Fort Tryon Center for Rehabilitation and Nursing

In the surveyor’s words

From the most serious findings on record at Fort Tryon Center for Rehabilitation and Nursing, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF880Jan 7, 2021

  Based on observation, record review, and staff interviews during a fifth Focused Infection Control COVID-19 Survey conducted on 01/07/2021, the facility did not ensure infection control surveillance designed to help prevent the development and transmission of COVID-19. Specifically, the COVID-19 staff screening completed upon entry did not include screening questions to confirm if staff members had signs and symptoms of COVID-19. The finding is: The Centers for Medicare and Medicaid Services (CMS) released a memo titled, Guidance for Infection Control and Prevention of Coronavirus Disease 2019 (COVID-19) in nursing homes, Ref: QSO-20-14-NH (dated 03/04/2020 and revised 09/28/2020). […]

• No harm, potential for more than minimal, patternF760Jun 3, 2021

  F760 Based on interviews and record review during an abbreviated survey (Case # NY00275054), on 05/13/2021, the facility did not ensure its residents were free from any significant medication errors. Specifically, (Resident #1, #2, and #3), were ordered to take nothing by mouth (NPO), however the physician ordered medications to be administered by mouth. The findings were: Review of the facility policy titled Medication Administration, revised 01/20/2021 documented that medications are to be given as ordered, if there is any question in regard to dose, route of administration or medication form, the person in doubt is not to give the medication until verification is received from the physician. […]

• No harm, potential for more than minimal, isolatedF557Dec 18, 2025

  Based on observation, record review, and interviews, the facility failed to ensure that a resident was treated with respect and dignity and cared for each resident in a manner and in an environment that promotes maintenance or enhancement of their quality of life, recognizing each resident's individuality. This was evident for two (2) (Residents #42 and #9) of three (3) residents reviewed for Dignity out of 35 total sampled residents. Specifically, Residents #42 and #9 were observed wearing hospital patient gowns on multiple occasions.The findings are: The facility's policy titled Residents Rights: Dignity dated 12/01/2025 documented that it is the policy of the facility to ensure that all residents are treated with respect and dignity, including the right to retain and use personal… […]

• No harm, potential for more than minimal, isolatedF584Dec 18, 2025

  Based on observation, record review, and interviews, the facility failed to ensure that necessary housekeeping and maintenance services were provided to maintain a safe, clean, comfortable and homelike environment for residents. This was evident for one (1) (3rd Floor) of five (5) resident units observed. Specifically, accumulation of dust, dirt, and stains were noted on bedside tables, intravenous poles, feeding pumps, oxygen concentrators and suction machines; and torn arm rests and soiled wheelchairs were observed in resident rooms on the 3rd Floor. […]

• No harm, potential for more than minimal, isolatedF656Dec 18, 2025

  Based on observation, record review, and interviews, the facility failed to ensure that a comprehensive care plan was developed to address a resident's sleep pattern disturbance. This was evident for one (1) (Resident #187) of 38 sampled residents. Specifically, Resident #187 who was receiving Ambien for Insomnia had no care plan developed and implemented to address the resident's ongoing difficulty staying asleep. The findings include:The facility's policy titled Care Plan Development with a last reviewed date of 12/12/2024 documented the facility shall develop, implement, and maintain a comprehensive, person-centered care plan for each resident. […]