Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Harlem Center For Nursing And Rehabilitation, L L during CMS and state inspections, most recent first.
Failure to Maintain Safe Indoor Temperatures: A facility did not maintain a comfortable environment on multiple resident-occupied floors, with room, corridor, and day room temperatures measured far below the stated 71 F to 81 F range. The Administrator said the loss of heat was not reported to DOH because she believed notification was only needed if it lasted longer than 4 hours, while the DOR stated the boiler repair was short-lived and a clogged supply line needed cleaning. Sink water temperatures were also measured as low as 48 F.
A resident with multiple medical conditions did not receive stat laboratory tests as ordered to evaluate acute symptoms. Although other diagnostic tests were completed, there was no documentation that the blood work was performed or any explanation for its omission, despite facility policy requiring such documentation.
A resident with schizophrenia and dementia, not previously identified as an elopement risk, exited the facility unsupervised by passing a new, untrained security guard at the front desk. Staff did not notice the resident's absence for several hours, as it was routine for the resident to visit the lobby vending machine alone. The facility's policies for preventing unauthorized departures were not effectively implemented, leading to a delayed response in recognizing and reporting the elopement.
The facility did not ensure the Medical Director's participation in the QAPI and QAA committee meetings as required. The Medical Director did not sign attendance sheets for any of the quarterly meetings in 2024, and interviews revealed that the Medical Director was briefed post-meeting rather than attending in person. This failure to include the Medical Director in the meetings constitutes a deficiency.
The facility failed to maintain proper infection control practices, as evidenced by three LPNs not following Enhanced Barrier Precautions during medication administration and wound care. One LPN did not wear a gown while administering IV medications to a resident with a central catheter, and another did not wear a gown for a resident with a Gastrostomy tube. Additionally, an LPN failed to establish a clean field and perform hand hygiene during wound care for a resident with multiple wounds.
A resident with osteomyelitis and diabetes received intravenous antibiotics through a PICC by an LPN, contrary to facility policy. The LPN, new to the facility, was not adequately trained on intravenous administration, leading to improper medication administration. Facility staff interviews revealed communication and monitoring gaps in ensuring only qualified staff administer medications through central lines.
A resident with severe cognitive impairment and multiple ulcers did not receive necessary pressure-relieving devices or preventative measures, as required by the facility's policy. Despite being at moderate risk for pressure ulcers, the resident was observed without heel booties, offloading, or a pressure-reducing mattress. Staff interviews confirmed the lack of adherence to protocols, contributing to the deficiency in care.
The facility did not ensure proper disposal of garbage and refuse, as observed during a survey. Despite a policy requiring waste to be kept in covered, leak-proof containers, garbage bins were found without lids, leaving waste exposed. Staff interviews confirmed the absence of lids, and the administrator contacted the vendor to address the issue.
A resident with Multiple Sclerosis and Hemiplegia was not provided with ordered Range of Motion exercises, despite documentation indicating otherwise. Interviews with CNAs and the resident revealed that the exercises had not been performed for months. Facility staff were unaware of the lapse, highlighting a failure in maintaining accurate records and following care plans.
A resident with limited mobility and a physician's order for daily range of motion (ROM) exercises did not receive the required care, despite documentation indicating otherwise. Staff interviews revealed that ROM exercises had not been performed for several months, and CNAs were unaware of the current care plan. The deficiency was further compounded by inaccurate documentation in the medical record.
The facility did not post daily nurse staffing information, including total staff and hours, as required. Observations during a survey revealed the absence of this information in the lobby and nursing unit. Interviews with the Staffing Coordinator, DON, and Administrator confirmed the oversight, as the information was attached to the schedule at the end of the day but not posted. This non-compliance with facility policy and state regulation led to the deficiency.
Failure to Maintain Safe Indoor Temperatures
Penalty
Summary
The facility did not maintain a comfortable environment on five resident-occupied floors, including the Second, Third, Fourth, Fifth, and Sixth Floors, during a period when resident room temperatures ranged from 46 F to 57 F. During an initial tour with the Director of Maintenance, temperatures measured with an infrared temperature gun showed resident rooms, corridors, and day rooms on each of these floors well below the facility’s stated target range of 71 F to 81 F. On the Sixth Floor, resident rooms were measured as low as 49.4 F, with the corridor at 54.6 F and the Day Room at 60.2 F. On the Fifth Floor, resident rooms were measured as low as 51.7 F, with the corridor at 57.8 F and the Day Room at 57.9 F. On the Fourth Floor, resident rooms were measured as low as 52.5 F, with the corridor at 58.7 F and the Day Room at 62.8 F. On the Third Floor, resident rooms were measured as low as 52.9 F, with the corridor at 60.4 F and the Day Room at 62.8 F. On the Second Floor, resident rooms were measured as low as 46.9 F, with the corridor at 58.4 F and the Day Room at 59.2 F. The report also noted that 14 water temperatures in resident bathroom sinks and 3 Day Room sinks were measured using the facility’s digital cooking thermometer, with temperatures as low as 48 F and as high as 52 F. The Administrator stated the facility did not report the loss of heat to the Department of Health because she believed it was not necessary unless it lasted longer than 4 hours. The Director of Maintenance stated the boiler vendor had been at the facility the day before, changed a pump, and the boiler began running in the evening, but the fix was short-lived and the vendor returned to assess a clogged supply line that needed cleaning. The facility policy for Extreme Weather-Cold stated that immediate actions were to be taken when heating systems were inoperable to maintain temperatures within 71 F to 81 F and to provide blankets, warm beverages, warming centers, consider evacuation, and notify the New York State Department of Health.
Failure to Complete and Document Stat Laboratory Orders
Penalty
Summary
A deficiency occurred when a resident with diagnoses including diabetes mellitus, hypertension, and urinary tract infection, who had moderately impaired cognition, did not receive laboratory tests as ordered by a nurse practitioner via telehealth. The orders for a comprehensive metabolic panel and complete blood count were placed stat to evaluate symptoms of headache, abdominal pain, and chest pain. Although the chest x-ray and urine sample were completed, there was no documented evidence that the blood work was performed, nor was there any explanation in the medical record for why the tests were not completed. Interviews with facility staff, including registered nurses, the physician, the DON, and the administrator, revealed uncertainty about why the laboratory orders were not carried out. Some staff suggested the resident may have refused the blood draw, but there was no documentation to support this. The facility's policy and staff statements indicated that any refusal or inability to complete laboratory orders should be documented in the medical record, but this was not done in this case.
Resident Elopement Due to Inadequate Supervision and Security Oversight
Penalty
Summary
A deficiency occurred when a resident with diagnoses of paranoid schizophrenia and dementia, who had moderately impaired cognition, was able to exit the facility without staff awareness or intervention. The resident was not identified as being at risk for elopement according to prior assessments, and therefore did not have an elopement care plan in place. On the day of the incident, the resident left their unit, took the elevator to the lobby, and walked past a security guard at the front desk who was sitting with their head down. The security guard did not stop the resident from leaving, and the resident exited through the automatic front doors. Staff interviews revealed that it was routine for the resident to go to the lobby vending machine unsupervised, and staff did not consider the resident to have exit-seeking behavior. The absence of the resident was not noticed until several hours later, after a Certified Nursing Assistant returned from a break and found the resident's dinner tray untouched. Subsequent searches by staff were unsuccessful in locating the resident, and the absence was reported up the chain of command, eventually leading to a facility-wide search and notification of law enforcement. The facility's policies required staff to attempt to prevent residents from leaving the premises and to notify nursing leadership if a resident was observed leaving. However, the security guard at the front desk was new, in training, and left unsupervised at the time of the incident. The guard did not recognize the resident or their status and was unaware of the elopement until informed days later. The facility did not become aware of the resident's departure until hours after the event, resulting in a significant delay in initiating search and notification procedures.
Medical Director's Absence in QAPI Meetings
Penalty
Summary
The facility failed to ensure that the Quality Assurance & Performance Improvement (QAPI) and Quality Assessment & Assurance (QAA) committee included the Medical Director or their designee in its quarterly meetings, as required by their policy. The facility's policy, last revised in August 2022, mandates that the QAA committee must include the director of nursing services, the medical director or designee, and at least one other member of the facility staff, with meetings held quarterly. However, a review of the Quarterly Meeting Attendance Sheets revealed that the Medical Director did not sign the attendance sheets for any of the four quarterly meetings in 2024. Interviews conducted during the survey revealed discrepancies in the Medical Director's participation. The Director of Nursing stated that the Medical Director only attends quarterly meetings, while the Medical Director claimed to attend some meetings and be informed by the Administrator about the meetings. The Administrator confirmed that the Medical Director does not physically attend the quality assurance meetings but is briefed afterward. This lack of documented participation by the Medical Director in the QAPI and QAA meetings constitutes a deficiency in meeting the facility's policy requirements.
Infection Control Deficiencies in Medication Administration and Wound Care
Penalty
Summary
The facility failed to maintain proper infection control practices and procedures, as evidenced by the actions of three Licensed Practical Nurses (LPNs) during medication administration and wound care. LPN #2 did not follow Enhanced Barrier Precautions by failing to don a gown while administering intravenous medications to a resident with a Peripherally Inserted Central Catheter. This LPN was unaware of the need for such precautions due to a lack of education on Enhanced Barrier Precautions. Similarly, LPN #3 did not wear a gown while administering medications through a Gastrostomy tube to another resident, despite signage indicating the need for Enhanced Barrier Precautions. Additionally, LPN #1 did not establish a clean field for wound care supplies and failed to perform hand hygiene after removing soiled dressings during a dressing change for a resident with multiple wounds, including pressure ulcers and an arterial ulcer. This resident had a history of osteomyelitis and diabetes mellitus, which required careful infection control measures. The LPN admitted to omitting critical infection control steps due to nervousness during the procedure. The facility's policies on Enhanced Barrier Precautions and wound care were not adhered to, as evidenced by the observations and interviews conducted during the survey. Despite the facility's claim that all nurses had been oriented on these procedures, the deficiencies observed indicate a gap in knowledge and practice among the nursing staff. The Assistant Director of Nursing and the Director of Nursing acknowledged the issues and stated that measures were in place to ensure compliance, but the deficiencies suggest these measures were not effectively implemented.
Improper IV Medication Administration by LPN
Penalty
Summary
The facility failed to ensure that care and services were provided according to accepted standards of clinical quality and practice, specifically in the administration of intravenous medications. This deficiency was identified during a recertification survey, where it was observed that an LPN administered intravenous antibiotics through a Peripherally Inserted Central Catheter (PICC) for a resident, despite facility policy prohibiting LPNs from performing such tasks. The resident in question was admitted with osteomyelitis and diabetes mellitus, requiring intravenous medication administration. The facility's policy clearly states that LPNs are not permitted to flush or administer medications through a central venous line, including a PICC. However, during the survey, an LPN was observed administering a saline flush and an antibiotic solution through the resident's PICC. The LPN, who had been employed for only a month, admitted to not being sure if the line was a central catheter and had not received in-service training on intravenous administration. This lack of training and oversight led to the improper administration of medication. Interviews with facility staff, including the unit supervisor, Assistant Director of Nursing, and Director of Nursing, revealed gaps in communication and monitoring of medication administration. The facility's procedures for ensuring that only qualified staff administer medications through central lines were not effectively implemented. The Assistant Director of Nursing acknowledged that they did not audit the Medication Administration Records for signatures of nurses performing intravenous medication administration, which contributed to the oversight in this case.
Failure to Provide Pressure Ulcer Prevention and Care
Penalty
Summary
The facility failed to provide necessary treatment and services to promote wound healing for a resident with pressure ulcers, as observed during a recertification survey. Resident #389, who was admitted with osteomyelitis of the left ankle and foot and diabetes mellitus, had severely impaired cognition and was dependent on staff for all bed mobility and transfers. Despite being identified as at moderate risk for developing pressure ulcers, the resident did not receive appropriate pressure-relieving devices or preventative measures, such as heel booties, offloading of heels, or a pressure-reducing mattress. Observations conducted on multiple occasions revealed that Resident #389 was either in bed or sitting without the necessary pressure-relieving devices. The facility's policy on pressure ulcer prevention, which includes the use of special mattresses and heel offloading, was not followed. Additionally, the Certified Nursing Assistant Accountability Record for February 2025 did not document any intervention or task for turning and repositioning the resident, which was a critical component of the care plan. Interviews with facility staff, including a registered nurse and the Director of Nursing, confirmed that the necessary preventative measures and equipment were not in place for Resident #389. The registered nurse acknowledged that the protocol for residents at risk of pressure ulcers was not followed, and the Director of Nursing admitted that the unit manager and admission nurse failed to ensure the implementation of these measures. The lack of documentation and adherence to the facility's protocol contributed to the deficiency in care for Resident #389.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to ensure proper disposal of garbage and refuse, as observed during a recertification survey. The facility's policy, revised in January 2025, mandates that all waste be kept in lined containers with lids, leak-proof, and non-absorbent before disposal. However, observations on February 10th and 11th, 2025, revealed that garbage bins in the disposal room and pickup area were without lids, leaving waste exposed. Interviews with the Director of Food Service and the Housekeeping Director confirmed that the bins were not equipped with lids, and the waste company had never provided bins with lids. The facility administrator acknowledged the issue and contacted the vendor to address it.
Inaccurate Documentation of Resident Care
Penalty
Summary
The facility failed to ensure accurate documentation of resident care in accordance with professional standards, as evidenced by the case of a resident with Multiple Sclerosis, Hemiplegia, and Osteoarthritis. This resident was supposed to receive Range of Motion (ROM) exercises as per a physician's order and a comprehensive care plan. However, despite documentation indicating that these exercises were being performed, interviews with staff and the resident revealed that the exercises had not been provided for several months. The resident, who is cognitively intact and requires assistance with activities of daily living, reported that the ROM exercises initially provided by nursing staff had ceased. Certified Nursing Assistants (CNAs) assigned to the resident confirmed that they were not performing the exercises and were unaware of any current program requiring them to do so. Despite this, the CNA documentation inaccurately reflected that the exercises were being completed, suggesting a discrepancy between recorded and actual care. Interviews with facility staff, including a Physical Therapist and a Registered Nurse, highlighted a lack of awareness and communication regarding the resident's care plan. The Director of Nursing acknowledged the need for staff training on performing and documenting ROM exercises accurately. This deficiency indicates a failure in maintaining accurate medical records and ensuring that care plans are followed, as required by professional standards.
Failure to Provide Ordered Range of Motion Exercises and Inaccurate Documentation
Penalty
Summary
A deficiency was identified when a resident with diagnoses including Multiple Sclerosis, Hemiplegia, and Osteoarthritis, and who was cognitively intact, did not receive ordered range of motion (ROM) exercises as required. The resident had a physician's order and a care plan in place for daily active and passive ROM exercises to both upper and lower extremities, with specific instructions for frequency and duration. Documentation in the certified nursing assistant (CNA) record indicated that these exercises were being provided and tolerated. However, interviews with the resident and multiple staff members revealed that the ROM exercises had not been performed for several months. The resident confirmed that after physical therapy was discontinued, nursing staff initially performed the exercises but then stopped completely. CNAs assigned to the resident stated they were not performing ROM exercises and were unaware of any current program or instructions to do so. They also could not explain why documentation reflected that the exercises were completed, suggesting inaccuracies in the medical record. Further interviews with the physical therapist and nursing staff confirmed that the resident was supposed to be on a maintenance restorative nursing program for ROM, and that the responsibility for providing these exercises fell to the CNAs during ADL care. The DON acknowledged that unit supervisors were responsible for reviewing care plans and ensuring care was provided, but staff required additional training on performing and documenting ROM exercises accurately. The failure to provide the ordered ROM exercises and the inaccurate documentation led to the deficiency.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that daily nurse staffing information was posted as required during the Recertification Survey conducted from February 5, 2025, to February 12, 2025. Observations revealed that the daily nurse staffing information, including the total number of staff and total number of hours, was not posted in the lobby or nursing unit. The facility's policy, revised on January 2, 2025, mandates that this information be readily available in a readable format to residents and visitors in prominent places. However, the daily schedule posted in the lobby only included staff names and unit assignments, not the total staffing numbers and hours. Interviews with facility staff, including the Staffing Coordinator, Director of Nursing, and Administrator, confirmed the oversight. The Staffing Coordinator acknowledged that the daily staffing information was attached to the schedule at the end of the day but not posted as required. The Director of Nursing admitted to being unaware of the missing information and did not verify its posting. Similarly, the Administrator, who usually checks the postings, had not done so since the survey began and was unaware of the deficiency. This lack of compliance with the facility's policy and state regulation 10 NYCRR 415.13 resulted in the deficiency.
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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 New York
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Northern Manhattan Rehabilitation And Nursing Ctr | 0.7 mi | ★★★★★ | 12 | 0 |
| Henry J. Carter Skilled Nursing Facility | 0.9 mi | ★★★★★ | 2 | 1 |
| St Marys Center Inc | 1 mi | ★★★★★ | 0 | 0 |
| Highbridge Woodycrest Center | 1.2 mi | ★★★★★ | 0 | 0 |
| Concourse Rehabilitation And Nursing Center, Inc | 1.4 mi | ★★★★★ | 0 | 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 July 2026) and official state health department websites.