Inspection Reports for Tarrytown Rehabilitation and Nursing Center
20 Wood Ct, Tarrytown, NY 10591, NY, 10591
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
14.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
180% worse than New York average
New York average: 5.1 deficiencies/yearDeficiencies per year
20
15
10
5
0
Inspection Report
Annual Inspection
Deficiencies: 5
Date: Sep 28, 2024
Visit Reason
The inspection was conducted as part of the recertification and abbreviated surveys from 9/24/24 to 9/28/24 to assess compliance with regulatory requirements for nursing home care.
Findings
The facility was found deficient in multiple areas including failure to ensure resident privacy due to a broken bathroom light, insufficient nursing staff to meet resident needs, lack of annual performance appraisals and mandatory training for Certified Nurse Aides, improper feeding assistance by untrained Resident Assistants, and inadequate nurse aide training hours.
Deficiencies (5)
Resident's right to privacy was not ensured due to a broken bathroom light and being told to leave the door open for light.
Insufficient nursing staff provided on all units/shifts to meet resident needs.
Annual performance appraisals were not performed for 5 of 5 Certified Nurse Aides reviewed.
Two residents were fed by staff members who did not complete a State-approved training course for feeding assistance.
Certified Nurse Aides were not provided the required 12 hours of annual training to ensure safe delivery of care.
Report Facts
Days understaffed for Certified Nurse Aides: 35
Days understaffed for Nurses: 24
Certified Nurse Aides without annual performance appraisal: 5
Certified Nurse Aides missing required training hours: 5
Duration of feeding assistance training for Resident Assistants: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide #21 | Certified Nurse Aide | Interviewed regarding broken bathroom light in Resident #80's room. |
| Director of Maintenance | Interviewed regarding maintenance response to broken bathroom light. | |
| Administrator | Provided staffing data and interviewed about staffing shortages. | |
| Certified Nurse Aide #2 | Certified Nurse Aide | Interviewed about understaffing and working extra shifts. |
| Director of Nursing | Director of Nursing | Interviewed about lack of annual performance appraisals and training for Certified Nurse Aides. |
| Human Resources Director | Interviewed about lack of annual performance appraisals and training for Certified Nurse Aides. | |
| Resident Assistant #5 | Resident Assistant | Observed feeding residents and interviewed about training. |
| Resident Assistant #6 | Resident Assistant | Observed feeding Resident #52 and interviewed about training. |
| Speech Language Pathologist | Provided feeding training to Resident Assistants and interviewed about training requirements. | |
| Resident Assistant #10 | Resident Assistant | Observed feeding Resident #22 and interviewed about training. |
| Regional Director of Quality Assurance and Performance Improvement | Interviewed about Resident Assistant feeding practices and training. |
Inspection Report
Annual Inspection
Deficiencies: 7
Date: Sep 28, 2024
Visit Reason
The inspection was conducted as a recertification and abbreviated survey from 9/24/24 to 9/28/24 to assess compliance with regulatory requirements for nursing home care.
Findings
The facility was found deficient in multiple areas including failure to ensure residents' rights to privacy, incomplete pre-admission screening for mental disorders, inadequate pressure ulcer care, insufficient nursing staff, lack of annual performance appraisals and training for Certified Nurse Aides, and improper feeding assistant training and supervision.
Deficiencies (7)
Resident #80's bathroom light was not working and they were told to leave the door open to create light while using the bathroom, violating the resident's right to privacy.
The facility did not ensure that each resident's screen for a mental disorder or intellectual disability was completed for 2 of 24 residents reviewed for Pre admission Screening and Resident Review.
For Resident #48, bilateral heel floats while in bed for pressure reduction were not provided as per physician order and/or care plan.
The facility did not ensure there was sufficient nursing staff to meet the needs of residents; understaffing was documented for Certified Nurse Aides and Nurses over a 35-day period.
The facility did not ensure annual performance appraisals were performed for 5 of 5 Certified Nurse Aides reviewed.
Two residents were fed by staff members who did not complete a State-approved training course to assist residents in eating or drinking as required by regulations.
Certified Nurse Aides were not provided the required 12 hours of training to ensure safe delivery of care; documentation was incomplete or missing for 5 of 5 CNAs reviewed.
Report Facts
Staffing understaffed days: 35
Staffing understaffed days: 24
Certified Nurse Aides without annual performance appraisal: 5
Certified Nurse Aides without required training hours: 5
Residents reviewed for PASARR screening: 24
Residents with missing PASARR screening: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide #21 | Mentioned in relation to bathroom light deficiency | |
| Certified Nurse Aide #2 | Mentioned in relation to pressure ulcer care and staffing deficiency | |
| Licensed Practical Nurse #3 | Mentioned in relation to pressure ulcer care deficiency | |
| Registered Nurse Manager #4 | Mentioned in relation to pressure ulcer care deficiency | |
| Director of Nursing | Mentioned in relation to pressure ulcer care, staffing, performance appraisals, and feeding assistant training | |
| Director of Social Work | Mentioned in relation to PASARR screening deficiency | |
| Administrator | Mentioned in relation to staffing and feeding assistant training | |
| Director of Maintenance | Mentioned in relation to bathroom light deficiency | |
| Speech Language Pathologist | Mentioned in relation to feeding assistant training deficiency | |
| Resident Assistant #6 | Observed feeding resident without state-approved training documentation | |
| Resident Assistant #10 | Observed feeding resident without state-approved training documentation | |
| Certified Nurse Aide #14 | Mentioned in relation to missing annual performance appraisal and training | |
| Certified Nurse Aide #15 | Mentioned in relation to missing annual performance appraisal and training | |
| Certified Nurse Aide #16 | Mentioned in relation to missing annual performance appraisal and training | |
| Certified Nurse Aide #17 | Mentioned in relation to missing annual performance appraisal and training | |
| Certified Nurse Aide #18 | Mentioned in relation to missing annual performance appraisal and training | |
| Regional Director of Quality Assurance and Performance Improvement | Mentioned in relation to feeding assistant training and CNA training deficiencies |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 17
Date: Sep 28, 2024
Visit Reason
Multiple standard health and life safety code deficiencies were identified, mostly Level 2 with no actual harm but potential for minor discomfort. Deficiencies included feeding assistance, nurse aide training, resident rights, and various life safety code issues. All were corrected by early 2025.
Findings
Multiple standard health and life safety code deficiencies were identified, mostly Level 2 with no actual harm but potential for minor discomfort. Deficiencies included feeding assistance, nurse aide training, resident rights, and various life safety code issues. All were corrected by early 2025.
Deficiencies (17)
Feeding asst/training/resident
Nurse aide peform review-12 hr/yr in-service
Pasarr screening for md & id
Required in-service training for nurse aides
Resident rights/exercise of rights
Sufficient nursing staff
Treatment/svcs to prevent/heal pressure ulcer
Cooking facilities
Corridor - doors
Electrical equipment - power cords and extens
Fire alarm system - testing and maintenance
Hazardous areas - enclosure
Illumination of means of egress
Sprinkler system - installation
Sprinkler system - maintenance and testing
Stairways and smokeproof enclosures
Standards of construction for new existing nh
Inspection Report
Capacity: 60
Deficiencies: 1
Date: Apr 15, 2024
Visit Reason
One Level 2 standard health citation for reporting to national health safety network with widespread scope; no correction noted.
Findings
One Level 2 standard health citation for reporting to national health safety network with widespread scope; no correction noted.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Capacity: 60
Deficiencies: 1
Date: Apr 8, 2024
Visit Reason
One Level 2 standard health citation for reporting to national health safety network with widespread scope; no correction noted.
Findings
One Level 2 standard health citation for reporting to national health safety network with widespread scope; no correction noted.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Capacity: 60
Deficiencies: 1
Date: Mar 11, 2024
Visit Reason
One Level 2 standard health citation for reporting to national health safety network with widespread scope; no correction noted.
Findings
One Level 2 standard health citation for reporting to national health safety network with widespread scope; no correction noted.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Capacity: 60
Deficiencies: 1
Date: Feb 20, 2024
Visit Reason
One Level 2 standard health citation for reporting to national health safety network with widespread scope; no correction noted.
Findings
One Level 2 standard health citation for reporting to national health safety network with widespread scope; no correction noted.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Capacity: 60
Deficiencies: 1
Date: Nov 21, 2022
Visit Reason
One Level 2 standard health citation for reporting to national health safety network with widespread scope; no correction noted.
Findings
One Level 2 standard health citation for reporting to national health safety network with widespread scope; no correction noted.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Jun 17, 2022
Visit Reason
The inspection was conducted as a routine annual survey of the Tarrytown Hall Care Center to assess compliance with health and safety regulations.
Findings
No health deficiencies were found during the inspection, indicating the facility met the required standards at the time of the survey.
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 7
Date: Jun 17, 2022
Visit Reason
Multiple Level 2 life safety code citations including building construction, corridor doors, electrical systems, exit signage, illumination of egress, sprinkler system maintenance, and stairways; all corrected by August 2022.
Findings
Multiple Level 2 life safety code citations including building construction, corridor doors, electrical systems, exit signage, illumination of egress, sprinkler system maintenance, and stairways; all corrected by August 2022.
Deficiencies (7)
Building construction type and height
Corridor - doors
Electrical systems - essential electric syste
Electrical systems - maintenance and testing
Exit signage
Illumination of means of egress
Sprinkler system - maintenance and testing
Inspection Report
Annual Inspection
Deficiencies: 2
Date: Mar 20, 2019
Visit Reason
The inspection was conducted as a recertification survey to assess compliance with regulatory requirements related to resident dignity and respect, and the maintenance or improvement of residents' ability to perform activities of daily living.
Findings
The facility was found deficient in ensuring residents were treated with dignity and respect, as staff entered resident rooms without knocking. Additionally, the facility failed to evaluate and respond to progressive declines in residents' activities of daily living, including bed mobility, eating, personal hygiene, and dressing, with inadequate communication and follow-up for therapy services.
Deficiencies (2)
Failure to honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights, evidenced by staff entering rooms without knocking.
Failure to ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason, including lack of evaluation and response to progressive decline and lack of therapy services.
Report Facts
Residents Affected: 1
Residents Affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Supply Manager #1 | Supply Manager | Observed entering resident rooms without knocking |
| Director of Nursing | Director of Nursing | Interviewed regarding staff in-service on dignity and respect |
| Director of Rehabilitation | Director of Rehabilitation | Documented rehab intervention and interviewed about therapy follow-up |
| MDS Registered Nurse | Registered Nurse | Interviewed regarding MDS assessments and referrals for ADL declines |
| Licensed Practical Nurse | Licensed Practical Nurse | Interviewed regarding CNA reporting of ADL declines |
| RN responsible for corporate oversight | Registered Nurse | Interviewed regarding therapy follow-up and education of DR |
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