Average — CMS composite of the measures below.
The next survey window likely opens around January 2027
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 Taconic Rehabilitation And Nursing At Hopewell during CMS and state inspections, most recent first.
Surveyors found that the facility did not follow its food storage policy requiring all opened items to be labeled and dated, identifying twelve food items across refrigerators, freezers, and dry/bulk storage that lacked identification labels and/or open dates. Unlabeled or undated items included milk, half & half, almond milk, chicken tenders, meatless chicken tenders, frozen pizza, hot dogs, cereal, breadcrumbs, elbow macaroni, rice, and flour. The Food Service Manager confirmed that these practices were not acceptable and that staff were expected to comply with the facility’s labeling and dating requirements.
A resident admitted for short-term rehab with intact cognition and a stated goal to return to the community was not invited to participate in a comprehensive, interdisciplinary care plan meeting, and there was no documented ongoing evaluation of discharge needs or options. Despite documentation that active discharge planning was occurring and that the resident wished to go home, no care plan meeting was held before Medicare coverage ended and the resident began paying privately. The resident did not recall any care plan meeting, and the Director of Social Work acknowledged that discharge planning beyond initial documentation had not occurred and that a meeting should have been scheduled sooner.
Two residents reported missing personal property, including a red flip phone, a gold-colored chain with a cross, and an iPhone case, and filed grievances that were documented as resolved after staff searches and offers of reimbursement. One resident was cognitively intact and another had moderately impaired cognition, and both had significant medical conditions such as heart failure, spinal stenosis, ESRD, and diabetes. Despite the grievances being marked resolved and reimbursement having been offered, there was no documentation of reimbursement amounts, no evidence that payments were made, and no recorded follow-up sufficient to finalize resolution, as confirmed by resident and staff interviews.
Surveyors found that the facility did not send required copies of transfer/discharge notices to the State LTC Ombudsman for two residents who were transferred to the hospital, one with a hip fracture and dementia and another with dementia and breast cancer experiencing uncontrolled pain and later hospice planning. Although transfer/discharge forms and bed-hold documents were completed and kept in a binder, the Director of Social Work acknowledged that no copies or monthly transfer/discharge lists had been sent to the Ombudsman for several months, and the Ombudsman confirmed not receiving notices or monthly lists during that period.
Two residents’ MDS assessments were inaccurately coded by an LPN, resulting in failure to reflect actual falls and pressure ulcer status. One resident with orthopedic and oncologic conditions had two documented falls, yet their quarterly and annual MDS assessments indicated no falls during the relevant look-back periods. Another resident with cancer, hypertension, and anemia developed a facility-acquired stage 3 pressure ulcer to the left ischium, but the subsequent quarterly MDS incorrectly coded the ulcer as present on admission, despite documentation and the LPN’s acknowledgment that it was not present on admission.
Surveyors found that the facility did not update comprehensive care plans to reflect two residents’ current medication regimens. One resident with atrial fibrillation was receiving Eliquis, as documented on the MDS and physician orders, but the cardiac care plan did not address atrial fibrillation or anticoagulant use, and the DON and a unit manager confirmed no such care plan existed. Another resident with dementia and anxiety was receiving olanzapine for major depressive disorder, but the psychosocial care plan only referenced non-psychotropic medications and did not include antipsychotic use or related interventions, which was confirmed by an LPN unit manager and the Director of Social Work.
Two residents at risk for pressure ulcers did not receive ordered and care-planned pressure-relief interventions. One resident with severe cognitive impairment, impaired mobility, and a stage IV pressure ulcer on admission had a care plan and CNA Kardex directing staff to float heels when in bed, yet surveyors repeatedly observed the heels resting on the mattress, and staff acknowledged they should have been offloaded. Another resident with epilepsy, diabetes, impaired mobility, and documented risk for pressure ulcers had physician orders and care plan interventions to offload heels in bed and use a pressure-reducing wheelchair cushion, but observations showed heels on the mattress and no cushion in the wheelchair. A CNA reported not knowing about the heel-offloading requirement because it was not on the Kardex and admitted not reporting the missing cushion, while nursing and rehab staff confirmed the existence of the orders and care plan interventions and that they had not been carried out or reported.
A resident with severe cognitive impairment, dysphagia, and a stage 4 sacral wound on enhanced barrier precautions received oxygen via nasal cannula at a higher flow rate than ordered, with the concentrator repeatedly observed at 3 L/min instead of the prescribed 2 L/min. An LPN acknowledged not verifying the exact oxygen order and failing to adjust the flow rate to match it. In addition, a CNA handled and reinserted the resident’s nasal cannula from the resident’s hair into the nostrils without performing hand hygiene or using required PPE (mask, gloves, gown), despite the resident being on enhanced barrier precautions.
A resident admitted with Hospice care did not have a comprehensive, patient-centered Hospice care plan developed or implemented, as required by facility policy. Despite receiving Hospice services, there were no Hospice orders, progress notes, or care plans in the medical record, and staff interviews revealed communication failures during the admissions process that led to the omission.
A resident receiving Hospice care from an outside agency did not have any orders, progress notes, or a comprehensive care plan addressing Hospice services in their medical record. Facility staff and the Hospice provider confirmed that while the resident received multiple Hospice visits, documentation and communication about these services were not integrated into the facility's records, and staff were unclear about the process for documenting and coordinating Hospice care.
A resident with limited mobility and a deep tissue injury did not have consistent documentation or evidence of being turned and positioned every two hours as required by their care plan. Staff interviews revealed confusion and lack of clarity regarding documentation procedures, with both CNAs and nursing staff unable to confirm when interventions were performed. Facility policies required close monitoring and documentation, but no reliable system was in place to ensure these interventions were carried out and recorded.
A resident admitted on Hospice care did not have any physician orders or progress notes entered to continue Hospice services, and the medical provider was unaware of the resident's Hospice status. The absence of required documentation and orders was confirmed by record review and staff interviews, revealing a lapse in the facility's process for coordinating Hospice care.
Multiple residents were found living in rooms with environmental deficiencies, including windows covered with duct tape or plastic, broken furniture, and unpainted spackled wall patches. Residents reported drafts, water leaks, and concerns about cleanliness and safety, while staff confirmed delays in repairs and a lack of a formal work order system.
Certified Nurse Aides failed to complete required annual abuse prevention training, with overdue assignments and significant gaps between trainings, despite reminders and notifications from facility staff. Interviews confirmed that multiple staff were out of compliance with mandatory in-service requirements, and the facility's policy did not specify training frequency.
A resident with multiple medical conditions, including dementia and recent fractures, did not receive a timely follow-up with an orthopedic surgeon as ordered in hospital discharge instructions. Facility staff discussed the need for the appointment and transportation issues with the family, but there was no documentation that the appointment was scheduled or completed, nor evidence of required follow-up communication. The absence of records and follow-through led to a failure to provide care according to professional standards.
Failure to Label and Date Multiple Food Items in Storage Areas
Penalty
Summary
The facility failed to ensure that food was stored in accordance with professional standards and its own policy requiring all opened items to be labeled, dated, and discarded after three days. During a recertification survey kitchen inspection, surveyors observed multiple food items in various storage areas without required identification labels or open dates. In the night prep refrigerator, there was a gallon container of milk and a quart container of half & half with no opened dates. In the walk-in refrigerator, one bag of chicken tenders and one bag of meatless chicken tenders lacked identification labels. In the freezer, a bag of frozen pizza and a container of hot dogs were stored without identification labels. Additional unlabeled or undated items were found in dry and bulk storage areas. In the dry storage area, surveyors observed a tray of Cheerio cereal in bowls with no identification label, a bag of breadcrumbs with no opened date and no identification label, and a bag of dry elbow macaroni with no opened date. In the bulk storage area, a container of rice and a container of flour had no identification labels. In the milk storage refrigerator, a quart container of almond milk had no opened date. During an interview, the Food Service Manager acknowledged that it was not acceptable for food to be unlabeled or undated and stated that staff were expected to follow the facility’s food storage policy.
Failure to Involve Resident in Person-Centered Discharge Planning
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was included in person-centered care planning and ongoing discharge planning. The resident was admitted for short-term rehabilitation with diagnoses including repeated falls, chronic kidney disease, and benign prostatic hyperplasia. A social work note documented that the resident was alert and oriented in all spheres, able to make needs known, and that the overall goal was to discharge to the community. The five-day MDS documented intact cognition, resident participation in assessment and goal setting, a goal to discharge to the community, and that active discharge planning was occurring. The care plan for discharge planning documented maintaining the resident’s customary routine/treatment and evaluating preferences and needs for possible transition to the community. However, there was no documented evidence that the resident or their representative was invited to participate in a comprehensive care plan meeting. The record further showed that the resident signed a Notice of Medicare Non-Coverage indicating Medicare coverage would end on 01/23/2026, and an appeal of this non-coverage was later denied. Despite these events, there was no documented evidence of an interdisciplinary care plan meeting to address discharge planning prior to the end of Medicare coverage or the start of private pay. In interviews, the resident did not recall having a care plan meeting and stated they planned to go home. The Director of Social Work stated that discharge plans start at admission and that they were aware the resident wanted to return home, but acknowledged that no care plan meeting had been held since admission and that there had been no further discharge planning until 02/12/2026. The Director of Social Work stated they should have planned a meeting sooner and could not explain why it was missed.
Failure to Timely Resolve Grievances for Missing Personal Property
Penalty
Summary
The facility failed to ensure grievances related to missing personal property were resolved in a timely manner for two residents. One resident with heart failure and depression, who was cognitively intact per a quarterly MDS assessment, reported via a grievance form that a red flip phone had been missing for four days. The grievance form, dated in late November, indicated the family had replaced the phone and the facility would reimburse the cost upon receipt of documentation from the family, and the form was signed as resolved in early December. However, there was no documented evidence of the reimbursement amount or that a check was provided, and the resident later stated in an interview that the phone was never found and no reimbursement had been received. Another resident with spinal stenosis, end stage renal disease, and diabetes, and with moderately impaired cognition per a quarterly MDS assessment, reported through a grievance form that a gold-colored chain with a medal cross and an iPhone case were missing. The grievance form documented that housekeeping and dietary staff were notified, a room search was completed, and reimbursement was offered while the facility awaited an estimate from the family; the grievance was also signed as resolved in early December. Despite this, there was no documentation of the reimbursement cost or that payment was made. In interviews, the Director of Social Work and two administrators acknowledged that reimbursement had been offered and that they preferred to resolve grievances within 24 hours, but they had no explanation for why reimbursement had not been provided or why there was no documentation of follow-up efforts or final resolution, even though the items had been reported missing months earlier.
Failure to Notify State Ombudsman of Resident Hospital Transfers
Penalty
Summary
The deficiency involves the facility’s failure to provide required copies of transfer or discharge notices to the State Long Term Care Ombudsman for residents who were hospitalized. Facility policy titled “Discharge Notice,” last revised 06/2025, states that when a resident is temporarily transferred on an emergency basis to an acute care facility, notice of the transfer may be provided to the resident and resident representative as soon as practicable, and that copies of notices for emergency transfers must also be sent to the Ombudsman, which may be done when practicable, such as in a monthly list. For Resident #14, who had diagnoses including fracture of the right femur, essential hypertension, and dementia, nursing progress notes documented admission to the hospital on 11/16/2025 with a right hip fracture. A transfer/discharge notice dated 11/16/2025 showed the resident representative’s signature dated 11/17/2025, and a bed-hold policy form dated 11/18/2025 also had the representative’s signature. However, there was no documented evidence that the New York State Ombudsman office was notified of this transfer. For Resident #153, who had diagnoses including unspecified dementia and malignant neoplasm of the left breast, a nursing progress note dated 11/13/2025 documented that the resident was sent to the hospital due to uncontrolled pain. A transfer/discharge notice dated 11/15/2025 documented that the resident representative was verbally notified on 11/13/2025, and a nursing progress note dated 11/14/2025 recorded that the emergency room nurse reported the designated representative was at the bedside requesting transfer to hospice for end-of-life care. Despite this documentation of the transfer and representative notification, there was no documented evidence that the New York State Ombudsman office was notified of the 11/13/2025 transfer. During interview, the Director of Social Work stated they kept a binder with a monthly transfer/discharge list, completed transfer/discharge forms, and bed-hold forms available for Ombudsman review, but acknowledged that they had not sent or emailed copies of completed transfer/discharge notification forms or a monthly transfer/discharge list to the Ombudsman office during the last six months. The Ombudsman confirmed they had not received copies of the transfer/discharge notifications for these residents and had not received a monthly list of discharged/transferred residents since April 2025.
Inaccurate MDS Coding for Falls and Pressure Ulcer Status
Penalty
Summary
The deficiency involves inaccurate completion of Minimum Data Set (MDS) assessments for two residents, contrary to facility policy requiring that the MDS accurately reflect resident status. One resident with diagnoses including orthopedic conditions, cancer, and osteoarthritis of the knee experienced a documented fall on 08/09/2025, when they were observed on the floor in front of their wheelchair, and another documented fall on 10/21/2025, when they were observed on the floor of their room. Despite these incidents, the 09/26/2025 quarterly MDS assessment documented no falls anytime in the last month prior to admission and no falls in the last 2 to 6 months, and the 12/12/2025 annual MDS assessment documented no falls since admission/entry or reentry or the prior assessment. During interview and record review, the MDS LPN acknowledged that these falls were not documented on the respective MDS assessments, stated they had entered "no falls" in error, and reported they had overlooked the resident’s falls and were not aware of the correct process to identify falls at the time of the assessments. A second resident, with diagnoses including cancer, hypertension, and anemia, had a wound care note dated 12/04/2025 documenting an initial evaluation of a stage three pressure ulcer to the left ischium, indicating it was facility-acquired. However, the 01/23/2026 quarterly MDS documented that this resident had a stage three pressure ulcer that was present on admission. In interview, the MDS LPN stated they entered the wound information on the MDS based on evaluations, progress notes, and wound care notes in the electronic medical record, confirmed that the resident did not have a pressure ulcer on admission, and stated they should have coded the pressure ulcer as not present on admission when completing the 01/23/2026 MDS assessment.
Failure to Update Care Plans for Anticoagulant and Antipsychotic Medication Use
Penalty
Summary
The deficiency involves the facility’s failure to ensure comprehensive care plans were reviewed and revised with each assessment and as needed to reflect residents’ changing needs, as required by facility policy and regulation. For one resident with diagnoses including peripheral vascular disease and atrial fibrillation, a quarterly MDS documented moderate cognitive impairment and receipt of anticoagulants, and a physician order specified Eliquis 5 mg by mouth twice daily. However, there was no documented evidence in the resident’s cardiac care plan addressing the diagnosis of atrial fibrillation or the use of anticoagulants. During interview, the DON confirmed they could not locate a care plan addressing anticoagulant use for this resident and acknowledged that interventions to monitor and report signs and symptoms of bleeding or bruising should have been in place. The LPN Unit Manager stated they were aware of the anticoagulant order and that an RN could add an anticoagulant care plan, and identified that updating care plan interventions was a unit manager role. For another resident with diagnoses including dementia with anxiety and unspecified pain, a quarterly MDS documented moderate cognitive impairment and receipt of antipsychotic medication. A physician order documented olanzapine 5 mg by mouth at bedtime for major depressive disorder. The psychosocial care plan in place documented administration of non-psychotropic medication per physician order, but there was no care plan with interventions specifically addressing the use of antipsychotic medications. The LPN Unit Manager confirmed the resident received antipsychotic medication and could not locate a care plan addressing antipsychotic use, stating that such interventions could have been added under the psychosocial care plan and that the Social Work Department updated psychosocial care plans. The Director of Social Work stated that antipsychotic medication use was to be documented under psychosocial care plans, could not locate this on the resident’s care plan, and acknowledged responsibility for updating the care plan to address antipsychotic use, including interventions such as documenting antipsychotic use, psychology/psychiatry consults as needed, and monitoring and reporting changes in behavior.
Failure to Implement Heel Offloading and Pressure-Relief Interventions for At-Risk Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide pressure ulcer prevention and treatment consistent with professional standards and residents’ care plans for two residents identified as being at risk for pressure ulcers. One resident had diagnoses including bipolar disorder, unspecified dementia without behavior disturbance, and dysphagia, and was care planned under Skin Integrity as being at risk for impaired skin integrity related to impaired mobility, with an intervention to float/offload heels when in bed. The resident’s quarterly MDS documented severe cognitive impairment, dependence on staff for bed mobility, risk for pressure ulcers, and the presence of a stage IV pressure ulcer on admission. The CNA Kardex also directed staff to float the resident’s heels when in bed, reposition every two to four hours, and use a pressure relief mattress. Despite these documented interventions, surveyor observations on multiple dates showed the resident’s bilateral heels resting directly on the mattress, not offloaded or floated. During interviews conducted concurrently with observations, a CNA acknowledged that the resident’s heels were resting on the mattress and confirmed they should have been offloaded/floated, stating that the heels should have been checked after the resident was hand-fed lunch. An LPN similarly confirmed that the resident’s heels were not offloaded/floated, acknowledged the care plan intervention for heel offloading when in bed, and stated that all nursing staff, including CNAs, were responsible for ensuring the heels were offloaded, with nurses responsible for ensuring CNA tasks were completed. The LPN Unit Manager also confirmed the care plan intervention for heel offloading and stated that staff should have used pillows or a wedge device to offload the heels. The second resident had diagnoses including unspecified epilepsy non-intractable with status epilepticus, history of transient ischemic attack and cerebral infarction without residual deficits, and bipolar disorder. A physician order directed staff to offload the resident’s heels on a pillow in bed every shift as tolerated, and the Skin Integrity care plan documented the resident was at risk for impaired skin integrity related to type 1 diabetes and impaired mobility, with interventions including offloading/floating heels while in bed, turning and repositioning every two to four hours as needed, and use of a pressure reduction device when out of bed. The Transfer care plan also specified a pressure reduction device for out-of-bed use. The quarterly MDS documented moderate cognitive impairment, substantial/maximal assistance needed for bed mobility, and risk for pressure ulcers, with no current pressure ulcer. However, repeated observations showed the resident in bed with heels resting on the mattress, not offloaded, and in a wheelchair without a pressure-relieving cushion. A CNA confirmed the absence of a pressure-relieving cushion, stated they had last seen it weeks earlier when the resident used a Geri chair, admitted they had not reported the missing cushion, and stated they were unaware of the heel offloading order and care plan intervention because it was not on the CNA Kardex. The LPN Unit Manager confirmed the existence of the physician order and care plan interventions for heel offloading and wheelchair pressure reduction device, acknowledged the tasks were not completed, and stated that no staff had reported the missing cushion. The acting Director of Rehabilitation confirmed that a pressure reduction device for the wheelchair had been added to the care plan and that staff were expected to report missing cushions, but no such report had been received.
Failure to Follow Oxygen Orders and Enhanced Barrier Precautions
Penalty
Summary
The deficiency involves failure to provide respiratory care consistent with professional standards and the resident’s care plan for one resident receiving oxygen therapy. The resident had diagnoses including bipolar disorder, unspecified dementia without behavior disturbance, dysphagia, and a stage 4 sacral wound requiring enhanced barrier precautions. The care plan directed staff to administer oxygen per physician order, and the physician order specified continuous oxygen via nasal cannula at 2 liters per minute. However, on multiple observations, the resident was receiving oxygen at 3 liters per minute. An LPN reported checking the oxygen concentrator earlier in the shift and confirmed it was set at 3 liters per minute, and also stated they were not initially aware of the exact physician order. After reviewing the order, the LPN acknowledged the order was for 2 liters per minute and that they should have verified the order and adjusted the flow rate accordingly. The deficiency also includes failure to follow enhanced barrier precautions and infection control practices when handling the resident’s nasal cannula. The resident was on enhanced barrier precautions due to a stage 4 sacral wound. During observation, the nasal cannula was resting in the resident’s hair/scalp, and a CNA removed the cannula from the hair and inserted the prongs into the resident’s nostrils without performing hand hygiene, donning gloves, or wearing a gown. The CNA later stated they should have applied appropriate PPE and performed hand hygiene before handling and placing the nasal cannula. The LPN unit manager stated that nursing staff were required to check oxygen flow rates during medication administration and each shift to ensure they matched the physician order, and that staff should mask, glove, and gown when providing care to residents on enhanced barrier precautions, with nurses responsible for supervising CNAs to ensure PPE use.
Failure to Develop and Implement Hospice Care Plan Upon Admission
Penalty
Summary
A deficiency was identified when a resident admitted from a hospital with Hospice care in place did not have a comprehensive, patient-centered Hospice care plan developed or implemented upon admission. The facility's policies require the interdisciplinary team to create and regularly update a care plan that includes collaboration with Hospice, the resident, and family. However, review of the resident's electronic medical record revealed no Hospice orders, no progress notes from medical providers indicating collaboration with Hospice, and no care plans addressing Hospice services. Despite documentation from the hospital and Hospice provider confirming the resident was receiving Hospice care, this information was not reflected in the facility's care planning documentation. Interviews with facility staff and the Hospice provider confirmed that Hospice services were being provided, including nursing, aide, and social work visits. However, communication breakdowns were evident, as the admissions process failed to relay the Hospice status to the care team, and staff were unaware or unable to document the resident's Hospice care in the system. The Director of Social Work stated they could not update the care plan without being informed of the resident's Hospice status, and the Nurse Liaison acknowledged that the information was not communicated as required. This lack of coordination and documentation resulted in the absence of a comprehensive Hospice care plan for the resident.
Failure to Document and Coordinate Hospice Care Services
Penalty
Summary
The facility failed to provide services in accordance with professional standards of care for a resident receiving Hospice care from an outside agency. The resident's medical record lacked documentation, including orders for Hospice, progress notes from medical providers, and a comprehensive care plan addressing Hospice services. Despite the facility's policy requiring nursing coordination and ongoing collaboration with Hospice, as well as the development and regular review of a resident-centered care plan by the interdisciplinary team, these requirements were not met. The electronic medical record did not contain any evidence of Hospice involvement, and communication about the resident's Hospice status was not documented or relayed to relevant staff. Interviews with facility staff and the Hospice provider revealed that while the resident did receive multiple visits from Hospice nurses, aides, and a social worker, the documentation of these services was not integrated into the facility's records. Staff were unclear about the process for documenting Hospice care, with some believing that notes were kept in a binder on the unit, while others, including the Medical Director, were unaware of such a system. The lack of communication and documentation resulted in the facility not having an order for Hospice or a care plan reflecting the resident's Hospice status, and the information about the resident's enrollment in Hospice was not properly conveyed to the admissions or care team.
Failure to Document and Implement Pressure Injury Prevention Interventions
Penalty
Summary
The facility failed to provide consistent evidence that care plan interventions for pressure injury prevention were carried out for a resident admitted with a deep tissue injury. The resident, who had multiple diagnoses including a femur fracture, hypotension, and was receiving palliative care, had a care plan intervention requiring turning and positioning every two hours. However, documentation from the period reviewed showed only 14 notes suggesting the resident may have been moved, with just five notes specifically indicating that turning and positioning occurred. Most documentation did not clearly state that the intervention was performed as required by the care plan. Facility policies required close monitoring and documentation of pressure ulcers and chronic wounds, as well as adherence to care plan interventions for activities of daily living, including turning and positioning. Interviews with staff revealed a lack of clarity and consistency in documenting these interventions. Certified Nurse Aides reported that they were not instructed to document turning and positioning, and that communication about these interventions was informal and not reliably recorded. Attempts to demonstrate electronic documentation were unsuccessful, and staff were unable to confirm when the resident was last turned or positioned. Nursing staff, including LPNs and the Assistant Director of Nursing, confirmed that there was no systematic documentation of turning and positioning, either on paper or electronically. They expressed uncertainty about when interventions were performed and acknowledged that there was no tracking system in place. This lack of documentation and inconsistent communication among staff led to the deficiency in ensuring that the resident's care plan interventions for pressure injury prevention were consistently implemented and recorded.
Failure to Document and Order Hospice Care for Admitted Resident
Penalty
Summary
A deficiency was identified when a resident admitted to the facility, who was already receiving Hospice care at their prior facility, did not have any physician orders or progress notes entered to continue Hospice care upon admission. Record review showed that from the time of admission until discharge, there were no documented orders for Hospice services, nor any physician notes indicating awareness of the resident's Hospice status. The facility's policy requires a collaborative effort with Hospice providers and mandates a written agreement and documentation for residents with life-limiting illnesses, but this was not followed in this case. During interviews, the Medical Director confirmed that it is standard practice to write an order for Hospice care and acknowledged that there were no such orders or notes for this resident. The Medical Director stated they were unaware of the resident's Hospice status and had not seen any documentation or binders related to Hospice for this individual. The lack of physician documentation and orders for Hospice care was attributed to an oversight that went unnoticed by facility staff.
Failure to Maintain Safe and Homelike Resident Environment
Penalty
Summary
Surveyors identified that the facility failed to provide a safe, clean, comfortable, and homelike environment for residents, as required by regulation. Observations revealed that multiple resident rooms on the Roosevelt unit had significant environmental deficiencies, including windows covered with duct tape or plastic, window screens with holes, broken furniture, and numerous unpainted spackled patches on the walls. In several cases, residents were newly admitted and found their rooms in these conditions upon arrival, with some expressing dissatisfaction and concern about the state of their living environment. Residents reported ongoing issues such as drafts and water leaks from windows, with temporary fixes like duct tape and plastic coverings being used instead of permanent repairs. One resident noted that the plastic covering on their window had been in place for over a month, and water would accumulate and leak during rain. Another resident expressed concern about spackle dust from unpainted wall patches, which had been left after the removal of equipment from the walls. Residents also reported broken dressers that prevented them from storing their clothing properly. Interviews with facility staff, including the Maintenance Director and Administrator, confirmed that there was no formal work order system in place, and that maintenance rounds sometimes missed needed repairs. The Maintenance Director acknowledged that the Roosevelt unit had not been painted in several years, and that sanding and painting of spackled areas had been delayed due to workload. Staff also confirmed that temporary measures, such as plastic window coverings, were not appropriate for extended use, and that some windows and furniture were overdue for repair or replacement.
Failure to Ensure Timely Completion of Abuse Prevention Training by CNAs
Penalty
Summary
The facility failed to ensure that Certified Nurse Aides (CNAs) maintained the required competencies and completed annual abuse prevention training as mandated by facility policy and regulatory requirements. Record review revealed that three CNAs involved in separate allegations of abuse had not completed their required annual abuse training on time. Specifically, each CNA had significant gaps between their last completed abuse training and the date of the incident or the most recent training, with overdue assignments not completed until several months after they were due. The facility's abuse prevention policy did not specify the frequency of required training, and staff were found to be out of compliance with annual training requirements. Interviews with facility staff, including the Staffing Educator, Regional DON, Interim Administrator, and DON, confirmed that multiple staff members had not completed mandatory in-service trainings on time. The Staffing Educator reported that notifications and reminders were sent to staff and administration regarding overdue trainings, but these measures were not effective in ensuring compliance. One CNA stated they did not recall their last abuse training and had not received disciplinary action for missing required trainings. The deficiency was identified through record review and staff interviews, with documentation showing that the required abuse prevention training was not completed annually as required.
Failure to Ensure Timely Orthopedic Follow-Up After Resident Fracture
Penalty
Summary
Resident #4, who had diagnoses including dementia, multiple fractures, nontraumatic intracerebral hemorrhage, and repeated falls, experienced an unwitnessed fall resulting in pelvic and iliac crest fractures. Following hospitalization, the discharge instructions specified that the resident should remain non-weight bearing on the right lower extremity and have a follow-up appointment with an orthopedic surgeon within 2-4 weeks. The facility's policy required assistance in scheduling outside appointments per provider recommendations. However, there was no documented evidence that the required orthopedic follow-up appointment was scheduled or completed as directed by the hospital discharge instructions. Interviews with facility staff revealed that discussions about the follow-up appointment and transportation occurred, but no documentation was provided to confirm these discussions or any follow-up actions. The Director of Therapy mentioned attempting to arrange a telehealth consultation with an orthopedic surgeon but could not provide documentation or a date for this action. The Director of Nursing confirmed that the unit manager and unit clerk were responsible for reviewing discharge paperwork and scheduling follow-up appointments, but no records of an orthopedic consult or appointment were available. The lack of documentation and follow-through resulted in the resident not receiving care in accordance with professional standards and the hospital's discharge instructions.
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.
Illustrative
What surveyors actually found near you
We read the 228 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
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Fishkill
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 | 4.3 mi | ★★★★★ | 0 | 0 |
| Sapphire Nursing At Wappingers | 4.5 mi | ★★★★★ | 3 | 0 |
| Fishkill Center For Rehabilitation And Nursing | 4.7 mi | ★★★★★ | 3 | 0 |
| Sapphire Nursing At Meadow Hill | 10.1 mi | ★★★★★ | 0 | 0 |
| The Pines At Poughkeepsie Ctr For Nursing & Rehab | 11.1 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Taconic Rehabilitation And Nursing At Hopewell.
100% money-back within 48 hours.
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.