Inspection Reports for
Fishkill Center for Rehabilitation and Nursing
22 Robert R. Kasin Way, Beacon, NY, 12508
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Inspection Report — Dec 26, 2025
Abbreviated Survey CMS
Date: Dec 26, 2025
Visit Reason
The visit was an abbreviated survey to assess compliance with care planning, notification of significant changes, and accident prevention protocols.
Findings
The facility failed to timely notify the correct family representative of a resident's significant change in condition after a fall, did not update comprehensive care plans for cognitive impairment for two residents, and failed to implement adequate fall prevention interventions for a high-risk resident, resulting in actual harm.
Citations (3)
F 0580: The facility did not ensure the correct family representative was timely informed of Resident #1's significant change in condition after a fall on 09/27/2025, resulting in delayed notification until 10/30/2025.
F 0657: The facility failed to review, update, and revise comprehensive care plans for cognitive impairment for Residents #1 and #3 in accordance with the most recent assessments.
F 0689: The facility failed to implement adequate fall prevention interventions for Resident #1, who was identified as high risk for falls, resulting in a fall with injuries and actual harm on 09/27/2025.
Report Facts
Fall risk score: 12
Fall risk score: 14
Residents reviewed: 3
Residents affected: 1
Residents affected: 2
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #2 | Licensed Practical Nurse | Named in relation to notification attempts to Resident #1's representative after the fall. |
| Licensed Practical Nurse #5 | Licensed Practical Nurse | Named in relation to notification discrepancy and fall prevention safety checks. |
| Social Worker | Responsible for updating cognitive care plans and interviewed regarding care plan deficiencies. | |
| Director of Nursing | Director of Nursing | Reviewed care plans and interviewed regarding care plan and fall prevention deficiencies. |
| Certified Nurse Aide #3 | Certified Nurse Aide | Observed Resident #1 prior to fall and reported concerns. |
| Certified Nurse Aide #2 | Certified Nurse Aide | Interviewed regarding Resident #1's mobility and condition. |
| Registered Nurse #3 | Registered Nurse | Previous unit manager interviewed regarding fall risk documentation. |
Inspection Report — Dec 26, 2025
Complaint Investigation State
Date: Dec 26, 2025
Visit Reason
State-compiled facility profile showing 8 inspections from June 2022 to May 2026 with citation and enforcement history.
Complaint Details
The state logged 68 complaints about this facility; 12 led to on-site inspections. The facility received 45.8 complaints per 100 beds, below the statewide rate of 57.4. 13 citations resulted from those complaints.
Findings
Across 8 inspections, 6 resulted in citations totaling 38, including 29 standard health and 9 life safety code citations. The facility had 68 complaints with 12 on-site inspections and 2 enforcement actions totaling $4,000 in fines.
Citations (33)
Care Plan Timing And Revision: Failed to timely revise care plans as required.
Free Of Accident Hazards/supervision/devices: Failed to ensure resident safety from accident hazards.
Notify Of Changes (injury/decline/room, Etc.): Failed to notify appropriate parties of resident changes.
Covid-19 Immunization: Failed to meet Covid-19 immunization requirements.
Develop/implement Comprehensive Care Plan: Failed to develop or implement comprehensive care plans.
Dispose Garbage And Refuse Properly: Failed to properly dispose of garbage and refuse.
Food Procurement,store/prepare/serve-sanitary: Failed to maintain sanitary food procurement and preparation.
Influenza And Pneumococcal Immunizations: Failed to provide required immunizations.
Nurse Aide Peform Review-12 Hr/yr In-service: Failed to perform required nurse aide reviews and in-service training.
Quality Of Care: Deficiencies in quality of care standards.
Resident Rights/exercise Of Rights: Failed to ensure residents could exercise their rights.
Residents Are Free Of Significant Med Errors: Failed to prevent significant medication errors.
Safe/clean/comfortable/homelike Environment: Failed to maintain a safe and comfortable environment.
Fire Alarm System - Testing And Maintenance: Failed to properly test and maintain fire alarm systems.
Hazardous Areas - Enclosure: Failed to properly enclose hazardous areas.
ADL Care Provided For Dependent Residents: Failed to provide adequate activities of daily living care.
Administration: Deficiencies in administrative functions.
Department Criminal History Review: Failed to properly review criminal history as required.
Free Of Accident Hazards/supervision/devices: Failed to ensure safety from accident hazards, posing immediate jeopardy.
Governing Body: Deficiencies in governing body oversight.
Investigate/prevent/correct Alleged Violation: Failed to properly investigate and correct alleged violations.
Label/store Drugs And Biologicals: Failed to properly label and store drugs and biologicals.
Treatment/svcs To Prevent/heal Pressure Ulcer: Failed to provide adequate treatment to prevent or heal pressure ulcers.
Discharge From Exits: Failed to maintain proper discharge from exits.
Exit Signage: Failed to maintain proper exit signage.
Organization And Administration: Deficiencies in organization and administration under Life Safety Code.
Physical Environment: Deficiencies in physical environment under Life Safety Code.
Plan Based On All Hazards Risk Assessment: Failed to maintain an adequate all hazards risk assessment plan, not yet corrected.
Portable Space Heaters: Unsafe use of portable space heaters posing immediate jeopardy.
Sprinkler System - Installation: Deficiencies in sprinkler system installation.
Develop/implement Comprehensive Care Plan: Failed to develop or implement comprehensive care plans.
Free Of Accident Hazards/supervision/devices: Failed to ensure resident safety from accident hazards.
Free From Abuse And Neglect: Failed to protect residents from abuse and neglect.
Report Facts
Inspections on page: 8
Total violations/deficiencies cited: 38
Inspections with violations: 6
Inspections without violations: 2
Total complaints: 68
On-site complaint inspections: 12
Complaint citations issued: 13
Enforcement actions: 2
Total fines: 4000
Inspection Report — Feb 14, 2025
Annual Inspection CMS
Date: Feb 14, 2025
Visit Reason
The inspection was a recertification survey conducted to assess compliance with regulatory standards for nursing home care and facility operations.
Findings
The facility was found deficient in multiple areas including resident dignity, environmental safety, care planning, medication administration, staff performance reviews, food safety, waste disposal, vaccination policies, and COVID-19 vaccination education and documentation.
Citations (10)
F 0550: The facility did not maintain resident dignity by serving milk and water in plastic storage cups with lids and staff used inappropriate terminology referring to a resident as a feeder.
F 0584: The facility did not ensure a safe, clean, comfortable, and homelike environment; broken tiles, cracked walls, hanging curtains, damaged windows, and an open hallway window caused resident discomfort.
F 0656: The facility failed to develop a comprehensive care plan with goals and interventions specific to the use of a cervical collar for a resident with fractures.
F 0684: The facility had multiple omissions in medication and treatment administration records related to pain management for a resident, with no documented reasons for omissions.
F 0730: The facility did not complete annual performance reviews for three of five Certified Nurse Aides within the last 12 months.
F 0760: A significant medication error occurred when a resident was administered methadone not prescribed to them, resulting in hospital transfer for evaluation.
F 0812: The facility did not ensure food was stored safely; beverages in the nutrition refrigerator were unlabeled and outdated, and an open parcel of flour was not sealed or dated.
F 0814: The facility failed to properly dispose of garbage and refuse; the dumpster was left open and surrounded by debris, old furniture, and large metal containers.
F 0883: The facility did not ensure residents were offered pneumococcal vaccinations or provided education regarding the vaccine for two residents reviewed.
F 0887: The facility did not ensure staff were screened, offered COVID-19 vaccination, or provided education about the vaccine; no documentation or signage was available to confirm compliance.
Report Facts
Residents affected: 10
Certified Nurse Aides without performance reviews: 3
Medication omissions: 15
Medication error dose: 150
Outdated beverage date: 3
Residents reviewed for pneumococcal vaccine: 5
Staff reviewed for COVID vaccine: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Assistant #7 | Certified Nurse Assistant | Named in dignity deficiency for inappropriate terminology use |
| Food Service Director | Interviewed regarding use of plastic cups and food storage | |
| Director of Rehabilitation | Interviewed regarding use of drinking cups | |
| Director of Nursing | Interviewed regarding dignity in-services and medication omissions | |
| Registered Nurse Unit Manager #10 | Registered Nurse Unit Manager | Interviewed regarding care plan deficiencies and pain management |
| Human Resource Director | Interviewed regarding Certified Nurse Aide performance reviews | |
| Assistant Administrator | Interviewed regarding Certified Nurse Aide performance reviews | |
| Assistant Director of Nursing | Interviewed regarding Certified Nurse Aide performance reviews and COVID vaccine education | |
| Registered Nurse #9 | Registered Nurse | Involved in medication error administration |
| Licensed Practical Nurse #8 | Licensed Practical Nurse | Responded to medication error and resident evaluation |
| Director of Maintenance | Interviewed regarding dumpster and refuse management | |
| Administrator | Interviewed regarding dumpster and refuse management | |
| Director of Nursing | Interviewed regarding vaccine program and COVID-19 vaccination | |
| Licensed Practical Nurse #25 | Licensed Practical Nurse | Interviewed regarding COVID-19 vaccination |
Inspection Report — Jan 11, 2024
Annual Inspection CMS
Date: Jan 11, 2024
Visit Reason
The inspection was a recertification survey conducted from January 2, 2024 to January 11, 2024, to assess compliance with regulatory requirements for the nursing home.
Findings
The facility was found deficient in multiple areas including residents' rights to dignity during feeding and care, failure to thoroughly investigate injuries of unknown origin, incomplete care plan updates, inadequate assistance with bathing, improper pressure ulcer care, unsafe use of space heaters posing immediate jeopardy, unsecured medication carts, and lack of effective oversight by the governing body.
Citations (9)
F550: The facility failed to ensure residents' right to a dignified existence during meals and procedures, including staff standing over residents while feeding and lab draws done in common areas.
F610: The facility did not thoroughly investigate injuries of unknown origin for Resident #54, lacking staff interviews to rule out abuse.
F657: The facility failed to timely review and revise Resident #69's care plan to reflect the need for two-person assist after a fall.
F677: Residents #12 and #88 did not receive scheduled twice-weekly showers, with documentation gaps and staffing shortages cited.
F686: Resident #100 was not provided appropriate pressure ulcer care, observed without ordered heel lift suspension booties and oxygen tubing ear protectors.
F689: Immediate jeopardy due to unsafe use of space heaters in 17 resident rooms affecting 26 residents, with lack of staff education and oversight.
F761: Medication carts on S1 unit were observed unlocked and unattended, and morning medications were left with Resident #99.
F835: The facility lacked effective oversight and management, failing to ensure safety and compliance related to accidents and space heater use.
F837: The governing body did not establish or implement policies ensuring regulatory compliance and failed to maintain consistent communication with the Administrator.
Report Facts
Residents affected by space heaters: 26
Residents admitted: 21
Residents admitted: 21
Residents admitted: 13
Staff education completion: 95
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #17 | Licensed Practical Nurse | Observed feeding Resident #38 while standing and not making eye contact. |
| Staff #7 | Observed feeding Resident #139 and heard calling resident a feeder. | |
| Director of Nursing | Provided multiple interviews regarding feeding practices, lab draw privacy, and injury investigations. | |
| Staff #28 | Registered Nurse Unit Manager | Stated expectations for redirecting consultants and care plan updates. |
| Staff #13 | Licensed Practical Nurse | Left medication cart unlocked and left medications with Resident #99. |
| Staff #30 | Licensed Practical Nurse | Left medication cart unlocked while moving car. |
| Maintenance Director | Discussed space heater use, inspections, and heating system repairs. | |
| Administrator | Discussed space heater policy, heating system issues, and governing body communication. | |
| Medical Director | Unaware of space heater use and heating issues prior to survey. | |
| Registered Nurse Unit Manager #6 | Reported resident wandering and safety concerns with space heaters. | |
| Certified Nurse Aide #4 | Reported no education on space heater use. | |
| Certified Nurse Aide #3 | Reported no education on space heater management. | |
| Certified Nurse Aide #5 | Observed towels placed over space heaters. | |
| Governing Body Representative | Discussed lack of awareness and communication regarding heating issues and space heater use. | |
| Director of Nursing | Stated corporate was the governing body and communication lines. |
Inspection Report — Dec 29, 2023
Complaint Investigation CMS
Date: Dec 29, 2023
Visit Reason
The inspection was conducted as a complaint survey (#NY00290874) to investigate concerns related to the development of a person-centered care plan addressing risk for abuse for a resident.
Complaint Details
The complaint investigation found that the resident had a history of displaying behaviors and was not care planned for risk of abuse until after an allegation of abuse was made on 2/7/2022. Staff interviews confirmed the care plan was initiated only after the resident self-advocated following the abuse allegation.
Findings
The facility failed to develop and implement a comprehensive care plan with measurable objectives, time frames, and interventions to address the risk for abuse for one resident with cognitive impairment and behavioral issues. Interviews and record reviews confirmed the care plan for risk of abuse was only initiated after an allegation of abuse was made.
Citations (1)
F 0656: The facility did not develop a complete care plan with measurable objectives, time frames, and interventions to address the risk for abuse for one resident with progressive neurological conditions, cognitive impairment, and behavioral symptoms.
Report Facts
Mood score: 17
Mood score: 13
Date: Dec 22, 2022
Date: Feb 1, 2022
Date: Feb 7, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #4 | Registered Nurse/Director of Nursing | Interviewed regarding resident's behavior history and care planning for risk of abuse |
| Staff #5 | Administrator | Interviewed regarding criteria for initiating risk for abuse care plan |
Inspection Report — Oct 25, 2023
Abbreviated Survey CMS
Date: Oct 25, 2023
Visit Reason
The abbreviated survey was conducted to assess the facility's compliance with safety protocols related to accident prevention and supervision following multiple falls of a resident.
Findings
The facility failed to ensure adequate supervision and intervention to prevent falls for Resident #1, who experienced multiple falls resulting in a displaced femur fracture and hospitalization. The facility did not update fall risk assessments or implement sufficient monitoring and safety measures despite the resident's high fall risk and dementia.
Citations (1)
F 0689: The facility did not ensure adequate supervision and assistance to prevent accidents for Resident #1, who had multiple falls and a refractured left femur. Fall risk assessments were not updated after falls and interventions were insufficient to prevent subsequent incidents.
Report Facts
Fall risk score: 8
Number of falls: 5
Aide to residents ratio: 3
Aspirin dosage held: 81
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Interviewed about procedures when discovering a resident on the floor | |
| Licensed Practical Nurse (LPN #1) | Interviewed regarding Resident #1's falls, hospital admission, and interventions | |
| Director of Nursing (DON) | Interviewed about supervision policies and Resident #1's fall incident |
Inspection Report — May 25, 2023
Abbreviated Survey CMS
Date: May 25, 2023
Visit Reason
The abbreviated survey was conducted to investigate the facility's compliance with resident rights, specifically regarding protection from abuse, mistreatment, neglect, and exploitation.
Findings
The facility failed to ensure that residents were free from abuse, mistreatment, neglect, and exploitation. Specifically, a Certified Nursing Assistant was found to have handled a resident roughly, causing bruising, and the facility terminated the responsible CNA after investigation.
Citations (1)
F 0600: The facility did not protect Resident #4 from abuse when CNA #4 handled the resident roughly during incontinent care, causing bruising to the left forearm. The facility investigation concluded there was cause to believe abuse occurred.
Report Facts
Residents Affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #4 | Certified Nursing Assistant | Named as responsible for rough handling causing bruising to Resident #4; terminated by facility |
| CNA #5 | Certified Nursing Assistant | Discovered bruising on Resident #4 and reported incident |
| Director of Nursing | Director of Nursing | Interviewed regarding incident and termination of CNA #4 |
| Assistant Director of Nursing | Assistant Director of Nursing | Interviewed regarding incident and investigation |
Inspection Report — Feb 28, 2020
Annual Inspection CMS
Date: Feb 28, 2020
Visit Reason
The inspection was a recertification survey to assess compliance with regulatory requirements for Fishkill Center for Rehabilitation and Nursing.
Findings
The survey identified multiple deficiencies including failure to maintain resident dignity, incomplete care plan implementation, improper respiratory care, unsecured medications, improper food labeling, and breaches in infection control practices.
Citations (6)
F 0550: The facility did not ensure that care was provided to maintain dignity for a resident with a urinary catheter, as the urinary drainage bag was not concealed from view.
F 0656: The facility did not ensure care plan interventions were implemented consistently for a resident requiring positioning devices, resulting in improper positioning and lack of communication to staff.
F 0695: The facility did not ensure proper respiratory care for a resident, administering oxygen at higher flow rates and frequencies than ordered without proper monitoring.
F 0761: Medications were not secured in a locked storage area; a medication cup with pills was left on a resident's bed without supervision.
F 0812: Food items brought in from outside were not labeled or dated appropriately and were not discarded within the required timeframe in two resident units.
F 0880: Infection prevention and control practices were not followed; a CNA failed to use PPE when caring for a resident on contact precautions and an LPN did not follow proper hand hygiene and cross contamination prevention during wound care.
Report Facts
Residents reviewed for urinary catheter: 1
Residents reviewed for position/mobility: 2
Residents reviewed for respiratory care: 2
Residents reviewed for infection control: 3
Medication pills observed: 4
Food items undated or improperly dated: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant (CNA #1) | Named in urinary catheter dignity deficiency for forgetting to cover drainage bag | |
| Director of Rehabilitation | Interviewed regarding positioning device use for Resident #123 | |
| Assistant Rehabilitation Director | Interviewed about communication of positioning device use to CNAs | |
| Licensed Practical Nurse (LPN #2) | Interviewed regarding oxygen administration and medication supervision | |
| Licensed Practical Nurse Unit Manager (LPN #2) | Interviewed regarding oxygen order and medication supervision | |
| Certified Nurse Aide (CNA #2) | Observed not wearing PPE while caring for resident on contact precautions | |
| Licensed Practical Nurse (LPN #1) | Observed breaching infection control during wound care procedure |
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