Taconic Rehabilitation and Nursing at Hopewell

Inspectors wroteBased on observation and interview during a recertification survey from 2/05/2026 to 2/12/2026, the facility did not ensure that food was stored in accordance with professional standards for food service safety. Specifically, twelve (12) food items were not properly identified and dated in the kitchen refrigerators, freezers, and food storage areas.

Inspectors wroteBased on interview and record review the facility did not ensure that staff facilitated the inclusion of the resident or resident representative in all aspects of person-centered care planning that supports the resident's goals, choices, and preferences including potential for return to a community setting for one (1) of two (2) residents reviewed for Discharge. Specifically, Resident #22 was admitted on [DATE] for short term rehabilitation and there was no documented evidence that Resident #22 and/or their representative were invited to participate in the Comprehensive Care Plan meeting. Additionally, there was no documented evidence that evaluation of Resident #22's discharge needs and/or options was ongoing prior to notification of their Medicare coverage ending on 01/23/2026.

Inspectors wroteBased on observation, interview, and record review during the recertification survey and abbreviated survey (NY002683111) the facility did not ensure that grievances were resolved in a timely manner for (2) two of (4) four residents (Residents #24, and #162) reviewed for Personal Property. Specifically, 1) Resident #24 was missing a red flip phone as of 11/24/2025 and (2) Resident #162 was missing an iPhone case, and gold colored chain and cross as of 11/21/2025. Both residents were not provided with reimbursement as of 2/12/26.

Inspectors wroteBased on interview and record review the facility did not ensure that a copy of the notice of transfer or discharge was sent to the State Long Term Care Ombudsman for two (2) of three (3) residents (Resident #14, Resident #158) reviewed for Hospitalization. Specifically, 1) there was no documented evidence that a notice of transfer was sent to the New York State Ombudsman when Resident #14 was transferred to the hospital on [DATE], and 2) there was no documented evidence that a notice of transfer was sent to the New York State Ombudsman when Resident #158 was transferred to the hospital on [DATE]

Inspectors wroteBased on record review and interview the facility did not ensure accuracy of resident assessments for (1) one of (1) one resident (Resident #110) reviewed for Accidents, and (1) one of (1) one resident (Resident # 2) reviewed for Edema. Specifically, Resident #110 had documented falls on 08/09/2025 and 10/21/2025 that were not identified on their Minimum Dat Set assessments, and Resident #2 had a documented 12/04/2025 facility acquired stage three pressure ulcer that was coded on the Minimum Data Set assessment as having been present on admission to the facility.

Inspectors wroteBased on observation, interview, and record review the facility did not ensure comprehensive care plans were reviewed and revised with each assessment and as needed to reflect residents changing needs. This was evident for two (2) (Resident #4 and Resident #11) of five (5) residents reviewed for Unnecessary Medication. Specifically, 1) the cardiac care plan for Resident #4 did not address the diagnosis of atrial fibrillation and use of anticoagulants, and 2) the psychosocial care plan for Resident #11 did not address the use of antipsychotic medication.

Inspectors wroteBased on observation, record review, and interview during the recertification and abbreviated survey (623104/NY00345976), the facility did not ensure each resident received care, consistent with professional standards of practice, to treat and/or prevent pressure ulcers for two (2) of seven (7) (Residents #13 and Resident #143) reviewed for Pressure Ulcers. Specifically, 1) Resident #13 who was assessed as at risk for pressure ulcers was not provided heel offload/float as per the comprehensive care plan, 2) Resident #143 who was assessed as at risk for pressure ulcers was not provided heel offload/float as per physician order and comprehensive care plan and a pressure reducing device was not provided as per comprehensive care plan.

Inspectors wroteBased on observation, interview, and record review the facility did not ensure care consistent with professional standards of practice, and the comprehensive person-centered care plan was provided for one (1) of three (3) residents (Resident #13) reviewed for Respiratory Care. Specifically, Resident #13 was administered oxygen at a liter flow greater than the current physician's order. Additionally, Certified Nurse Aide #8 did not adhere to enhanced barrier precautions when they had contact with and handled Resident #13's nasal cannula.

Inspectors wroteBased on record review and interviews during an abbreviated survey (NY00341591), the facility did not have a comprehensive patient centered care plan developed or implemented for 1 (Resident #1) out of three residents reviewed for care planning. Specifically, Resident #1 was admitted to the facility from a local hospital on [DATE] and when they came into the facility, they already had Hospice care in place from the hospital. Review of Resident #1's care plan revealed they did not have a Hospice care plan in place. The facility's policy titled Hospice Services with a revision date of 07/2025 documents that the resident and family participate in developing the care plan where appropriate and that nursing coordinates the plan of care and ongoing collaboration and communication closely with Hospice, the resident and family, and other disciplines. [...]

Inspectors wroteBased on record review, and interviews conducted during the abbreviated Survey (NY00341591), the facility did not provide services in accordance with professional standards of care. Specifically, for one (Resident #1) of three residents reviewed for Hospice, Resident #1 was receiving Hospice care from an outside agency; however, the resident record contained no documentation, orders, progress notes, medical provider notes, or care plans addressing the Hospice care. The facility policy titled Hospice Services last revised 07/2025 documented that nursing coordinates the plan of care and ongoing collaboration and communication closely with Hospice, the resident and family, and other disciplines. [...]

Inspectors wroteBased on record review and staff interviews, the facility did not provide evidence that care plan interventions were consistently carried out for the resident reviewed for pressure injuries. Specifically, Resident #1 who was admitted with a deep tissue injury, had an intervention to turn and position every two hours which wasn't consistently documented indicating this intervention was not properly performed. Review of the policy titled Documentation of Pressure Ulcer and Chronic Wounds last revised 6/2023 documented that Pressure ulcers and chronic wounds are monitored closely to monitor effectiveness of treatment and change in risk factors. [...]

Inspectors wroteBased on record review and interviews during an abbreviated survey (NY00341591), the facility did not have a resident's total program of care created, specifically orders for Hospice were never entered by the medical provider for one (Resident #1) of three residents reviewed for Hospice. Specifically, Resident #1 was admitted on [DATE] and was on Hospice care from their prior facility and the Physician has no progress note addressing this and there are no orders to continue Hospice care for Resident #1 who was being seen regularly by the outside Hospice provider. The facility policy titled Hospice Services with a revision date of 07/2025 document that there is a collaborative effort between Hospice and the facility for residents with life-limiting illnesses. The Facility will maintain a written agreement with Hospice. [...]

Inspectors wroteBased on observations, record review, and interviews conducted during an abbreviated survey (NY00359790/623106), the facility did not ensure that the residents had a right to a safe, clean, comfortable, and homelike environment, including housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for 5 (Resident #5, #6, #7, #8 and #9) of 9 residents rooms observed for environmental concerns. Specifically, 1) In room [ROOM NUMBER]B of the Roosevelt unit, occupied by Resident #5, a new admit, the window was observed to have gray duct tape covering the entire bottom width of the windowsill. The window screen contained multiple ripped holes of varying sizes, several spackle paste were noted on the wall behind the Resident's bed, and the dresser drawer was broken and unable to close; [...]

Inspectors wroteBased on record review and interviews conducted during an abbreviated Survey (NY00380249/623119, NY00382698/623133 ), the facility did not ensure that Certified Nurse Aides had the appropriate competencies and skills sets necessary to care for residents' needs, and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments, and described in the plan of care. Specifically, 1) Certified Nurse Aide #1 was involved in an allegation of abuse on 05/07/2025. Review of their employee file revealed Certified Nurse Aide #1's required abuse training was last completed on 06/19/2025. Prior to that, the last abuse training was completed on 03/14/2024. [...]

Inspectors wroteBased on record review, and interviews conducted during an abbreviated survey (NY00348484/623066), the facility did not ensure residents received quality of care in accordance with professional standards of practice for 1 (Resident #4) of 4 residents reviewed. Specifically, Resident #4 had an unwitnessed fall on 03/24/2024 which resulted in a pelvic and iliac crest fracture. The hospital discharge instructions documented for Resident #4 to be non-weight bearing to the right lower extremity and to follow up with the orthopedic surgeon in 2-4 weeks. The facility was unable to provide documented evidence that Resident #4's follow-up appointment with the orthopedic surgeon as per the hospital physician's discharge instructions was done.

Inspectors wroteBased on observations, interviews, and record review conducted during the recertification survey from 5/01/2023 to 5/08/2023, the facility did not ensure they provided a safe, clean, comfortable, and homelike environment on 3 of 3 units. Specifically, gray markings were noted on a resident room ceiling, an air vent was dusty/dirty/chipped/scratched, and peeling paint, peeling wallpaper, and broken bathroom floor tiles were observed.

Inspectors wroteBased on observations, interviews, and record review conducted during the recertification survey from 5/1/2023 to 5/8/2023, the facility failed to store drugs and biologicals in accordance with currently accepted professional principles. Specifically, 1) Expired drugs and biologicals were found in 2 of 3 medication storage rooms (Boscobel and Roosevelt units) and 4 of 6 medication carts (2 medication carts on the Boscobel unit and 1 medication cart on the Roosevelt unit) reviewed for medication storage and labeling; and 2) Medications were stored improperly and left out on a resident's bedside table (Resident #94).

Inspectors wroteBased on observations, record reviews and interviews during a Recertification Survey conducted from 5/1/2023-5/08/2023, the facility did not ensure 9 of 9 residents were treated in a dignified manner while dining (Residents #51, #106, #46, #20, #5, #79, #63, #37 and #72). Specifically, a Licensed Practical Nurse (LPN) was observed standing over Resident #51 while feeding the resident; four staff members (Certified Nurse Aides (CNA) #5, #3, #6 and Activity Aide #1) were observed pointing to Residents #46 and #106 and referred to them as feeders; Resident #37 was served a meal 8 minutes after their tablemate was served; and staff spoke to Resident #72 in an undignified manner during a meal.

Inspectors wroteBased on observations, interviews, and record review conducted during the recertification survey from 5/1/2023 to 5/8/2023, the facility failed to ensure each resident's right to personal privacy for 1 of 4 residents (Resident #70) reviewed for dignity, and 1 of 3 nursing units ([NAME] Grove) reviewed for confidentiality of resident records. Specifically, 1) Resident #70 was not provided privacy during an ultrasound procedure and, 2)A unit roster with confidential medical record information for multiple residents was discovered visible and unattended in a public area on the [NAME] Grove unit.

Inspectors wroteBased on observation, interview, and record review conducted during a recertification survey, the facility did not ensure that the resident and/or their representative were provided a written summary of the Baseline Care Plan of the initial plan for delivery of care and services by receiving a written summary of the Baseline Care Plan within 48 hours of admission. This was evident for 1 of 26 sampled residents. Specifically, Resident #78 or their representative did not receive a written copy of their Baseline Care Plan within 48 hours.

Inspectors wroteBased on interview and record review conducted during a recertification survey, the facility did not ensure that a person-centered care plan addressing oxygen use was developed for 1 of 1 resident (Resident #55) reviewed for respiratory care. Specifically, there was a physician order for oxygen and there was no evidence in the electronic medical record (EMR) that a care plan was created for the use of oxygen.

Inspectors wroteBased on observation and interview conducted during a recertification survey conducted 5/1/2023-5/8/2023, the facility did not ensure that food was stored and prepared in a manner to prevent contamination. Specifically, sliced tomato was stored in the walk-in refrigerator in the kitchen and was not labeled with the date it was sliced and stored in the refrigerator.

Inspectors wroteBased on observation, interviews and record review conducted during a recertification survey, the facility did not ensure that sufficient staff was available to meet the needs of the residents.

Inspectors wroteBased on record review and interview during a recertification survey, the facility did not ensure that the Facility Assessment (FA) dated 04/25/2019, noted accurate bed capacity and accurate level of support required by the resident population.

Inspectors wroteBased on observation, interview and record review conducted during a recertification survey, the facility did not ensure that comprehensive person-centered care plans with measurable goals, interventions, and timeframe were put in place to address pressure ulcers and vision deficits. Specifically, 1 of 5 residents (Resident # 84) reviewed for pressure ulcers did not have a care plan in place to address her right heel Deep Tissue Injury pressure ulcer.

Inspectors wroteBased on observation, record review and interview conducted during a recertification survey, the facility did not ensure that each residents' Comprehensive Care Plan (CCP) was reviewed and revised to reflect the resident's current health status. This was evident for 1 (Resident #81) of 5 residents reviewed for accidents. Specifically, Resident #81 had a fall on 3/6/19 and the CCP was not reviewed and revised to reflect the fall and interventions developed to decrease risk for further falls.

Inspectors wroteBased on observations and interviews conducted during the Recertification Survey, it was determined that for 1 of 1 residents reviewed for Activities of Daily Living, the facility did not provide the necessary care and services to maintain personal hygiene. Specifically, personal care was not provided in a timely manner. (Residents# 49).

Inspectors wroteBased on observation, interview, and record review conducted during a recertification survey, the facility did not ensure that its medication error rate did not exceed 5% for 1 of 3 residents (Resident # 19) observed during a medication pass, for a total of 2 out of 26 opportunities for error resulting in an error rate of 7.6%.

Inspectors wroteBased on observations, record review and interview conducted during a recertification survey, the facility did not ensure food was stored in accordance with professional standards for food service safety to ensure prevention of foodborne illness. Specifically, a refrigeration unit designed for holding foods during meal service/tray line was found to have an internal thermometer reading greater than 41-degrees Fahrenheit and contain time and Temperature Controlled for Safety (TCS) foods which were not maintained at 41 degrees F or less. Additionally, expired TCS foods were stored in two (2) refrigerated units, and four (4) food storage units were not maintained in a sanitary manner.

Inspectors wroteBased on observation, interviews and record review conducted during the recertification survey, the facility did not ensure that garbage was contained and disposed of in an appropriate manner. Specifically, the trash compactor area was not maintained in a sanitary condition to prevent harborage of pests.