Tarrytown Hall Care Center

Based on record review and interview conducted during the recertification and abbreviated surveys (NY00352594, NY00352648, NY00348708) from 9/24/24 to 9/28/24, the facility did not ensure there was sufficient nursing staff to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, upon review of the staffing schedule from August 22, 2024 through September 25, 2024 the facility did not consistently provide adequate staffing on all units/shifts, to meet the needs of the resident/s. The findings are: During an interview on 09/25/24 at 11:20 AM, with the Administrator, the Facility Wide Assessment was reviewed and daily resident census information was requested. The Administrator stated they would provide clarification of minimum staffing requirements per shift, per title and per census. The following data was provided by Administrator: Certified Nurse Aides: 13-15 day shift, 10-13 evening shift, 6 night shift. Licensed Practical Nurses: 5-6 day shift, 4-5 evening shift, 3 night shift. Registered Nurses: 3-4 day shift, 1…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record reviews and interviews conducted during the recertification and abbreviated surveys (NY00352594, NY00352648) from 9/24/24 to 9/28/24, the facility did not ensure that annual performance appraisals were performed for Certified Nurse Aides staff. Specifically, the facility was unable to provide evidence that 5 of 5 Certified Nurse Aides (Staff #14, Staff #15, Staff #16, Staff #17 and Staff #18), received an annual performance appraisal. The Facility Policy titled Staff Development Program (dated 11/8/23) documented: Nurses aides (Certified Nurse Assistants) are required to complete no less than 12 hours annually of in-service training that is sufficient to ensure the continuing competency of nurse aides and address any specific areas of weakness identified in performance evaluations and through the facility assessment. The findings are: During an observation and interview on 09/25/24 at 03:10 PM with Director of Nursing and Human Resources Director, the Director of Nursing was provided a random sample of five staff members to provide documentation of annual performance…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review conducted during the Recertification Survey and Abbreviated Surveys (NY 00352594, NY 00352648) from 9/24/24-9/28/24, the facility did not ensure two residents (Resident #52 and #22) were fed by staff members who completed a State-approved training course to assist residents in eating or drinking as required by regulations. Specifically, the facility was not able to provide documentation that Resident Assistants successfully completed a State approved training course for two Resident Assistants (Staff #6 and Staff #10) observed feeding Resident # 52 with a diagnosis of dysphagia/receiving a pureed diet and Resident #22 assessed to hold food in the mouth/cheeks or residual food in the mouth after meals and receiving a mechanically altered diet. The findings are: 1. Resident #52 diagnoses included dementia, dysphagia, and significant weight change. The 5/14/24 Physician Order documented regular diet, pureed texture, thin liquids consistency. The 7/12/24 Quarterly Minimum Data Set documented Resident # 52 had severe cognitive impairment,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview conducted during the recertification and abbreviated surveys (NY 00352594, NY 00352648) from 9/24/24 to 9/28/24, the facility did not ensure that Certified Nurse Aides were provided the required 12 hours of training to ensure safe delivery of care. Specifically, the facility was unable to provide evidence that 5 of 5 Certified Nurse Aide #14, #15, #16, #17 and #18), reviewed for Nurse Aide training, were provided 12 hours of mandatory training. The findings are: The Facility Policy titled Staff Development Program (dated 11/8/23) documented: Nurses Aides are required to complete no less than 12 hours annually of in-service training that is sufficient to ensure the continuing competency of Nurse Aides and address any specific areas of weakness identified in performance evaluations and through the facility assessment. During an observation and interview on 09/25/24 at 03:10 PM the Director of Nursing and Human Resources Director provided documentation of 7.0 hours of in-service training for Certified Nurse Aide #14, #15, #16 and #17. The Director…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview conducted during the recertification and abbreviated surveys (NY 00342701) from 9/24/24 to 9/28/24, the facility did not ensure that a resident's right to privacy was respected for 1 of 3 (Resident #80) residents reviewed for Dignity. Specifically, Resident #80's bathroom light was not working and they were told to leave the door open to create light while using the bathroom. The findings are: Resident #80 was admitted to the facility on [DATE] with diagnoses of hyperlipidemia, Alzheimer's Disease, and Non-Alzheimer's Dementia. The Quarterly Minimum Data Set assessment dated [DATE] documented the resident had severe cognitive deficits and needed partial to moderate assist for toileting and showering, and supervision for transfers. When interviewed on 9/24/24 at 1:51 PM, Resident #80's family member stated Resident #80 was told about 2 months ago to leave the door open for light while using the bathroom because the bathroom light was not working. The family…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interviews conducted during the recertification survey from 9/24/24 to 9/28/24, the facility did not ensure that each resident's screen for a mental disorder or intellectual disability was completed for 2 of 24 (Residents #31 and #48) residents reviewed for Pre admission Screening and Resident Review. Specially, there was no documented evidence of pre-admission screening and resident review assessments for Residents #31 and #48. The findings are: The facility policy, Pre-admission Screening and Resident Review dated 11/25/23 documented all residents have the required pre-admission screen prior to admission to the facility, and any time there is a significant change that has a bearing on the resident's specialized service needs. 1. Resident #31 had diagnoses which included mild cognitive impairment, depression, and seizure disorder. Resident #31's electronic medical record revealed there was no documented evidence that a pre-admission screen and resident review assessment was completed. On 9/26/24 at 3:05 PM during an interview with the Director of Social…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview during the recertification survey from 9/24/2024 to 9/28/2024, the facility did not ensure residents at risk for pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote wound healing, prevent infection, and prevent new ulcers from developing for 1 of 2 residents (Residents #48) reviewed for Pressure Ulcers. Specifically, for Resident #48's bilateral heel floats while in bed for pressure reduction were not provided as per physician order and/or care plan. Findings include: The Policy and Procedure titled Pressure Injury Prevention and Management dated 3/2021 documented It is the policy of the facility to have appropriate interdisciplinary preventative care plan implemented when indicated. Purpose to prevent avoidable pressure injuries. Resident #48 had diagnoses of of cerebral vascular accident, hemiplegia, and hypertension. The Quarterly Minimum Data Set (an assessment tool) dated 7/26/2024,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review conducted during the recertification survey the facility did not ensure that residents were treated with dignity and respect. This was evident for 1 of 5 residents reviewed for dignity.(Resident #28). Findings include: Resident #28 was admitted with diagnoses including; hypertension, cerebrovascular accident and osteoporosis. Review of the most recent MDS (Minimum Data Set- a resident assessment tool) dated 12/21/2018 revealed the resident to be cognitively intact with a BIMS (Brief Interview for Mental Status) score of 13 out of a possible 15. During the initial screening process on 03/14/19 at 09:58 AM the resident stated that staff enter her room without knocking and requesting permission to enter. An observation performed on 03/14/19 at 10:25 AM revealed CNA #1 entering her room without knocking. On 03/15/19 at 09:25 AM Supply Manager #1 (SM#1) was observed on the 2nd floor entering resident rooms without knocking and waiting for permission to enter. On 03/19/19 at 09:45 AM, SM#1 was observed on the 1st floor entering resident…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview conducted during the recertification survey, the facility did not ensure that each resident is given the appropriate treatment and services to maintain or improve his or her ability to carry out the activities of daily living, including bed mobility, eating, personal hygiene, and dressing. Specifically, the facility did not evaluate and respond to a progressive decline in function as identified on the Resident Assessment. This was evident for 1 resident (#71) reviewed for activities of daily living. The findings are: Resident # 71 was admitted on [DATE] with diagnoses including: Cardiovascular Accident, Non-Alzheimer's Dementia and Parkinson's disease. The annual Minimum Data Set (MDS: an assessment tool) dated 7/31/18 documented the resident had severely impaired cognitive skills for decision making. It further documented the following; functional status and activities of daily living (ADLs) assistance was documented as: bed mobility: extensive assistance-one person physical…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.