Inspection Reports for
Tarrytown Rehabilitation and Nursing Center
20 Wood Ct, Tarrytown, NY 10591, NY, 10591
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Inspection Report — Sep 28, 2024
Annual Inspection CMS
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.
Citations (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 — Sep 28, 2024
State
Date: Sep 28, 2024
Visit Reason
State-compiled facility profile showing 8 inspections from June 2022 to September 2024 with deficiency history and complaint details.
Complaint Details
The facility received 40 total complaints with 3 on-site inspections resulting from complaints. Six citations were issued related to complaints during the reporting period.
Findings
Across 8 inspections, 29 citations were issued including 12 standard health and 17 Life Safety Code citations. Most deficiencies were Level 2 with minor potential harm, and no formal enforcement actions were recorded.
Citations (22)
Standard Health Citation — quality of care: Feeding Assistant training and supervision deficiencies noted.
Standard Health Citation — quality of care: Nurse Aide performance review and in-service training requirements not met.
Standard Health Citation — quality of care: PASARR screening for mental and intellectual disabilities incomplete.
Standard Health Citation — quality of care: Required in-service training for nurse aides not provided.
Standard Health Citation — quality of care: Resident rights and exercise of rights not fully ensured.
Standard Health Citation — quality of care: Nursing staff levels insufficient.
Standard Health Citation — quality of care: Treatment and services to prevent or heal pressure ulcers inadequate.
Life Safety Code Citation — NFPA requirements: Cooking facilities deficiencies noted.
Life Safety Code Citation — NFPA requirements: Corridor doors not compliant.
Life Safety Code Citation — NFPA requirements: Electrical equipment power cords and extensions unsafe.
Life Safety Code Citation — NFPA requirements: Fire alarm system testing and maintenance deficient.
Life Safety Code Citation — NFPA requirements: Hazardous areas enclosure inadequate.
Life Safety Code Citation — NFPA requirements: Illumination of means of egress insufficient.
Life Safety Code Citation — NFPA requirements: Sprinkler system installation not compliant.
Life Safety Code Citation — NFPA requirements: Sprinkler system maintenance and testing deficient.
Life Safety Code Citation — NFPA requirements: Stairways and smokeproof enclosures noncompliant.
Life Safety Code Citation — NFPA requirements: Standards of construction for new and existing nursing home met with no harm potential.
Standard Health Citation — quality of care: Reporting to National Health Safety Network incomplete or deficient.
Standard Health Citation — quality of care: Reporting to National Health Safety Network incomplete or deficient.
Standard Health Citation — quality of care: Reporting to National Health Safety Network incomplete or deficient.
Standard Health Citation — quality of care: Reporting to National Health Safety Network incomplete or deficient.
Standard Health Citation — quality of care: Reporting to National Health Safety Network incomplete or deficient.
Report Facts
Inspections on page: 8
Total violations/deficiencies cited: 29
Inspections with violations: 7
Inspections without violations: 1
Plan of correction counts: 29
Total complaints: 40
On-site complaint inspections: 3
Citations issued from complaints: 6
Total enforcement actions: 0
Inspection Report — Jun 17, 2022
Annual Inspection CMS
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 — Mar 20, 2019
Annual Inspection CMS
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.
Citations (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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