Inspection Reports for
Fort Tryon Center for Rehabilitation and Nursing
801 W 190th St, New York, NY 10040, United States, NY, 10040
Back to Facility ProfileInspection Report — Dec 18, 2025
Citations: 2
Date: Dec 18, 2025
Visit Reason
The inspection was conducted to assess the facility's compliance with maintaining a safe, clean, comfortable, and homelike environment for residents, focusing on housekeeping and maintenance services.
Findings
The facility failed to ensure necessary housekeeping and maintenance services were provided, as evidenced by accumulation of dust, dirt, stains on equipment and furniture, and torn and soiled wheelchairs in one of five resident units observed on the 3rd Floor.
Citations (2)
Accumulation of dust, dirt, and stains on bedside tables, intravenous poles, feeding pumps, oxygen concentrators, and suction machines.
Torn arm rests and soiled wheelchairs observed in resident rooms on the 3rd Floor.
Report Facts
Resident units observed: 5
Resident units with deficiencies: 1
Porters responsible for cleaning wheelchairs: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Housekeeping Services | Interviewed regarding housekeeping responsibilities and cleaning procedures | |
| Director of Maintenance | Interviewed regarding maintenance logbook and repair procedures |
Inspection Report — Dec 18, 2025
Complaint Investigation
Citations: 15
Date: Dec 18, 2025
Visit Reason
State-compiled facility profile showing 4 inspections from 2022 to 2025 with deficiency history, complaint investigations, and enforcement actions.
Complaint Details
The state logged 50 complaints about this facility; 3 led to on-site inspections. Two citations resulted from those complaints.
Findings
Across 4 inspections, 21 citations were issued including 12 standard health and 9 Life Safety Code citations. The facility had 50 complaints with 3 on-site inspections and 2 enforcement actions totaling $24,000 in fines.
Citations (15)
Care Plan Timing And Revision: Standard Health Citation — quality of care with isolated minor potential harm.
Develop/implement Comprehensive Care Plan: Standard Health Citation — quality of care with isolated minor potential harm.
Respect, Dignity/right To Have Prsnl Property: Standard Health Citation — quality of care with isolated minor potential harm.
Safe/clean/comfortable/homelike Environment: Standard Health Citation — quality of care with isolated minor potential harm.
Physical Environment: Life Safety Code Citation — NFPA requirements with isolated minor potential harm.
Sprinkler System - Maintenance And Testing: Life Safety Code Citation — NFPA requirements with pattern minor potential harm.
Accuracy Of Assessments: Standard Health Citation — quality of care with isolated minor potential harm.
Maintains Effective Pest Control Program: Standard Health Citation — quality of care with isolated minor potential harm.
Responsibilities Of Providers; Required Notif: Standard Health Citation — quality of care with isolated minor potential harm.
Electrical Equipment - Power Cords And Extens: Life Safety Code Citation — NFPA requirements with isolated minor potential harm.
Electrical Systems - Other: Life Safety Code Citation — NFPA requirements with pattern minor potential harm.
Electrical Systems - Receptacles: Life Safety Code Citation — NFPA requirements with pattern minor potential harm.
Illumination Of Means Of Egress: Life Safety Code Citation — NFPA requirements with isolated minor potential harm.
Sprinkler System - Maintenance And Testing: Life Safety Code Citation — NFPA requirements with pattern minor potential harm.
Reporting - National Health Safety Network: Standard Health Citation — quality of care with widespread minor potential harm not yet corrected.
Report Facts
Inspections on page: 4
Total violations/deficiencies cited: 21
Inspections with violations: 3
Inspections without violations: 1
Total complaints: 50
On-site complaint inspections: 3
Citations from complaints: 2
Enforcement actions: 2
Total fines: 24000
Inspection Report — Jun 21, 2024
Annual Inspection
Citations: 2
Date: Jun 21, 2024
Visit Reason
The inspection was conducted as a Recertification Survey and Complaint Survey to assess compliance with regulatory requirements including resident assessments and environmental conditions.
Complaint Details
The inspection included a complaint survey (NY00334169) related to pest control issues, with findings substantiating vermin presence and inadequate pest management.
Findings
The facility failed to ensure accurate Minimum Data Set assessments for residents, specifically misdocumenting vision impairment for one resident. Additionally, the facility did not maintain an effective pest control program, with evidence of vermin excrement and resident reports of mice and roaches in multiple areas.
Citations (2)
Minimum Data Set assessment inaccurately documented a resident's vision status, failing to reflect legal blindness.
Facility did not maintain an effective pest control program, with vermin excrement observed and resident reports of mice and roaches.
Report Facts
Residents sampled: 38
Residents affected: 1
Floors observed: 5
Pest control visits per week: 2
Pest control visits per week: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant #3 | Interviewed regarding resident vision impairment | |
| MDS Coordinator | Interviewed and acknowledged assessment error | |
| Certified Nursing Assistant #2 | Interviewed regarding pest sightings and droppings | |
| Licensed Practical Nurse #1 | Interviewed regarding health risks from mouse droppings | |
| Registered Nurse Supervisor #1 | Interviewed regarding pest presence and control | |
| Administrator | Interviewed regarding pest reports and internal communications | |
| Pest Control representative | Interviewed regarding pest control services and observations | |
| Director of Housekeeping | Interviewed regarding pest control rounds and documentation | |
| Chief Operating Officer | Interviewed regarding pest control challenges and service changes |
Inspection Report — Mar 17, 2022
Annual Inspection
Citations: 2
Date: Mar 17, 2022
Visit Reason
The inspection was conducted as a Recertification Survey from 03/10/2022 to 03/17/2022 to assess compliance with regulatory requirements for the Fort Tryon Center for Rehabilitation and Nursing.
Findings
The facility failed to provide activities that meet all residents' needs, specifically not providing a non-English speaking resident with television channels in their native language. Additionally, the facility failed to ensure that a resident's weights were measured and recorded according to the Physician's order.
Citations (2)
Facility did not provide a non-English speaking resident with television channels in their native language as per their preferences.
Resident's weights were not measured and recorded according to the Physician's order.
Report Facts
Residents reviewed for Activities: 38
Residents reviewed for Nutrition: 7
Residents affected: 1
Residents affected: 1
Weight recorded: 257
Weight recorded: 264.2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant #1 | CNA | Interviewed regarding Resident #104's activity and language preferences |
| Activities Assistant | AA | Conducted activity assessment for Resident #104 and interviewed about language line usage |
| Acting Director of Recreation | ADR | Interviewed about activity assessments and availability of TV channels for non-English speakers |
| Certified Nursing Assistant #2 | CNA | Interviewed regarding weight measurement procedures |
| Licensed Practical Nurse #1 | LPN | Interviewed about weight measurement and documentation for Resident #37 |
| Registered Nurse Supervisor #1 | RNS | Interviewed about weight measurement policies and documentation |
| Registered Dietitian #1 | RD | Interviewed about weight review and follow-up procedures |
| Director of Nursing | DON | Interviewed about weight measurement policies and staff responsibilities |
Inspection Report — Jun 18, 2019
Annual Inspection
Citations: 5
Date: Jun 18, 2019
Visit Reason
The inspection was a recertification survey to assess compliance with state and federal regulations for Fort Tryon Center for Rehabilitation and Nursing.
Findings
The facility was found deficient in multiple areas including failure to post survey results for residents, delayed submission and inaccuracies in Minimum Data Set (MDS) assessments, incomplete and inaccurate resident care plans, and inadequate infection control practices such as improper handling of Foley catheter drainage bags and wound vac tubing.
Citations (5)
Failure to post the most recent survey results in a place readily accessible to residents and family members.
Delayed electronic transmission of Minimum Data Set (MDS) assessments to CMS, with 10 of 17 residents having late submissions.
Inaccurate MDS assessments for 2 residents, including incorrect documentation of falls and assistance needs.
Failure to review and revise a resident's Comprehensive Care Plan (CCP) to reflect Advance Directives.
Failure to maintain infection control practices, including Foley catheter drainage bag resting on the floor and wound vac tubing lying on the floor.
Report Facts
Residents reviewed for MDS assessments: 17
Residents reviewed for care plans: 38
Residents reviewed for MDS accuracy: 73
Resident Council members: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| MDS Coordinator #1 | MDS Coordinator | Interviewed about delays in MDS assessment submissions and backlog |
| MDS Coordinator #2 | MDS Coordinator | Acknowledged mistake in MDS assessment related to resident falls and initiated correction |
| Director of Nursing | Director of Nursing (DNS) | Interviewed regarding resident fall status and MDS assessment process |
| Director of Social Work | Director of Social Work (DSW) | Interviewed about errors in documenting Advance Directives and updating care plans |
| Certified Nursing Assistant #1 | Certified Nursing Assistant (CNA) | Interviewed about Foley catheter drainage bag care and observations |
| Registered Nurse #1 | Registered Nurse (RN) | Interviewed about proper Foley catheter drainage bag handling |
| Registered Nurse #3 | Registered Nurse (RN) | Observed wound vac tubing on floor and explained handling practices |
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