Inspection Reports for
Fishkill Center for Rehabilitation and Nursing
22 Robert R. Kasin Way, Beacon, NY, 12508
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
13.6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
167% worse than New York average
New York average: 5.1 deficiencies/yearDeficiencies per year
28
21
14
7
0
Inspection Report
Abbreviated Survey
Deficiencies: 3
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.
Deficiencies (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
Annual Inspection
Deficiencies: 3
Date: Feb 14, 2025
Visit Reason
The inspection was a recertification survey conducted to assess compliance with regulatory requirements for Fishkill Center for Rehabilitation and Nursing.
Findings
The facility was found to have environmental maintenance issues including broken tiles, cracked walls, and open windows causing discomfort to residents. Additionally, Certified Nurse Aide performance reviews were not completed for several aides within the required 12-month period. A significant medication error occurred where a resident was administered medication not prescribed to them, resulting in hospital transfer.
Deficiencies (3)
F 0584: The facility failed to maintain a safe, clean, and homelike environment; broken tiles, cracked walls, hanging curtains, damaged windows, and an open hallway window caused resident discomfort.
F 0730: The facility did not ensure Certified Nurse Aide performance reviews were completed at least once every 12 months for three of five aides reviewed.
F 0760: The facility failed to ensure residents were free from significant medication errors; a resident was given methadone not prescribed to them, resulting in hospital transfer.
Report Facts
Certified Nurse Aides without performance reviews: 3
Medication error incident date: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse #9 | Registered Nurse | Named in medication error finding for administering wrong medication to Resident #399. |
| Licensed Practical Nurse #8 | Licensed Practical Charge Nurse | Interviewed regarding medication error and resident condition. |
| Director of Nursing | Director of Nursing | Reported and investigated medication error and coordinated follow-up. |
| Assistant Director of Nursing | Assistant Director of Nursing | Interviewed regarding Certified Nurse Aide performance reviews. |
| Human Resource Director | Human Resource Director | Interviewed regarding responsibility for Certified Nurse Aide performance reviews. |
Inspection Report
Annual Inspection
Deficiencies: 10
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.
Deficiencies (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
Complaint Investigation
Capacity: 60
Deficiencies: 12
Date: Feb 14, 2025
Visit Reason
Complaint Survey with 10 health and 2 life safety citations including deficiencies in immunizations, care plans, food sanitation, resident rights, and fire safety systems. All deficiencies corrected by April 15, 2025 or March 3, 2025.
Findings
Complaint Survey with 10 health and 2 life safety citations including deficiencies in immunizations, care plans, food sanitation, resident rights, and fire safety systems. All deficiencies corrected by April 15, 2025 or March 3, 2025.
Deficiencies (12)
Covid-19 immunization — Standard Health Inspection Citation
Develop/implement comprehensive care plan — Standard Health Inspection Citation
Dispose garbage and refuse properly — Standard Health Inspection Citation
Food procurement, store/prepare/serve-sanitary — Standard Health Inspection Citation
Influenza and pneumococcal immunizations — Standard Health Inspection Citation
Nurse aide perform review-12 hr/yr in-service — Standard Health Inspection Citation
Quality of care — Standard Health Inspection Citation
Resident rights/exercise of rights — Standard Health Inspection Citation
Residents are free of significant med errors — Standard Health Inspection Citation
Safe/clean/comfortable/homelike environment — Standard Health Inspection Citation
Fire alarm system - testing and maintenance — Standard Life Safety Code Citation
Hazardous areas - enclosure — Standard Life Safety Code Citation
Inspection Report
Annual Inspection
Deficiencies: 1
Date: Jan 11, 2024
Visit Reason
The inspection was conducted as a recertification survey to assess compliance with care standards, specifically focusing on residents' activities of daily living and bathing assistance.
Findings
The facility failed to ensure that two residents received the scheduled twice-weekly showers, with documentation showing inconsistent bathing and showering and staff citing staffing shortages as a reason for missed showers.
Deficiencies (1)
F 0677: The facility did not provide necessary assistance for bathing to maintain personal hygiene for two residents, who did not receive twice weekly showers as scheduled. Documentation and interviews revealed many missed showers and inconsistent bathing records.
Report Facts
Residents affected: 2
Shower documentation missing weeks: 6
Shower documentation one shower weeks: 4
Shower documentation two showers week: 1
Bathing not documented date ranges: 7
Inspection Report
Annual Inspection
Deficiencies: 9
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.
Deficiencies (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
Complaint Investigation
Capacity: 60
Deficiencies: 17
Date: Jan 11, 2024
Visit Reason
Complaint Survey with 10 health and 7 life safety citations including deficiencies in ADL care, administration, care plans, accident hazards, resident rights, and fire safety. One immediate jeopardy citation corrected by February 19, 2024.
Findings
Complaint Survey with 10 health and 7 life safety citations including deficiencies in ADL care, administration, care plans, accident hazards, resident rights, and fire safety. One immediate jeopardy citation corrected by February 19, 2024.
Deficiencies (17)
ADL care provided for dependent residents — Standard Health Inspection Citation
Administration — Standard Health Inspection Citation
Care plan timing and revision — Standard Health Inspection Citation
Department criminal history review — Standard Health Inspection Citation
Free of accident hazards/supervision/devices — Standard Health Inspection Citation
Governing body — Standard Health Inspection Citation
Investigate/prevent/correct alleged violation — Standard Health Inspection Citation
Label/store drugs and biologicals — Standard Health Inspection Citation
Resident rights/exercise of rights — Standard Health Inspection Citation
Treatment/svcs to prevent/heal pressure ulcer — Standard Health Inspection Citation
Discharge from exits — Standard Life Safety Code Citation
Exit signage — Standard Life Safety Code Citation
Organization and administration — Standard Life Safety Code Citation
Physical environment — Standard Life Safety Code Citation
Plan based on all hazards risk assessment — Standard Life Safety Code Citation
Portable space heaters — Standard Life Safety Code Citation
Sprinkler system - installation — Standard Life Safety Code Citation
Inspection Report
Complaint Investigation
Deficiencies: 1
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.
Deficiencies (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
Complaint Investigation
Capacity: 60
Deficiencies: 1
Date: Dec 29, 2023
Visit Reason
Complaint Survey with 1 health citation for developing and implementing a comprehensive care plan, corrected by April 16, 2024.
Findings
Complaint Survey with 1 health citation for developing and implementing a comprehensive care plan, corrected by April 16, 2024.
Deficiencies (1)
Develop/implement comprehensive care plan — Standard Health Inspection Citation
Inspection Report
Abbreviated Survey
Deficiencies: 1
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.
Deficiencies (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
Complaint Investigation
Capacity: 60
Deficiencies: 1
Date: Oct 25, 2023
Visit Reason
Complaint Survey with 1 health citation for free of accident hazards/supervision/devices, corrected by November 21, 2023.
Findings
Complaint Survey with 1 health citation for free of accident hazards/supervision/devices, corrected by November 21, 2023.
Deficiencies (1)
Free of accident hazards/supervision/devices — Standard Health Inspection Citation
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 1
Date: May 25, 2023
Visit Reason
Complaint Survey with 1 health citation for free from abuse and neglect, corrected by June 20, 2023.
Findings
Complaint Survey with 1 health citation for free from abuse and neglect, corrected by June 20, 2023.
Deficiencies (1)
Free from abuse and neglect — Standard Health Inspection Citation
Inspection Report
Abbreviated Survey
Deficiencies: 1
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.
Deficiencies (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
Capacity: 60
Deficiencies: 1
Date: Feb 28, 2022
Visit Reason
Covid-19 Survey with 1 health citation for reporting to national health safety network, not corrected as of report date.
Findings
Covid-19 Survey with 1 health citation for reporting to national health safety network, not corrected as of report date.
Deficiencies (1)
Reporting - national health safety network — Standard Health Inspection Citation
Inspection Report
Annual Inspection
Deficiencies: 6
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.
Deficiencies (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 |
Inspection Report
Capacity: 60
Deficiencies: 0
Visit Reason
Two inspections with no citations reported.
Findings
Two inspections with no citations reported.
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