a prosthesis (artificial limb) were provided care and assistance consistent with resident preferences to use the prosthetic device. This was evident for 1 (Resident #24)of 1 resident reviewed for Mobility out of 40 total sampled residents. Specifically, Resident #24 did not receive assistance applying a cosmetic prosthetic limb.

Inspectors wroteBased on observations, interview, and record review conducted during the Recertification Survey from 3/9/23 to 3/16/23, the facility did not ensure a resident remained free of physical restraints. This was evidenced for 1 (Resident #94) of 1 resident(s) reviewed for physical Restraints. Specifically, Resident #94 was observed with bilateral upper 1/3 siderails (SR) in place on multiple occasions.

Inspectors wroteBased on observation, record review, and interviews conducted during the recertification survey from 3/9/23 to 3/16/23, the facility did not ensure menus were followed. This was evident for 1 (Resident #64) of 40 sampled residents. Specifically, Resident #64 did not receive a sandwich on their tray in accordance with the meal ticket.

Inspectors wroteBased on record review and interviews conducted during the Recertification Survey initiated on 3/9/23 and completed on 3/16/23, the facility did not implement policies and procedures to ensure that staff who were granted an exemption to the Covid-19 vaccine requirement adhere to additional precautions that are intended to mitigate the spread of Covid-19. This was evident for 1 of 1 medical exemptions provided by the facility. Specifically, an unvaccinated staff member providing direct care for residents had a valid medical exemption, but no additional precautions were in place.

Inspectors wroteBased on observations, interview, and record review conducted during the Recertification Survey from 3/9/23 to 3/16/23, the facility did not ensure a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. This was evident for 1 (Unit 5) of 5 units. Specifically, the Unit 5 Nursing Station was in disrepair with dirt and debris covering utility wires.

Inspectors wroteBased on observations and interviews conducted during the recertification survey, the facility did not ensure that each resident was treated with dignity and respect during care. Specifically, staff entered multiple residents room without knocking on the door. This was evident of 5 out of 5 residents reviewed for Dignity out of a total investigated sample of 40 residents (Resident #117, #155, #180, #458 and #459).

Inspectors wroteBased on observations and interviews during the Recertification Survey, the facility did not ensure that a safe, clean and homelike environment was maintained. Specifically, there were damaged and broken furniture, damaged walls, broken ceiling tiles, torn upholstery and missing brake handle covers. This was evident for 2 out of 5 Nursing Units (4th floor and 5th floor).

Inspectors wroteBased on observation, record reviews and staff interviews during the recertification survey the facility did not maintain infection control practices help prevent the development and transmission of communicable diseases and infections. Specifically, (1) oxygen tubing was observed on the floor; and (2) staff were obsrved entering the room of residents on contact preacutions without donning the appropriate Personal Protective Equipment (PPE). This was evident for 1 of 1 resident reviewed for oxygen therapy (Resident #5) and 2 of 2 residents reviewed in the area of Urinary Tract Infection (UTI). (Resident #4 and #126)

Inspectors wroteBased on record reviews and staff interviews conducted during the recertification survey, the facility did not ensure that a person-centered care plan with measurable goals, time frames and interventions was developed to address a resident behavior. Specifically, there was no documented evidence that a comprehensive person-centered care plan was developed to address a resident's hoarding behavior. This was evident for 1 of 1 resident reviewed for Behavior/Emotional (Resident #34).

Inspectors wroteBased on observations, interviews, and record review conducted during the recertification survey, the facility did not ensure the resident environment remains as free of accident hazards as possible and each resident receives adequate supervision to prevent accidents. Specifically: (1) an oversized television was positioned on a slant, on top of a smaller dresser in a resident's room; (2) the cause of a resident's fall was not evaluated to determine if updates were needed to the plan of care to prevent further falls. This was evident for 2 (two) of 4 (four) residents investigated for the Accident Care Area. (Resident # 163 and Resident # 176).

Inspectors wroteBased on observation, interview and record review the facility did not ensure that an appropriate environment and atmosphere were in place that was conducive to a resident's mental and psychosocial well-being; and the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Specifically, a resident with hoarding behaviors were not addressed. This was evident for 1 of 1 resident reviewed for Behavior/Emotional. (Resident #34)

Inspectors wroteBased on observations and interviews during the Recertification survey, the facility did not ensure that the corridor hand rails were firmly affixed to the wall. Specifically, during the initial tour of the 5th floor unit several corridor areas had loose hand rails. This was evident for 1 of 5 resident units observed for the Environment (5th floor) .