Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Fishkill Center For Rehabilitation And Nursing during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and high fall risk was not provided with adequate fall prevention interventions, despite being identified as high risk. Staff observed the resident attempting to get out of bed prior to a fall that resulted in injury, but necessary safety measures such as frequent monitoring and use of floor mats were not consistently implemented or documented. Inconsistent communication and documentation among staff contributed to the resident sustaining harm from a fall.
A resident with severe cognitive impairment suffered a fall resulting in facial and head injuries. Facility staff attempted to notify a family representative but contacted the wrong person and left only a voicemail, with no documented follow-up or attempts to reach other listed contacts. The correct representative was not informed of the incident until they visited the facility over a month later, despite the facility's policy requiring timely notification after significant changes in condition.
Two residents with cognitive impairment did not have their care plans reviewed or updated in accordance with required assessment schedules. Although goals and interventions were documented, there was no evidence that these were evaluated for effectiveness or that updates were made based on recent assessments. Staff interviews revealed inconsistencies in care plan documentation and transfer of meeting notes within the electronic medical record system.
The facility failed to test all components of the fire alarm system annually, specifically omitting hold open devices and magnetic release mechanisms, as required by NFPA standards. This was identified during a documentation review, and the Director of Maintenance acknowledged the oversight.
The facility did not ensure staff were offered the COVID-19 vaccine or provided with education on its benefits and risks. During a survey, it was found that ten staff members, including dietary aides, housekeeping staff, CNAs, LPNs, RNs, social workers, dining supervisors, and cooks, were not documented as having been offered the vaccine or educated about it. The facility's policy required offering the vaccine and posting signage, but no such signage was observed. Interviews revealed a lack of vaccine offers due to perceived disinterest and inadequate tracking of vaccine status.
The facility did not ensure that corridor doors to hazardous areas resisted smoke passage as per NFPA 101 standards. During a survey, it was found that storage room doors on one resident floor did not latch properly, with one door missing a knob and latching mechanism. The Director of Maintenance acknowledged the issue.
The facility did not ensure a safe, clean, and homelike environment in the North 2 unit, with issues such as broken tiles, a cracked wall, and a hanging curtain. A resident complained of feeling cold due to an open hallway window, despite the room thermometer reading 74 degrees. Staff were unaware of who opened the window, and the Maintenance Director cited ongoing renovations and issues with the shower drain.
The facility did not ensure that CNA performance reviews were conducted at least once every 12 months for three CNAs hired in 2017, 2018, and 2020. The Human Resource Director was unaware of the oversight, and the Assistant Administrator and Assistant Director of Nursing were unsure why the reviews were not completed. This deficiency was identified during a recertification survey.
A resident with a history of chronic conditions was mistakenly given methadone instead of their prescribed medication due to a nurse's failure to verify the resident's identity and medication details. Despite having identification methods in place, the nurse was distracted by alarms and did not follow the facility's medication administration policy, leading to the resident's transfer to a hospital for evaluation.
A facility failed to develop a comprehensive care plan for a resident with limited range of motion, specifically regarding the use of a cervical collar. Despite physician orders to monitor skin and maintain the collar, no care plan addressed these needs. Observations confirmed the resident consistently wore the collar, but the RN Unit Manager admitted the absence of specific goals and interventions. This deficiency was noted during a recertification survey.
The facility failed to ensure proper disposal of garbage and refuse, as the dumpster was left open with cardboard boxes inside, and the compactor was filled with old furniture. Old furniture, large metal containers, and debris were scattered around the dumpster. The maintenance department was responsible for this oversight, and the Director of Maintenance stated that the compactor was full and awaiting emptying, while the Food Service Director confirmed they were not responsible for the dumpster's condition.
The facility failed to adhere to professional standards for food service safety, as observed during a survey. Unlabeled and outdated beverages were found in the nutrition and storage refrigerator, and an open parcel of flour was left unsealed on a shelf. The Cook Supervisor and Food Service Director acknowledged these lapses, citing staffing shortages as a contributing factor. The facility's policy requires proper labeling and dating of food items, which was not followed.
The facility did not ensure that two residents were offered pneumococcal immunizations or received education about them. Both residents, who were cognitively impaired and dependent on staff, lacked documentation of being offered the vaccine or receiving education. The DON, responsible for the vaccine program, admitted to not monitoring or tracking the vaccine information closely.
A resident experienced multiple omissions in the documentation of pain management medications and treatments, with no reasons provided for these omissions. The resident, who had a care plan for pain management, reported ongoing pain despite receiving some medication. The RN Unit Manager and DON acknowledged the omissions and emphasized the need for proper documentation.
The facility failed to maintain residents' dignity by serving beverages in plastic storage cups with lids, despite residents' preference for hard plastic cups. Additionally, a CNA referred to a resident with severe cognitive impairment as a "feeder," a term also found in the resident's progress notes. The CNA later acknowledged the inappropriateness of the term, and the DON confirmed it is unacceptable in the facility.
Failure to Implement Fall Prevention Measures for High-Risk Resident
Penalty
Summary
A deficiency occurred when the facility failed to maintain an environment free from accident hazards and did not provide adequate supervision to prevent accidents for a resident identified as high risk for falls. The resident, who had diagnoses including cerebral infarction, aphasia, altered mental status, and severe cognitive impairment, was assessed as a high fall risk based on the facility's fall risk assessment protocol. Despite this, the resident's care profile did not reflect fall precautions, and interventions such as 30-minute safety checks and floor mats were either not implemented or not documented as required by facility policy. Staff interviews revealed that the resident was observed attempting to get out of bed prior to the fall, with half of their body hanging off the bed, but this observation did not result in additional interventions or updates to the care plan. The resident was dependent for bed mobility and transfers, and staff had varying perceptions of the resident's ability to move or self-transfer. On the night of the incident, the resident was found on the floor with injuries including a swollen eye, hematoma, and a scratch, after reportedly attempting to get out of bed to retrieve belongings. The facility's documentation and communication regarding fall risk interventions were inconsistent, with some staff unaware of the resident's increased risk and others noting that required safety measures were not in place or not documented. The facility's fall risk intervention protocol required immediate implementation of prevention measures for residents with high fall risk scores, but the resident's care plan and care profile were not updated accordingly. The lack of documentation and failure to implement or communicate appropriate interventions contributed to the resident sustaining actual harm from a fall. The deficiency was substantiated by observations, record reviews, and staff and representative interviews, which highlighted lapses in supervision, care planning, and adherence to established safety protocols.
Failure to Notify Correct Family Representative After Resident Injury
Penalty
Summary
The facility failed to ensure timely notification of a resident's representative following a significant change in the resident's physical condition. Specifically, after a resident with severe cognitive impairment and multiple diagnoses, including cerebral infarction and altered mental status, experienced a fall resulting in injuries to the face, eyes, and head, the facility did not promptly inform the correct family representative. The initial attempt to notify was made by calling the first contact listed on the resident's face sheet, but this was not the correct representative, and only a voicemail was left. There was no documented evidence of follow-up attempts or efforts to contact other listed representatives when the initial call was not returned. Interviews with staff revealed that the wrong contact was repeatedly called, and the correct representative was not informed of the incident until they visited the facility over a month later. The care plan for the resident included interventions to ensure safety and communication, but these were not effectively implemented regarding family notification. The facility's own policy required notification of family or significant others in the event of an accident or incident, but this was not followed, as evidenced by the lack of timely and appropriate communication with the designated representative.
Failure to Review and Update Cognitive Care Plans as Required
Penalty
Summary
The facility failed to ensure that comprehensive care plans were reviewed, updated, and revised for two out of three residents reviewed for care planning. Specifically, one resident with severe cognitive impairment and another with moderate cognitive impairment had care plans for impaired cognition that had not been reviewed or updated in accordance with the most recent comprehensive or quarterly assessments. The care plans contained goals and interventions, but there was no documented evidence that these were evaluated for effectiveness or that goals were met, as required by facility policy. Interviews with facility staff revealed that the responsibility for updating cognitive care plans typically falls to the Social Worker, who stated that updates are supposed to occur quarterly, annually, and with any significant changes. However, discrepancies were noted between the dates of care plan reviews in the electronic medical record and the actual care plan meeting documentation. The Social Worker and DON acknowledged that care plan updates were not consistently reflected in the system, and meeting notes were not always properly transferred to the care plan documents.
Fire Alarm System Testing Deficiency
Penalty
Summary
The facility failed to ensure that all devices associated with the fire alarm system were tested annually, as required by the 2012 NFPA 101 and 2010 NFPA 72 standards. Specifically, the annual vendor service report for the fire alarm system for the year 2024 did not include testing of hold open devices and magnetic release mechanisms. This omission was identified during a documentation review, where it was noted that the maintenance logs lacked evidence of these components being tested. The fire alarm system was last serviced on March 25, 2024. During an interview conducted at the time of the finding, the Director of Maintenance acknowledged the oversight and stated that the vendor would be contacted to address the issue. The absence of testing for these specific devices was a clear deviation from the required standards, as outlined in the NFPA codes and New York Codes, Rules, and Regulations (NYCRR). The deficiency was based on observations, staff interviews, and record reviews conducted during the survey.
Plan Of Correction
Plan of Correction: Approved February 28, 2025 All residents, staff, and visitors have the potential to be affected by the deficient practice. On 2/12/2025, the Director of Environmental Services or designee conducted a facility-wide audit and notated where all hold-open and magnetic release mechanisms are located. On 2/12/2025, the Director of Environmental Services or designee called the vendor to perform an annual test on all door holders and magnetic release mechanisms now and on an annual basis. Testing was completed on 2/14/2025. The Director of Environmental Services or designee will update a contract with the vendor to include the annual inspection of all hold-open and magnetic release mechanisms. The contract was received and signed on 2/13/2025. On 2/14/2025, the Director of Environmental Services or designee will educate the Maintenance staff on which elements the contractor should check when performing the annual inspection. The Director of Environmental Services or designee will report the findings of the annual testing of the door holders and magnetic release mechanisms in QAPI. Responsible party: Director of Environmental Services or designee.
Failure to Offer and Educate Staff on COVID-19 Vaccination
Penalty
Summary
The facility failed to ensure that all staff members were screened, offered the most recent COVID-19 vaccine, and provided with education regarding the benefits, risks, and potential side effects associated with the vaccine. This deficiency was identified during a recertification survey conducted from February 10 to February 14, 2025, where it was found that there was no documented evidence that COVID-19 vaccination was offered or that education was provided to ten staff members, including dietary aides, housekeeping staff, certified nurse aides, licensed practical nurses, registered nurses, social workers, dining supervisors, and cooks. The facility's policy, dated November 30, 2024, stated that consenting personnel would be offered the opportunity to receive the COVID-19 vaccine, and signage would be posted throughout the facility to remind personnel and residents of this offer. However, during the survey, no such signage was observed, and the facility could not provide documentation of vaccine offers or education. Interviews conducted during the survey revealed further issues. A licensed practical nurse stated they were not offered the COVID-19 vaccine and had not heard about it, although they would have consented if it had been offered. The Assistant Director of Nursing admitted to not offering the COVID-19 vaccines due to perceived lack of interest among staff, despite acknowledging the importance of staff education on vaccines. The Director of Nursing also admitted to not closely tracking vaccine status for staff and residents and was unaware of the missing signage. These inactions and lack of documentation contributed to the facility's failure to comply with the requirement to offer and educate staff about the COVID-19 vaccine.
Plan Of Correction
Plan of Correction: Approved February 28, 2025 F887 Ss=E The Plan of Correction is submitted in compliance with applicable law and regulation. To demonstrate continuing compliance with applicable law, the center has taken or will take actions set forth in following alleged deficiency. How corrective actions will be accomplished for residents found to have been affected by deficient practice: 1. Employee health nurse/ ADON is offering most recent covid 19 vaccinations with education pamphlet regarding benefits, risks and potential side effects associated with vaccine to all eligible staff members. Consent / declination forms and education are logged by Employee Health nurse/ ADON. Dietary aide #15, housekeeping #16, CNA #17, #18, #20, LPN #19, RN #21, Social work #22, Dining supervisor #23 and cook #24 have been provided education pamphlet on covid vaccine and consent/ declination logged week completed 2/25/25. All STAFF have the potential to be affected by this practice - Audit for all staff employed by the facility who are eligible for covid vaccine and are being provided with education/ information pamphlet, consent and declinations are being obtained. Measures put in place or systemic changes made to ensure that the deficient practice will not reoccur: - The Policy titled Management of covid 19 was reviewed by Director of Nursing and Administrator on 2/25/25, with no revisions needed. - The Director of nursing will educate the assistant director of nursing/ employee health nurse on covid vaccines, providing education/ information pamphlet and proof of consent or declination. - The Assistant director of nursing/employee health nurse will ensure staff who were offered the covid vaccine were educated and documentation of refusal or consent is logged. How facility plans to monitor performance to make sure the solutions are sustained: To ascertain the effectiveness of the education and audit was developed. The Director of Nursing/ infection preventionist/ Designee will perform an Audit for all staff employed in the facility who are eligible for covid vaccine and are being provided with education/ information pamphlet, consent and declinations are being obtained. Eligible staff will be audited weekly for 3 months. Audit for new hires will be done weekly x 3 months. Any discrepancies will be reported to Administrator and immediately corrected, staff re-educated and/or counseled as needed. The results of the Audit will be reported at monthly QAPI.
Deficiency in Corridor Door Smoke Resistance
Penalty
Summary
The facility failed to ensure that corridor doors to hazardous areas were able to resist the passage of smoke as required by NFPA 101 standards. During a Life Safety recertification survey, it was observed that the kitchen storage room opposite the kitchen and the storage room within the kitchen did not latch when tested to self-close. Additionally, the storage room within the shower enclosure was missing a door knob and latching mechanism, preventing it from latching properly. These deficiencies were noted on one of the two resident floors. The Director of Maintenance acknowledged the issue during an interview conducted at the time of the findings.
Plan Of Correction
Plan of Correction: Approved February 28, 2025 All residents, visitors, and staff have the potential to be affected by the deficient practice. On 2/12/2025, the Director of Environmental Services or Designee adjusted the self-closing mechanisms on 2 of the 3 doors cited in order for the doors to positive latch as per NFPA 101. The Director of Environmental Services or Designee installed the new hardware (doorknob) on the 3rd of 3 doors for the storage room within the shower enclosure to ensure it has a positive latch. On 2/12/2025, the Director of Environmental Services or Designee conducted an audit of all dietary closets with self-closing mechanisms as well as the doors to all 4 storage rooms in the shower enclosures (1 on each unit) to ensure all are in working order as per NFPA 101. Those found deficient will be repaired. On 2/14/2025, the Director of Environmental Services or Designee will educate all maintenance staff on how to properly check doors for positive latch. Starting on 2/14/2025, the Director of Environmental Services or Designee will audit the 3 doors that did not self-latch weekly for 1 month (4 weeks) then monthly for 3 months to ensure the doors are self-latching. All findings will be repaired and reported in QAPI. Responsible party: Director of Environmental Services or designee.
Facility Fails to Maintain Homelike Environment
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for residents in the North 2 unit, as observed during a recertification survey. Specific deficiencies included broken tiles in rooms X6 and X3, a cracked wall in room V1, and a hanging curtain in room S3. Additionally, the shower room had a damaged drain, and the hallway window near room V3 was left open, causing a resident to complain of feeling cold despite the room thermometer reading 74 degrees. The Maintenance Director acknowledged ongoing renovations and issues with the shower drain, attributing the problem to the weight of some residents. Interviews with staff revealed a lack of awareness regarding the open hallway window, with certified nurse aides and a registered nurse unable to identify who opened it. The registered nurse suggested it might have been opened for fresh air after care was provided but acknowledged it should have been closed. The absence of a documented work order logbook for repairs further highlighted the facility's failure to maintain a homelike environment, as required by regulations.
Plan Of Correction
Plan of Correction: Approved March 3, 2025 All Residents, Visitors, and staff have the potential to be affected by the deficient practice. On 2/12/2025, the Director of Environmental Services or designee repaired the curtain in room S3. On 2/12/2025, the Director of Environmental Services or designee patched the crack by the window in room X1. On 2/14/2025, the Director of Environmental Services or designee locked the windows on the corridor where V3 window is located to ensure that the window does not open and V3 does not get a draft. On 2/12/2025, the Director of Environmental Services or designee affixed the tiles in room X3 where they were coming loose. On 2/12/2025, the Director of Environmental Services or designee patched the scuffs under the window in room V1. On 2/14/2025, the Director of Environmental Services or designee hired a company to replace the floor in room X6. On 2/12/2025, the Director of Environmental Services or designee permanently affixed the drain cover to the north 2 shower drain. The Director of Environmental Services or designee will conduct monthly checks for 6 months in rooms S3, X1, X3, X6, V1, V3, and the shower room to ensure that the repairs that were made continue to hold their integrity. All findings will be discussed during QAPI.
Failure to Conduct Timely CNA Performance Reviews
Penalty
Summary
The facility failed to ensure that Certified Nurse Aide (CNA) performance reviews were conducted at least once every 12 months, as required. Specifically, three CNAs, hired in 2017, 2018, and 2020, did not have documented performance reviews within the last 12 months. During interviews, the Human Resource Director acknowledged that unit supervisors were responsible for completing these reviews and that they should be filed in employee folders. However, the director was unaware that the reviews for these CNAs had not been completed. The Assistant Administrator was also unsure why the reviews were not conducted, and the Assistant Director of Nursing, who had previously assisted with these reviews, believed they had been completed. This deficiency was identified during a recertification survey conducted from February 10 to February 14, 2025.
Plan Of Correction
Plan of Correction: Approved March 10, 2025 F730 Ss=D The Plan of Correction is submitted in compliance with applicable law and regulation. To demonstrate continuing compliance with applicable law, the center has taken or will take actions set forth in following alleged deficiency. How corrective actions will be accomplished for residents found to have been affected by deficient practice: - The performance reviews for Certified nurse aide #2, #3, #4 were completed on 2/17/25. The human resource director audited all current Certified nursing assistants to ensure performance reviews in place. No additional occurrences found. Measures put in place or systemic changes made to ensure that the deficient practice will not reoccur: - The Director of nursing and administrator reviewed staff performance review policy with no revisions needed. - The Director of human resources was educated on criteria that performance review of every nurse aide at least once every 12 months, and provide regular in-service education based on the outcome of these reviews. - The director of Human Resources/ designee will audit every 2 weeks for employees eligible for performance reviews to ensure they are completed per specifications x 1 month, then monthly x 3 months. - The director of Human Resources/ designee will keep a running log of all certified nursing assistants eligible for performance review and ensure they are filed in employee folders once completed. How facility plans to monitor performance to make sure the solutions are sustained: To ascertain the effectiveness of the education and audit was developed. - The Director of Human Resources/ designee will audit every 2 weeks for employees eligible for performance reviews to ensure they are completed per specifications x 1 month, then monthly x 3 months. - Any discrepancies will be reported to administrator and immediately corrected. - The results of the Audit will be reported at monthly QAPI.
Significant Medication Error Due to Nurse's Failure to Verify Resident Identity
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by an incident involving a resident who was administered a medication not prescribed by their physician. The resident, who had a medical history including Chronic Hepatitis C, Diabetes Mellitus, and Liver Cirrhosis, was mistakenly given methadone, a narcotic medication, instead of their prescribed medication. This error occurred despite the presence of multiple identification methods, such as an identification band, photo identification, and room label, which were not adequately utilized by the administering nurse. The incident unfolded when a registered nurse, distracted by alarms from a tube feeding pump, administered methadone to the wrong resident. The nurse failed to follow the facility's medication administration policy, which requires verifying the resident's identity and medication details before administration. The nurse did not check the resident's identification band or photo identification and did not confirm the resident's name against the medication label, leading to the administration of methadone to the resident. Upon realizing the error, the nurse reported it to the charge nurse, and the resident was subsequently evaluated by the facility's nurse practitioner. The resident, who was alert and oriented, was transferred to a local hospital for evaluation and observation. The Director of Nursing considered this a significant medication error and initiated an investigation, confirming that all identification and medication labeling protocols were in place but not followed by the nurse.
Plan Of Correction
Plan of Correction: Approved March 10, 2025 F760 Ss=D The Plan of Correction is submitted in compliance with applicable law and regulation. To demonstrate continuing compliance with applicable law, the center has taken or will take actions set forth in following alleged deficiency. How corrective actions will be accomplished for residents found to have been affected by deficient practice: 1. The nursing staff on unit where resident # 399 resides received education on medication administration, ensuring all individuals administering medications verifies identity before giving the resident their medication. Methods of identifying the resident include: checking the identification band, checking photograph attached to medical record and if necessary, verifying resident identification with other facility personnel, Date 2/25/25. Resident # 399 was discharged from facility on 5/8/25, and sent to ER no issues found related to medication error. All residents have the potential to be affected by this practice - Nurse #9 no longer works at the facility - 8 nurses observed during medication pass on 2/25/25. All were noted to follow the policy on verifying the resident and medications. No occurrences found. Measures put in place or systemic changes made to ensure that the deficient practice will not reoccur: - The Policy titled medication administration dated 4/20/21 was reviewed by Director of Nursing and Administrator on 2/25/25, with no revisions needed. - The director of nursing/designee will educate all nursing staff on medication administration, ensuring all individuals administering medications verifies identity before giving the resident their medication. Methods of identifying the resident include: checking the identification band, checking photograph attached to medical record and if necessary, verifying resident identification with other facility personnel. No occurrences found. How facility plans to monitor performance to make sure the solutions are sustained: To ascertain the effectiveness of the education and audit was developed. The Director of Nursing/ Designee will perform an Audit for medication administration 5 times per week for random shift to check that all individuals administering medications verifies identity before giving the resident their medication. Methods of identifying the resident include: checking the identification band, checking photograph attached to medical record and if necessary, verifying resident identification with other facility personnel x 3 months. Any discrepancies will be reported to Administrator and immediately corrected, staff re-educated and/or counseled as needed. The results of the Audit will be reported at monthly QAPI.
Lack of Comprehensive Care Plan for Resident with Cervical Collar
Penalty
Summary
The facility failed to ensure the development of a comprehensive person-centered care plan for a resident with limited range of motion, specifically regarding the use of a cervical collar. The resident, who was admitted with multiple diagnoses including fractures, was noted to have severely impaired cognition and required maximum assistance for activities of daily living. Despite the presence of a physician's order to monitor the skin and maintain the cervical collar, there was no evidence of a care plan addressing the fractures, positioning, cervical collar use, or skin integrity monitoring. Observations during the survey period confirmed that the resident consistently wore a cervical collar while in a wheelchair and in bed. However, the Registered Nurse Unit Manager acknowledged the absence of a care plan with specific goals and interventions for the cervical collar. Although an assessment documented the fractures, no new goals or interventions were added following the resident's most recent admission. This oversight was identified during the recertification survey, highlighting a deficiency in the facility's compliance with its policy on comprehensive care planning.
Plan Of Correction
Plan of Correction: Approved February 28, 2025 F656 ss=D The Plan of Correction is submitted in compliance with applicable law and regulation. To demonstrate continuing compliance with applicable law, the center has taken or will take actions set forth in following alleged deficiency. What corrective actions will be accomplished for the resident found to have been affected by the deficient practice: - Nurse manager #10 was educated on identification of residents who have splints, braces, casts, immobilizers or cervical collars. Including care plan initiation, appropriate measurable goals and interventions to ensure residents identified have limited range of motion or potential for in place. - The resident #37 care plan was developed to specifically state limited range of motion due to cervical collar for c2 fracture on 2/24/25. How the facility will prevent occurrence from happening to other residents having the potential to be affected by same deficient practice: - All Residents have the potential to be affected by this practice. Any resident with splint, brace, cast, immobilizer or cervical collar, medical records were audited to ensure limited range of motion or potential for was care planed with appropriate goals and interventions. No occurrences found. This audit was completed by the DON/ADON on 2/25/25. Measures put in place or systemic changes made to ensure that the deficient practice will not reoccur: - The policy titled, “Comprehensive care” was reviewed by the Director of Nursing and Administrator on 2/25/25. No changes indicated. - The Director of Nursing/Designee will educate the Unit Managers, Supervisors, administrator and Charge Nurses on the policies “Comprehensive care” completed 2/25/25. - The Director of Nursing/Designee will educate the Unit Managers, Supervisors, administrator and Charge Nurses on identification of residents who have splints, braces, casts, immobilizers or cervical collars. Including care plan initiation, appropriate measurable goals and interventions to ensure residents identified have limited range of motion or potential for in place. How facility plans to monitor performance to make sure the solutions are sustained: - To ascertain the effectiveness of the education an audit was developed. - DON/Designee will audit all new admission care plans with splint, brace, cast, immobilizer or cervical collar to ensure limited range of motion or potential for x 30 days then weekly x 2 months. - The Director of Nursing/Designee will perform chart Audit weekly on 10% of resident population care plans to ensure residents with splint, brace, cast, immobilizer or cervical collar to ensure limited range of motion or potential for was added to care plan x 3 months. Any discrepancies noted will be immediately rectified and re-education will be provided to appropriate licensed person by Director of Nursing/Designee. - The results of the Audit findings will be reported at monthly QAPI by the DON/designee for trending and analyzing for no less than 3 months or until the facility demonstrates sustained compliance as determined by committee.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to ensure proper disposal of garbage and refuse, as observed during a recertification survey. The facility's policy required all garbage and rubbish containers to have tight-fitting lids and to be kept covered when stored. However, during an observation, the dumpster was found open with cardboard boxes inside, and the compactor was filled with old furniture and left open. Additionally, old furniture, large metal containers, and debris were scattered on the ground around the dumpster. Interviews revealed that the maintenance department was responsible for ensuring the dumpster was closed and the area was free of garbage. The Director of Maintenance stated that the compactor was full, and they were waiting for the company to empty it, which would not happen until later. They also mentioned that the large metal containers were donations awaiting pick-up, and the old furniture was on the ground due to ongoing renovations. The Food Service Director confirmed that they were not responsible for the dumpster's condition and had reported concerns to the Maintenance Director.
Plan Of Correction
Plan of Correction: Approved March 3, 2025 All residents, visitors, and staff have the potential to be affected by the deficient practice. - 2/14/2025: The Director of Environmental Services or designee called the contracted sanitation company to empty and return the open-top construction container. - 2/24/2025: The Director of Environmental Services or designee will dispose of the debris that was around the overfilled open-top construction container. - 2/14/2025: The Director of Environmental Services or designee called the contracted sanitation company to repair/replace the cover for their recycling container so the facility can keep them closed. - 2/14/2025: The Director of Environmental Services or designee will begin educating all Maintenance, Housekeeping, and Dietary staff on ensuring that the 8-yard recycling container stays covered as well as the door for the compactor stays closed. - 2/14/2025: The Director of Environmental Services or designee will educate the Maintenance department on not overfilling the open-top container. - The Director of Environmental Services or designee will perform monthly checks on the open-top construction container to ensure it is not overfilled. The findings will be rectified and discussed during QAPI for 6 months. - The Director of Environmental Services or designee will perform weekly checks at random times and days to ensure that the cover for the recycling bin is being closed after being utilized. The findings will be rectified and discussed during QAPI for 6 months. Responsible party: Director of Environmental Services or designee.
Deficiency in Food Storage Practices
Penalty
Summary
The facility failed to ensure that food was stored in accordance with professional standards for food service safety, as observed during a recertification survey. During an initial tour of the kitchen, surveyors found several unlabeled 4-ounce cups filled with white, brown, and thickened yellow liquids in the nutrition and storage refrigerator. These liquids were dated 2/4 and 2/10, respectively, and were identified by the Cook Supervisor as [MEDICATION NAME] milk, prune juice, and smoothies. The Cook Supervisor acknowledged that the [MEDICATION NAME] milk and prune juice were outdated and should have been discarded after three days, but they remained in the refrigerator due to staffing shortages over the weekend. Additionally, an open parcel of all-purpose flour was found on a shelf, unsealed and undated, contrary to the facility's policy. The Food Service Director confirmed that the [MEDICATION NAME] milk and prune juice should have been labeled and discarded after three days, and the flour should have been sealed. The facility's policy, dated 6/26/2028, requires that dry foods be removed from their original packaging, labeled, and dated, and that beverages be dated when opened and discarded after three days. These lapses in food storage practices were in violation of the facility's own policies and professional standards for food service safety.
Plan Of Correction
Plan of Correction: Approved February 28, 2025 F812 Ss=D The Plan of Correction is submitted in compliance with applicable law and regulation. To demonstrate continuing compliance with applicable law, the center has taken or will take actions set forth in following alleged deficiency. How corrective actions will be accomplished for residents found to have been affected by deficient practice: 1. All outdated food identified was immediately removed and discarded. Audit of all food was performed to ensure food is stored in accordance with professional standards for food service safety. Cook supervisor #11 was educated on food receiving and storage. No additional occurrences found. Measures put in place or systemic changes made to ensure that the deficient practice will not reoccur: - The Policy titled Food receiving and storage was reviewed by Director of Dietary and Administrator on 2/28/25, with no revisions needed. - The Director of Dietary food services was in-serviced on dating, discarding and storage of consumable items. - The Director of Dietary/designee will educate all dietary staff on dating, discarding and storage of consumable items. - The Director of Dietary/designee will audit to ensure all foods are dated and properly discarded daily x 1 month, then weekly x 3 months. How facility plans to monitor performance to make sure the solutions are sustained: To ascertain the effectiveness of the education and audit was developed. The Director of Dietary/Designee will perform an Audit to ensure all foods are dated and properly discarded daily x 1 month, then weekly x 3 months. Any discrepancies will be reported to Administrator and immediately corrected. The results of the Audit will be reported at monthly QAPI.
Failure to Offer and Document Pneumococcal Vaccinations
Penalty
Summary
The facility failed to ensure that residents were offered pneumococcal immunizations and received education regarding the benefits and potential side effects of the immunizations. This deficiency was identified during a recertification survey for two residents. Resident #9, who had a diagnosis of [DIAGNOSES REDACTED], was cognitively impaired and dependent on staff for daily activities. There was no documented evidence that this resident or their representative received education about, was offered, or declined the pneumococcal vaccine. Similarly, Resident #50, with a diagnosis of [DIAGNOSES REDACTED] and severe cognitive impairment, also lacked documentation of being offered the vaccine or receiving education about it. The Director of Nursing, who also served as the Infection Preventionist, acknowledged during an interview that they were responsible for the vaccine program and documentation of each resident's vaccine status upon admission. However, they admitted to not closely monitoring the pneumococcal vaccines for residents and failing to track the vaccine information. This oversight led to the deficiency, as the facility did not adhere to its policy of offering pneumococcal vaccinations to all residents to prevent the spread of infectious disease and mitigate associated risks.
Plan Of Correction
Plan of Correction: Approved February 28, 2025 F883 Ss=D The Plan of Correction is submitted in compliance with applicable law and regulation. To demonstrate continuing compliance with applicable law, the center has taken or will take actions set forth in following alleged deficiency. How corrective actions will be accomplished for residents found to have been affected by deficient practice: 1. Residents #9 and #50 were reviewed and offered education to resident or primary advocate on pneumococcal vaccine with documentation provided that residents #9 and #50 received pneumococcal vaccine in house on 2/19/25. All residents have the potential to be affected by this practice - Audit for all residents residing in the facility who are eligible for pneumococcal vaccine and are being provided with education/information pamphlet, consent and declinations are being obtained. No additional issues found. Measures put in place or systemic changes made to ensure that the deficient practice will not reoccur: - The Policy titled Pneumococcal vaccine was reviewed by Director of Nursing and Administrator on 2/25/25, with no revisions needed. - The director of nursing/infection preventionist will educate the unit managers and charge nurses on pneumococcal vaccines, providing education/information pamphlet and proof of consent or declination. - The director of nursing/infection preventionist will ensure residents who were offered the pneumococcal vaccine were educated and documentation of refusal or consent is logged. How facility plans to monitor performance to make sure the solutions are sustained: To ascertain the effectiveness of the education and audit was developed. The Director of Nursing/infection preventionist/Designee will perform an Audit for all residents residing in the facility who are eligible for pneumococcal vaccine and are being provided with education/information pamphlet, consent and declinations are being obtained. Eligible residents will be audited weekly for 3 months for long term residents. Audit for new admission will be done weekly x 3 months. Any discrepancies will be immediately corrected and staff re-educated and/or counseled as needed. The results of the Audit will be reported at monthly QAPI.
Omissions in Pain Management Documentation
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice and the comprehensive care plan for pain management. Specifically, there were multiple omissions in the medication and treatment administration records for medications and treatments related to pain management for a resident. The resident, who was admitted with diagnoses including pain, had a comprehensive care plan that documented potential and intermittent pain related to activity level, with instructions to monitor for pain, administer medication as ordered, and monitor the effectiveness of medications. However, the Treatment Administration Record showed omissions for a prescribed cream on several dates, and the Medication Administration Record also had omissions for other pain medications, with no documented evidence explaining the reasons for these omissions. During interviews, the resident expressed experiencing pain and stated that they had received some pain medication but were still in pain. The resident later mentioned that their pain management was overall effective with the prescribed medications but believed they were in pain due to overexertion in therapy. The Registered Nurse Unit Manager acknowledged the omissions and stated that the medication nurse should have documented the reasons for not administering the medications. The Director of Nursing confirmed the expectation of no omissions in the medication or treatment administration records and stated that if a medication was not administered, the reason should be documented.
Plan Of Correction
Plan of Correction: Approved February 28, 2025 F684 Ss=D The Plan of Correction is submitted in compliance with applicable law and regulation. To demonstrate continuing compliance with applicable law, the center has taken or will take actions set forth in following alleged deficiency. How corrective actions will be accomplished for residents found to have been affected by deficient practice: 1. Nurse manager #10 and the nursing staff on unit where resident #15 resides received education on medication administration, ensuring all medications are signed for in MAR/TAR and no omissions present, Date 2/25/25. Resident #15 was discharged from facility on 2/20/25, no issues related to noted omissions found. All residents have the potential to be affected by this practice - All residents MAR/TAR were audited on 2/25/25 for omissions, no occurrences found. Measures put in place or systemic changes made to ensure that the deficient practice will not reoccur: - The Policy titled medication administration dated 4/20/21 was reviewed by Director of Nursing and Administrator on 2/25/25, with no revisions needed. - The director of nursing/designee will educate all nursing staff on medication administration, ensuring all medications are signed for in MAR/TAR and no omissions present. How facility plans to monitor performance to make sure the solutions are sustained: To ascertain the effectiveness of the education and audit was developed. The Director of Nursing/Designee will perform an Audit for medication administration 5 times per week for random shift to check for omissions x 3 months. Any discrepancies will be immediately corrected and staff re-educated and/or counseled as needed. The results of the Audit will be reported at monthly QAPI.
Dignity Violation: Inappropriate Beverage Service and Terminology
Penalty
Summary
The facility failed to maintain residents' dignity by serving milk and water in plastic storage cups with lids across four units. Observations during the survey period revealed that residents were consistently served beverages in these cups, despite their preference for hard plastic drinking cups. During a Resident Council Meeting, all ten residents expressed their dissatisfaction with the storage cups, preferring the hard plastic ones. The Food Service Director admitted to using storage cups due to portioning needs and was unaware that this practice was inappropriate. The facility had a limited number of hard plastic cups, which were primarily stored in the main dining room, and there was a delay in receiving new orders of these cups. The Director of Rehabilitation also noted the difficulty residents faced using the storage cups and had discussed this issue with the Director of Nursing. Additionally, a Certified Nurse Assistant (CNA) referred to a resident with severe cognitive impairment and dependency on eating assistance as a "feeder" during an interview. This terminology was also found in the resident's progress notes. The CNA acknowledged the inappropriateness of the term after the interview and had previously received in-service training on dignity. The Director of Nursing confirmed that the term "feeder" is unacceptable in the facility and should not be used in verbal communication or clinical documentation.
Plan Of Correction
Plan of Correction: Approved March 10, 2025 F550 Ss=D The Plan of Correction is submitted in compliance with applicable law and regulation. To demonstrate continuing compliance with applicable law, the center has taken or will take actions set forth in following alleged deficiency. How corrective actions will be accomplished for residents found to have been affected by deficient practice: 1. The residents observed drinking out of plastic cups on unit 4 of 4. Facility immediately removed plastic storage cups for drinking use from 4 of 4 units. Supply order of tumbler cups for all units. Residents updated on tumbler cup order through resident council and are pleased with solution - all residents will be provided with tumbler cup for each meal. Measures put in place or systemic changes made to ensure that the deficient practice will not reoccur: - The director of dietary/designee will audit to ensure that plastic drinking cups will no longer be used for drinking. - Tumbler cups have been purchased for all residents. - A small emergency supply of additional tumbler cups was ordered to ensure they are always available. How facility plans to monitor performance to make sure the solutions are sustained: To ascertain the effectiveness of the education and audit was developed - The Director of dietary/Designee will audit 2 random meals per day to ensure tumblers are provided to nursing staff for each meal 5 x per week x 1 month, then weekly for 3 months. Any discrepancies will be reported to administrator and immediately corrected. The results of the Audit will be reported at monthly QAPI. 2. Certified nursing aide #7, the nursing staff and social worker on unit where resident #26 resides received education on resident rights and dignity specifically on the term “feeder” as being unacceptable and the correct language for residents who require assistance for feeding, Date 2/25/25. Resident care plan adjusted to reflect current levels of assistance required updated on 2/24/25. All residents have the potential to be affected by this practice - All residents requiring assistance with feeding during meals were observed during weeks 2/25/25 to 2/28/25 for use of improper terminology when assisting a resident with feeding, no occurrences found. Measures put in place or systemic changes made to ensure that the deficient practice will not reoccur: - The Policy titled Resident Rights was reviewed by Director of Nursing and Administrator on 2/24/25, with no revisions needed. - The director of nursing/designee will educate all nursing staff on assisting residents with meals with dignity and ensuring the correct terminology is used to identify the level of assistance the resident requires. How facility plans to monitor performance to make sure the solutions are sustained: To ascertain the effectiveness of the education and audit was developed. The DIRECTOR OF NURSING/DESIGNEE will audit progress notes of 5 residents who need assistance with meals weekly x 1 month, then monthly x 3 months to ensure proper terminology is used. The Director of Nursing/Designee will perform an Audit for Dining Room Observation during meal time to observe for appropriate terminology during meals. Random meal times during random days will be observed for 5 meals per week for 3 months. Any discrepancies will be immediately corrected and staff re-educated and/or counseled as needed. The results of the Audit will be reported at monthly QAPI.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 238 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Beacon
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Taconic Rehabilitation And Nursing At Beacon | 1 mi | ★★★★★ | 0 | 0 |
| Taconic Rehabilitation And Nursing At Hopewell | 4.7 mi | ★★★★★ | 15 | 0 |
| Sapphire Nursing At Meadow Hill | 5.4 mi | ★★★★★ | 0 | 0 |
| Sapphire Nursing At Wappingers | 6.3 mi | ★★★★★ | 3 | 0 |
| The Pines At Poughkeepsie Ctr For Nursing & Rehab | 12.4 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.