Inspection Reports for
Harlem Center for Nursing and Rehabilitation
30 West 138th Street, New York, NY, 10037
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Inspection Report — Dec 17, 2025
Abbreviated Survey CMS
Date: Dec 17, 2025
Visit Reason
The visit was an on-site abbreviated survey to assess the facility's compliance with maintaining a safe, comfortable, and homelike environment, specifically regarding heating and temperature conditions.
Findings
The facility failed to maintain comfortable temperatures on five resident-occupied floors, with room temperatures ranging from 46°F to 57°F over a period from early morning on 12/16/2025 through 12/17/2025. The heating system was inoperable due to boiler issues, and the facility did not report the loss of heat to the Department of Health as required.
Citations (1)
F 0584: The facility did not maintain a safe, clean, comfortable, and homelike environment as resident room temperatures ranged from 46°F to 57°F over multiple floors for more than a day. The heating system was inoperable due to boiler malfunctions and the facility failed to report the loss of heat to the Department of Health.
Report Facts
Resident room temperatures: 46
Resident room temperatures: 57
Water temperatures: 48
Water temperatures: 52
Number of water temperatures measured: 14
Number of water temperatures measured: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Stated the facility did not report the loss of heat because she thought it was unnecessary unless it lasted longer than 4 hours | |
| Director of Maintenance | Reported boiler vendor activities and expected heat restoration timeline |
Inspection Report — Dec 17, 2025
Complaint Investigation State
Date: Dec 17, 2025
Visit Reason
State-compiled facility profile showing 8 inspections from 2022 to 2025 with deficiency history, complaint investigations, and enforcement actions.
Complaint Details
The state logged 93 complaints about this facility; 7 led to on-site inspections.
Findings
Across 8 inspections in the reporting period, 68 citations were issued including 30 standard health and 38 Life Safety Code citations. The facility had multiple deficiencies ranging from minor potential harm to immediate jeopardy, with 4 formal enforcement actions recorded.
Citations (45)
Organization And Administration: Standard Health Citation — quality of care with pattern scope.
Safe/clean/comfortable/homelike Environment: Standard Health Citation — quality of care with widespread scope.
Subsistence Needs For Staff And Patients: Standard Health Citation — quality of care with widespread scope.
Quality Of Care: Standard Health Citation — quality of care with isolated scope.
Free Of Accident Hazards/supervision/devices: Standard Health Citation — quality of care with isolated scope.
Dispose Garbage And Refuse Properly: Standard Health Citation — quality of care with isolated scope.
Increase/prevent Decrease In Rom/mobility: Standard Health Citation — quality of care with isolated scope.
Infection Prevention & Control: Standard Health Citation — quality of care with pattern scope.
Posted Nurse Staffing Information: Standard Health Citation — quality of care with widespread scope.
Qaa Committee: Standard Health Citation — quality of care with pattern scope.
Resident Records - Identifiable Information: Standard Health Citation — quality of care with isolated scope.
Services Provided Meet Professional Standards: Standard Health Citation — quality of care with isolated scope.
Treatment/svcs To Prevent/heal Pressure Ulcer: Standard Health Citation — quality of care with isolated scope.
Reporting - National Health Safety Network: Standard Health Citation — quality of care with widespread scope, not yet corrected.
Bedrails: Standard Health Citation — quality of care with isolated scope.
Care Plan Timing And Revision: Standard Health Citation — quality of care with isolated scope.
Covid-19 Vaccination Of Facility Staff: Standard Health Citation — quality of care with isolated scope.
Department Criminal History Review: Standard Health Citation — quality of care with scope.
Develop/implement Comprehensive Care Plan: Standard Health Citation — quality of care with isolated scope.
Menus Meet Resident Nds/prep In Adv/followed: Standard Health Citation — quality of care with isolated scope.
Prostheses: Standard Health Citation — quality of care with isolated scope.
Reporting Of Alleged Violations: Standard Health Citation — quality of care with isolated scope.
Right To Be Free From Physical Restraints: Standard Health Citation — quality of care with isolated scope.
Safe/functional/sanitary/comfortable Environ: Standard Health Citation — quality of care with isolated scope.
Corridor - Doors: Life Safety Code Citation — NFPA requirements with pattern scope.
Corridors - Construction Of Walls: Life Safety Code Citation — NFPA requirements with isolated scope.
Electrical Equipment - Power Cords And Extens: Life Safety Code Citation — NFPA requirements with isolated scope.
Electrical Systems - Maintenance And Testing: Life Safety Code Citation — NFPA requirements with pattern scope.
Electrical Systems - Other: Life Safety Code Citation — NFPA requirements with isolated scope.
Fire Drills: Life Safety Code Citation — NFPA requirements with isolated scope.
Fundamentals - Building System Categories: Life Safety Code Citation — NFPA requirements with isolated scope.
Sprinkler System - Installation: Life Safety Code Citation — NFPA requirements with pattern scope.
Sprinkler System - Maintenance And Testing: Life Safety Code Citation — NFPA requirements with pattern scope.
Subdivision Of Building Spaces - Smoke Barrie: Life Safety Code Citation — NFPA requirements with pattern scope.
Egress Doors: Life Safety Code Citation — NFPA requirements with isolated scope.
Electrical Systems - Essential Electric Syste: Life Safety Code Citation — NFPA requirements with isolated scope.
Emergency Lighting: Life Safety Code Citation — NFPA requirements with pattern scope.
Exit Signage: Life Safety Code Citation — NFPA requirements with isolated scope.
Fire Alarm System - Testing And Maintenance: Life Safety Code Citation — NFPA requirements with isolated scope.
Means Of Egress - General: Life Safety Code Citation — NFPA requirements with pattern scope.
Ramps And Other Exits: Life Safety Code Citation — NFPA requirements with isolated scope.
Stairways And Smokeproof Enclosures: Life Safety Code Citation — NFPA requirements with pattern scope.
Standards Of Construction For New Existing Nh: Life Safety Code Citation — NFPA requirements with isolated scope.
Subdivision Of Building Spaces - Smoke Barrie: Life Safety Code Citation — NFPA requirements with isolated scope.
Vertical Openings - Enclosure: Life Safety Code Citation — NFPA requirements with isolated scope.
Report Facts
Inspections on page: 8
Total violations/deficiencies cited: 68
Inspections with violations: 7
Inspections without violations: 1
Complaints total: 93
On-site complaint inspections: 7
Citations from complaints: 12
Enforcement actions: 4
Total fines: 38000
Plan of correction counts: 67
Plan of correction statuses: 1
Inspection Report — Dec 9, 2025
Abbreviated Survey CMS
Date: Dec 9, 2025
Visit Reason
The visit was an abbreviated survey triggered by Complaint #2634618 to investigate the facility's compliance with quality of care standards related to treatment and care of residents.
Complaint Details
Complaint #2634618 was investigated. The complaint was substantiated as the facility failed to carry out ordered lab tests for Resident #1 and did not document reasons for non-completion.
Findings
The facility failed to ensure that one resident (Resident #1) received ordered laboratory tests (comprehensive metabolic panel and complete blood count) as prescribed. There was no documentation explaining why the tests were not completed, and the facility did not follow proper procedures to document resident refusal or communicate with the physician.
Citations (1)
F 0684: The facility failed to provide appropriate treatment and care according to orders and resident preferences. Specifically, ordered laboratory tests for Resident #1 were not completed and lacked documentation explaining the omission.
Report Facts
Residents reviewed for quality of care: 3
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Physician #1 | Interviewed regarding the telehealth orders and lab work necessity | |
| Registered Nurse #2 | Nursing Supervisor | Interviewed about the missing lab work and inability to explain why it was not done |
| Director of Nursing | Interviewed about possible resident refusal and documentation requirements | |
| Medical Director | Interviewed about physician follow-up on telemedicine orders |
Inspection Report — Apr 3, 2025
Abbreviated Survey CMS
Date: Apr 3, 2025
Visit Reason
The abbreviated survey was conducted to assess compliance with regulations related to resident supervision and safety, specifically focusing on an incident of resident elopement.
Findings
The facility failed to ensure adequate supervision to prevent elopement of Resident #1, who left the facility unnoticed and was not located. Immediate corrective actions were taken, and the facility was found to be in substantial compliance by the time of the survey.
Citations (1)
F 0689: The facility did not ensure adequate supervision to prevent Resident #1 from eloping on 03/19/2025. Security Guard #1 failed to stop the resident from leaving, and staff did not notice the absence until hours later. This posed immediate jeopardy to resident health or safety.
Report Facts
Residents affected: 1
Staff in-service percentages: 91
Staff in-service percentages: 95
Staff in-service percentages: 95
Staff in-service percentages: 80
Staff in-service percentages: 100
Staff in-service percentages: 100
Staff in-service percentages: 100
Staff in-service percentages: 100
Staff in-service percentages: 71
Staff in-service percentages: 100
Staff in-service percentages: 80
Staff in-service percentages: 100
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nursing Supervisor #1 | Notified Assistant Director of Nursing about Resident #1's elopement and coordinated response | |
| Certified Nursing Assistant #1 | Observed Resident #1 leaving unit and did not stop them as resident was allowed to go to vending machine | |
| Licensed Practical Nurse #1 | Performed rounds and notified Registered Nursing Supervisor #1 when Resident #1 was missing | |
| Security Guard #1 | Failed to stop Resident #1 from leaving facility; was being trained and left alone at front desk | |
| Security Guard #2 | Was training Security Guard #1 and left front desk briefly; unaware Resident #1 left | |
| Director of Nursing | Instructed search and coordinated response after being notified of elopement | |
| Administrator | Informed of elopement and reviewed video surveillance; implemented new measures | |
| Medical Doctor | Provided care to Resident #1 and confirmed no prior exit-seeking behavior | |
| Assistant Director of Nursing #1 | Documented nursing progress note about Resident #1's elopement |
Inspection Report — Feb 12, 2025
Annual Inspection CMS
Date: Feb 12, 2025
Visit Reason
The inspection was a Recertification survey conducted from 02/05/2025 to 02/12/2025 to assess compliance with professional standards of care and regulatory requirements.
Findings
The facility was found deficient in multiple areas including improper intravenous medication administration by Licensed Practical Nurses, inadequate pressure ulcer care and prevention, failure to post daily nurse staffing information, improper garbage disposal practices, inaccurate resident documentation, lack of required Medical Director participation in Quality Assurance meetings, and lapses in infection prevention and control practices.
Citations (7)
F0658: Licensed Practical Nurse administered intravenous antibiotics through a Peripherally Inserted Central Catheter contrary to facility policy prohibiting LPNs from flushing or administering medications via central lines.
F0686: Resident with pressure ulcers did not receive pressure relieving devices or preventative measures such as heel booties or pressure reducing mattress to promote wound healing.
F0732: Facility did not post daily nurse staffing information including total number of staff and total hours in a readily accessible location.
F0814: Garbage bins in disposal and pickup areas lacked lids or covers, exposing waste and risking pest harborage.
F0842: Resident #66 was not provided with ordered range of motion exercises despite documentation indicating exercises were performed.
F0868: Medical Director did not attend 4 of 4 required quarterly Quality Assurance & Performance Improvement meetings.
F0880: Infection control lapses included failure of nurses to wear gowns during medication administration for residents with indwelling devices and failure to establish a clean field and perform hand hygiene during wound care.
Report Facts
Residents reviewed: 35
Residents reviewed for limited range of motion: 37
Quarterly meetings Medical Director missed: 4
Medication administrations observed: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #2 | Licensed Practical Nurse | Observed administering intravenous antibiotics through a Peripherally Inserted Central Catheter without proper training or gown. |
| Licensed Practical Nurse #3 | Licensed Practical Nurse | Observed administering medications via Gastrostomy tube without wearing a gown. |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Observed performing wound care without establishing a clean field or performing hand hygiene after removing soiled dressings. |
| Registered Nurse #1 | Unit Supervisor | Interviewed regarding medication administration policies and wound care oversight. |
| Assistant Director of Nursing | Assistant Director of Nursing/Infection Control Preventionist | Interviewed about staff education on Enhanced Barrier Precautions and infection control rounds. |
| Director of Nursing | Director of Nursing | Interviewed about Quality Assurance meetings, infection control policies, and staff accountability. |
Inspection Report — Feb 12, 2025
Complaint Investigation CMS
Date: Feb 12, 2025
Visit Reason
The inspection was conducted as a Complaint and Recertification survey from 2/5/2025 to 2/12/2025, triggered by a complaint regarding failure to provide range of motion exercises to a resident.
Complaint Details
The complaint investigation was substantiated, involving Resident #66 who was not provided with ordered range of motion exercises after physical therapy was discontinued.
Findings
The facility failed to provide range of motion exercises to Resident #66 as ordered by the physician, despite documentation indicating otherwise. Staff interviews confirmed that exercises were not performed for several months, and documentation errors were noted.
Citations (1)
10 NYCRR 415.12(e)(2) - The facility did not ensure Resident #66 received prescribed active and passive range of motion exercises daily as ordered, resulting in potential decline in mobility.
Report Facts
Residents reviewed for Limited Range of Motion: 2
Total sampled residents: 37
Range of motion exercises prescribed: 3
Repetitions per set: 10
Duration of exercises: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant #9 | Certified Nursing Assistant | Stated not performing range of motion exercises for Resident #66 and confirmed documentation errors |
| Certified Nursing Assistant #11 | Certified Nursing Assistant | Admitted to not providing range of motion exercises on 2/6/2025 and noted documentation errors |
| Physical Therapist | Physical Therapist | Reported Resident #66 last received therapy from 10/17/2024 to 11/6/2024 and was placed on maintenance restorative nursing program |
| Registered Nurse #3 | Registered Nurse | Responsible for nursing staff oversight and unaware Resident #66 was not receiving exercises |
| Director of Nursing Service | Director of Nursing Service | Responsible for unit nurse supervisor oversight and stated need for staff training on range of motion and documentation |
Inspection Report — Mar 16, 2023
Annual Inspection CMS
Date: Mar 16, 2023
Visit Reason
The survey was a Recertification Survey conducted from 3/9/23 to 3/16/23 to assess compliance with regulatory requirements for nursing home operations and resident care.
Findings
The facility was found deficient in multiple areas including maintenance of a safe, clean, and homelike environment; improper use and documentation of physical restraints; failure to timely report abuse and accidents; incomplete and outdated care plans; failure to provide assistance with prosthetic limb use; failure to follow resident dietary preferences; inadequate precautions for unvaccinated staff with medical exemptions; and unsafe and unsanitary conditions in the Unit 5 nursing station.
Citations (10)
F 0584: The facility failed to maintain a safe, clean, and homelike environment, evidenced by torn wheelchairs, rusty shower chairs, stained and leaking bathroom disinfectant tanks, and missing closet doors in resident rooms.
F 0604: Resident #94 was observed with bilateral upper 1/3 siderails raised, used as restraints without proper medical orders or documented clinical rationale.
F 0609: The facility failed to timely report a resident-to-resident altercation and an incident causing a resident's leg laceration requiring hospital intervention to the New York State Department of Health within required timeframes.
F 0656: The care plan for Resident #25 did not address the right leg laceration requiring 11 staples, and interventions to prevent recurrence were not documented or implemented.
F 0657: Resident #68's care plan related to hoarding behavior was not reviewed or revised quarterly to include person-centered interventions despite ongoing hoarding behavior.
F 0696: Resident #24 did not receive assistance applying a cosmetic prosthetic limb as ordered, and refusals were not documented.
F 0700: Resident #94 was observed with bilateral 1/3 siderails in place without documented risk assessment for entrapment and without proper interdisciplinary communication and consent documentation.
F 0803: Resident #64 did not receive a sandwich on their meal tray as indicated on the meal ticket, and the dietary staff failed to ensure menus were followed.
F 0888: The facility did not implement additional precautions for an unvaccinated staff member with a medical exemption to mitigate the spread of COVID-19.
F 0921: The Unit 5 Nursing Station was in disrepair with broken drawers, cracked Formica held by duct tape, and a nest of wires covered in dirt and dust, creating an unsafe and unsanitary environment.
Report Facts
Residents reviewed: 40
Units reviewed: 5
Staples for leg laceration: 11
Days for staple removal: 8
Scheduled work days: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #3 | Unvaccinated staff with medical exemption providing direct care without additional COVID-19 precautions | |
| Maintenance Worker #1 | Interviewed regarding wheelchair and nursing station repairs | |
| Director of Maintenance | Interviewed regarding maintenance rounds and nursing station condition | |
| Director of Nursing Services | Interviewed regarding siderail use and COVID-19 vaccination management | |
| Director of Rehabilitation | Interviewed regarding prosthetic limb use and siderail assessments | |
| Certified Nursing Assistant #1 | Interviewed regarding prosthetic limb application and Resident #24 care | |
| Licensed Practical Nurse #4 | Interviewed regarding Resident #64 dietary preferences and sandwich issues | |
| Dietician | Interviewed regarding menu planning and resident food preferences | |
| Dietary Supervisor | Interviewed regarding tray accuracy and sandwich delivery |
Inspection Report — Mar 16, 2023
Complaint Investigation CMS
Date: Mar 16, 2023
Visit Reason
The inspection was conducted as a recertification and complaint survey to investigate allegations of failure to timely report resident-to-resident abuse and failure to develop a comprehensive care plan for a resident's injury.
Complaint Details
The complaint investigation found that the facility did not report a resident-to-resident altercation involving Residents #246 and #119 within 2 hours as required, and did not report an incident involving Resident #25's leg laceration requiring hospital care within 24 hours. The facility also failed to develop a care plan for Resident #25's injury.
Findings
The facility failed to report a resident-to-resident altercation and a serious injury to the New York State Department of Health within required timeframes. Additionally, the facility did not develop and implement a comprehensive care plan to address a resident's right leg laceration caused by a Geriatric Chair armrest.
Citations (2)
F 0609: The facility did not timely report suspected resident-to-resident physical abuse and an incident causing a leg laceration requiring hospital intervention to the New York State Department of Health as required.
F 0656: The facility failed to develop and implement a comprehensive person-centered care plan to address Resident #25's right leg laceration requiring 11 staples and prevent further injury.
Report Facts
Residents reviewed for Abuse: 3
Residents reviewed for Accidents: 7
Total sampled residents: 40
Staples required: 11
Laceration size: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #6 | Licensed Practical Nurse | Interviewed regarding Resident #25's hospitalization and wound care |
| Director of Nursing Services | Director of Nursing Services | Interviewed about reporting procedures and care plan updates |
| Administrator | Administrator | Interviewed about reporting requirements for injuries |
| Certified Nursing Assistant #1 | Certified Nursing Assistant | Interviewed about care and transfer of Resident #25 |
| Licensed Practical Nurse #3 | Licensed Practical Nurse | Interviewed about care plan responsibilities |
| Director of Rehabilitation | Director of Rehabilitation | Interviewed about assessment of Resident #25's Geriatric Chair |
Inspection Report — Feb 27, 2020
Annual Inspection CMS
Date: Feb 27, 2020
Visit Reason
The survey was a recertification and recertification survey to assess compliance with federal nursing home regulations.
Findings
The facility was found deficient in multiple areas including resident dignity and respect, environmental safety and cleanliness, care planning, accident prevention, behavioral health care, infection control, and physical environment safety such as loose handrails.
Citations (7)
F 0550: The facility failed to ensure residents were treated with dignity and respect, as staff entered multiple residents' rooms without knocking, affecting 5 of 40 residents reviewed.
F 0584: The facility did not maintain a safe, clean, and homelike environment, with damaged furniture, broken ceiling tiles, torn upholstery, and missing wheelchair brake handle covers on 2 of 5 nursing units.
F 0656: The facility failed to develop and implement a complete person-centered care plan with measurable goals and interventions for a resident's hoarding behavior.
F 0689: The facility did not ensure the resident environment was free from accident hazards and failed to provide adequate supervision to prevent accidents, including unsecured televisions and lack of fall investigation for 2 residents.
F 0740: The facility failed to provide necessary behavioral health care and services to address a resident's hoarding behaviors, resulting in a cluttered and unsanitary room environment.
F 0880: The facility failed to maintain infection control practices, including oxygen tubing lying on the floor and staff not donning required personal protective equipment when entering rooms of residents on contact precautions.
F 0924: The facility did not ensure corridor handrails were firmly affixed to the wall, with several loose handrails observed on the 5th floor.
Report Facts
Residents reviewed for dignity: 40
Residents affected by dignity deficiency: 5
Nursing units observed for environment: 5
Nursing units affected by environment deficiency: 2
Boxes observed in resident room: 15
Handrails loose: 3
Residents investigated for accident care: 4
Residents affected by accident care deficiency: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Unit Manager | Unit Manager | Interviewed regarding resident hoarding behaviors and care plan responsibility |
| Assistant Director of Nursing | Assistant Director of Nursing | Interviewed regarding care plan development and infection control |
| Director of Nursing | Director of Nursing | Interviewed regarding accident investigations and infection control |
| Certified Nursing Assistant #1 | Certified Nursing Assistant | Interviewed regarding knocking on doors and oxygen tubing infection control issue |
| Certified Nursing Assistant #2 | Certified Nursing Assistant | Observed and interviewed regarding PPE use and resident room cleaning |
| RN Supervisor #5 | Registered Nurse Supervisor | Interviewed regarding fall incident investigation and PPE use |
| Maintenance Worker #6 | Maintenance Worker | Interviewed regarding TV mounting policy and handrail repairs |
| Acting Director of Maintenance | Acting Director of Maintenance | Interviewed regarding maintenance priorities and handrail repairs |
| Director of Housekeeping Services | Director of Housekeeping Services | Interviewed regarding housekeeping and maintenance coordination |
| Occupational Therapist | Occupational Therapist | Observed not wearing PPE when entering contact precaution room |
| Director Social Services | Director of Social Services | Interviewed regarding resident hoarding behaviors and discharge planning |
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