Fishkill Center for Rehabilitation and Nursing

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure that the resident environment remained as free of accident hazards as is possible; and that each resident received adequate supervision to prevent accidents for one (1) of three (3) residents (Resident #1) reviewed for accidents. Specifically, a review of the facility's fall risk assessment revealed that on 08/12/2025, Resident #1 was identified as a high risk for falls and further review of the resident's medical record revealed that the facility failed to implement interventions to prevent the resident from potential falls or to mitigate harm from actual falls. On 09/27/2025, Resident #1, had a fall and was found in their room on the floor and sustained a swollen right eye, a hematoma to the right side of their forehead and a scratch to their right forearm. [...]

Inspectors wroteBased on record review and interviews during an abbreviated survey (2650093), the facility did not ensure the residents representative were informed when there was a significant change in the resident's physical condition for 1 out of 3 residents (Resident #1) reviewed for notification. Specifically, Resident #1's had a fall and sustained injuries to the face, eyes and head on 09/27/2025. The family representative was not notified timely of the change in condition and physical status until they visited the resident on 10/30/2025.

Inspectors wroteBased on record review and interview during an abbreviated survey (2650093) the facility did not ensure the comprehensive care plans were reviewed, updated, and revised for 2 out of 3 residents (Resident #1, Resident #3) reviewed for care planning. Specifically, (1) Resident #1's cognitive impairment care plan had not been reviewed or updated since 10/18/2024. (2) Resident #3's cognitive impairment care plan had not been reviewed or updated since 08/27/2024.

Inspectors wroteBased on interview and record review during the recertification survey conducted on 2/10/25-2/14/25, the facility did not ensure each staff and was screened, offered the most recent COVID-19 vaccine and provided education regarding the benefits, risks and potential side effects associated with the vaccine for 10 of 10 staff reviewed for COVID vaccines. Specifically, there was no documented evidence Staff were offered, and education was provided for COVID vaccination for Dietary Aide #15, Housekeeping #16, Certified Nurse Aide #17, #18, #20, Licensed Practical Nurse #19, Registered Nurse #21, Social Worker #22, Dining Supervisor #23 and [NAME] #24.

Inspectors wroteBased on observation and interview conducted during the recertification survey, the facility did not ensure that resident's dignity was maintained. Specifically,1) residents were being served milk and water in plastic storage cups with lids on 4 of 4 units (South 1, North 1, South 2 and North 2) and 2) and Certified Nurse Assistant #7 referred to Resident #26 as a feeder. In addition, a Resident progress note in the facility Electronic Medical Record also referred to Resident #26 as a feeder.

Inspectors wroteBased on observation and interview conducted during the recertification survey, the facility did not ensure that a clean, comfortable, and homelike environment was provided. Specifically, North 2 unit rooms (S3, X1, X3, X6, V1, V3) had broken tiles, cracked walls, hanging curtains or damaged windows, the shower room had a damaged drain and the the hall window was open, resulting in the resident in room V3 offering complaints of feeling cold.

Inspectors wroteBased on observation, interview, and record review during the Recertification Survey from 2/10-2/14/25 the facility did not ensure comprehensive person centered care plans were developed for 1 of 3 residents (#37) reviewed for Limited Range of Motion. Specifically, Resident #37 did not have a care plan with goals and interventions specific to the use of a cervical collar.

Inspectors wroteBased on observations, interview, and record review during the recertification survey from 2/10/25-2/14/25, the facility did not ensure that residents receive treatment and care in accordance with professional standards of practice and the comprehensive care plan for 1 of 1 (Resident # 15) residents reviewed for pain management. Specifically, there were multiple omissions on the medication and treatment administration records for medications and treatments related to pain management for Resident #15.

Inspectors wroteBased on staff interview and record review during the recertification survey from 02/10/25 through 02/14/25, the facility did not ensure Certified Nurse Aide performance reviews were completed at least once every 12 months. Specifically, three of five Certified Nurse Aides (#2, #3, #4) did not have a performance review documented at least once every 12 months.

Inspectors wroteBased on record review and interview during the recertification and abbreviated surveys (NY00341482) conducted from 1/10/25 to 1/14/25, the facility did not ensure residents were free from significant medication errors for one of one residents (Resident #399) reviewed for Neglect and Medications. Specifically, staff administered a medication not physician prescribed to Resident #399 which resulted in Resident #399 being transferred to an acute care hospital for evaluation.

Inspectors wroteBased on observation and interview conducted during the recertification survey from 2/10/25 through 2/14/25 the facility did not ensure food was stored in accordance with professional standards for food service safety. Specifically, beverages stored in nutrition and storage refrigerator/s were not labeled and were outdated, and a parcel of flour was left open not dated on the shelf.

Inspectors wroteBased on observation, record review and interview conducted during the recertification survey conducted 2/10/25 through 2/14/25, the facility did not ensure proper disposal of garbage and refuse. Specifically, the garbage compactor /dumpster was left open and there were large metal containers, old furniture, and debris on the ground around the dumpster.

Inspectors wroteBased on record review and interview during the recertification survey conducted 02/10/25-02/14/25, the facility did not ensure each resident was offered pneumococcal immunizations and received education regarding the benefits and potential side effects of the immunizations for 2 of 5 residents (Residents #9, #50) reviewed. Specifically, there was no documented evidence Resident #9, and Resident #50 were offered, declined, or educated about the pneumococcal immunization.

Inspectors wroteBased on observation, record review and interview, during a recertification and extended survey from 1/2/2024 to 1/11/2024, the facility failed to ensure the resident environment remained as free of accident hazards as possible. Specifically, a total of 26 residents on 2 of 2 resident floors were residing in 17 rooms where space heaters were in use (room M1, M2, R6, R2, R1, O1, O2, O3, O4, Q3, Q2, N1, N2 and N3 on the locked dementia unit with residents wandering in and out of the rooms, and rooms S1, S4, and X2). Additionally, facility staff reported that at times they had seen towels placed over the space heaters. Subsequently, residents were at risk for injury with the likelihood for harm or death that was Immediate Jeopardy (IJ) to the health and safety of the facility's 151 residents.

Inspectors wroteBased on Observation, record review and interview conducted during the recertification survey (1/2/24-1/11/24) the facility did not ensure that operative oversight for an effective system was in place to maintain health, safety, and the highest practicable well-being of residents reviewed for accidents. Specifically, space heaters were in use for 26 residents in 17 rooms (M1, M2, N1, N2, N3, R1, R2, R6, O1, O2, O3, O4, Q2, and Q3 on the locked dementia unit with residents wandering in and out of the rooms) and rooms S1, S4, X2.

Inspectors wroteBased on observation, record review, and interviews conducted during the recertification survey (1/2/2024-1/11/2024), it was determined the governing body did not establish and implement policies regarding the management and operation of the facility. The governing body did not maintain consistent communication with the Administrator who was responsible for the management of the facility to ensure regulatory compliance. Specifically, multiple deficiencies were identified on the recertification survey including in the areas of accidents and hazards (F689), and space heaters not permitted (K781).

Inspectors wroteBased on observations, interviews, and record review during a recertification survey 1/02/2024-1/11/2024, the facility did not ensure residents had the right to a dignified existence for 6 residents (#38, #69. #80, #139 #82 and #98) observed during dining observation. Specifically, Residents #38, #69 and #80, were observed being fed by staff while staff were standing over the residents, Resident # 139 was heard being called a feeder by staff and Residents #82 and #98 had blood drawn in the common diningroom/dayroom while in the presence of other residents.

Inspectors wroteBased on record review and interview conducted during the recertification and abbreviated surveys (# NY00320640) from 1/2/2023 to 1/11/2024, the facility did not ensure all injuries of unknown origin were thoroughly investigated for 1 of 2 residents reviewed for abuse. Specifically, Resident #54 had an injury of unknown origin was not thoroughly investigated to rule out abuse. The investigation did not include interviews or statements from staff working with the resident.

Inspectors wroteF657 Based on record review and interview conducted during the recertification survey, from 1/2/24 through 1/11/24, the facility did not ensure that the comprehensive care plan was reviewed and revised in timely manner for 1 of 3 residents (Resident #69), reviewed for care planning revision. Specifically, Resident #69's care plan was not updated as planned to reflect the need of a 2 person assist for personal cares after a fall.

Inspectors wroteBased on observation, interview and record review conducted during a recertification survey from 1/2/24 to 1/11/24, the facility did not ensure residents received the necessary assistance for bathing to maintain personal hygiene for 2 of 4 residents (Residents #12 and #88), reviewed for activities of daily living (ADLs). Specifically, Resident #12 and #88 did not receive twice weekly showers as scheduled.

Inspectors wroteBased on observations, record review and interviews conducted during the recertification survey from 1/2/2024 through 1/11/2024, the facility did not ensure 1 of 1 resident (Residents #100) reviewed for pressure ulcers, received care and services to promote healing and to prevent new pressure ulcers from developing. Specifically, Resident #100 was observed on multiple occasions not wearing their heel lift suspension booties and oxygen tubing ear protectors as per physician orders.

Inspectors wroteBased on observation, record review and interview conducted during a Recertification Survey from 1/2/24-1/11/24, the facility did not ensure that all drugs and biologicals were stored in accordance with professional standards. Specifically, medication carts on the S1 unit were observed unlocked and unattended on 2 separate occasions, and morning medicines were left in Resident #99's room.

Inspectors wroteBased on record review and staff interview conducted during a complaint survey (#NY00290874), it could not be ensured that the facility developed a person-centered care plan that included measurable objectives, time frames and interventions in order to maintain the residents ' safety for 1 of 1 resident reviewed for physical abuse. Specifically, no comprehensive care plan was found in the record to address the risk for abuse for the resident who had been identified as displaying behaviors, had mood scores indicating moderate or moderately severe depression, brief interview for mental status scores indicating moderately impaired cognition, diagnoses of progressive neurological condition, anxiety, and depression, and functional limitations in activities of daily living.

Inspectors wroteBased on record review and interviews conducted during an abbreviated survey (NY00316307), the facility did not ensure that a resident received adequate supervision and assistance to prevent accidents for one of three residents (Resident #1) reviewed for accidents. Specifically, Resident #1 had multiple incidents of falls in the facility and the interventions in place to prevent falls was not reevaluated to prevent subsequent falls. Fall risk assessments were not updated after falls. On [DATE], Resident #1 fell and refractured their left hip which was repaired on [DATE]. Facility X-Ray findings documented Resident #1 sustained an acute markedly midshaft displaced fracture of the left mid femur. Resident #1 was discharged to the emergency room for higher level of care.

Inspectors wroteBased on observation, interview, and record review conducted during a recertification survey, the facility did not ensure that care was provided in a manner to maintain dignity for 1 of 1 resident (Resident # 87) reviewed for urinary catheter. Specifically, the resident's urinary drainage bag and tubing were not concealed to prevent direct observation by other residents and visitors.

Inspectors wroteBased on observation record review and interview the facility did not ensure that care plan interventions were implemented for resident #123. Specifically, a positioning device identified in the care plan was not provided to the resident on a consistent basis. This was evident for 1 of 2 residents reviewed for position/mobility.

Inspectors wroteBased on observations, interviews and record reviews conducted during a recertification survey, it was determined that for one (Resident #55) of two residents reviewed for respiratory care, the facility did not ensure that each resident received the proper respiratory treatment and care consistent with professional standards of practice, and the comprehensive person-centered care plan. Specifically, the resident was being administered oxygen at a liter flow greater, and at a frequency greater than the current physician's order.

Inspectors wroteBased on observations, interview and record review during the most recent recertification, the facility did not ensure that medications were secured in a locked storage area. Specifically, a medication cup with 4 pills was observed on a resident's bed not under direct supervision of authorized staff.

Inspectors wroteBased on observation and interview during the recent recertification survey, the facility did not ensure that food items brought in for residents from the outside were labeled and dated appropriately and discarded within the required time frame. This was evident for 2 of 4 resident units.

Inspectors wroteBased on observation, interview and record review conducted during the most recent re-certification survey, the facility did not ensure that care was provided in a manner to minimize the spread of infection. This was evident during the care of 1 resident (Resident #128) reviewed for transmission based infection and for 1 of 3 residents (Resident #390) reviewed for pressure sores. Specifically, 1) a certified nurse aide did not implement the use of personal protective equipment (PPE) while providing care to Resident #128 on contact precautions for Clostridium (C.) difficile; and 2) a Licensed Practical Nurse (LPN #1) did not follow proper procedure in hand hygiene and prevention of cross contamination during a wound care procedure.