Foltsbrook Center for Nursing and Rehabilitation

Inspectors wroteBased on observations, record review, and interviews during the recertification survey conducted 1/23/2025-1/29/2025, the facility did not ensure residents had the right to a safe, clean, comfortable, and homelike environment for the Physical Therapy gym and for 2 of 5 resident units (Units 1 and 4) reviewed. Specifically, the Physical Therapy gym, Unit 1, and Unit 4 had several walls with patched holes and missing paint.

Inspectors wroteBased on observation and interviews during the recertification survey conducted 1/23/2025-1/29/2025, the facility did not ensure residents were provided food and drink that was palatable, flavorful, and at an appetizing temperature for 2 of 2 meals reviewed (the 1/24/2025 2nd floor lunch meal and the 1/27/2025 1st floor lunch meal). Specifically, food was not flavorful and was not served at palatable and appetizing temperatures during the lunch meals on 1/24/2025 and 1/27/2025. Additionally, two residents (Residents #24 and #35) stated the food did not taste good and they did not receive enough food.

Inspectors wroteBased on observations, record review, and interviews during the recertification survey conducted 1/23/2025-1/29/2025, the facility did not ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety for 1 of 1 main kitchen. Specifically, the main kitchen had soiled and poorly maintained equipment and improper food and food product storage.

Inspectors wroteBased on observations, record review, and interviews during the recertification survey conducted 1/23/2025-1/29/2025, the facility did not maintain an effective pest control program so that the facility was free of pests for multiple resident areas on 1 of 5 resident units (5th floor) reviewed. Specifically, there were fruit flies on the 5th floor.

Inspectors wroteBased on observation, interview, and record review during the recertification survey conducted 1/23/2025-1/29/20254, the facility did not ensure the right to reside and receive services with reasonable accommodation of resident needs and preferences for 1 of 1 resident (Resident #4) reviewed. Specifically, Resident #4 was not provided with a meal before going to outside dialysis (filtering of blood during kidney failure) appointments.

Inspectors wroteBased on observations, record review. and interviews during the recertification and abbreviated (NY00361906 and NY00351460) surveys conducted 1/23/2025-1/29/2025, the facility did not ensure residents who were unable to carry out activities of daily living received the necessary services to maintain grooming and personal hygiene for 2 of 5 residents (Resident #116 and #226) reviewed. Specifically, Resident #116 was not shaved, and Resident #226 was not shaved and groomed.

Inspectors wroteBased on observation, record review, and interviews during the recertification and abbreviated (NY00351460) surveys conducted 1/23/2025-1/29/2025, the facility did not ensure residents with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote wound healing, prevent infection, and prevent new ulcers from developing for 1 of 3 residents (Resident #115) reviewed. Specifically, there was no documented evidence of a Comprehensive Care Plan for Resident #115's two Stage 2 (partial thickness tissue loss) pressure ulcers. Additionally, the resident had an alternating air pressure relieving mattress (a mattress with air filled cells that inflate and deflate to redistribute pressure) that was not set to their correct weight.

Inspectors wroteBased on observations and interviews during the recertification survey conducted 1/23/2025-1/29/2025, the facility did not ensure drugs and biologicals were labeled and stored in accordance with currently accepted professional principles and included the expiration date when applicable for 3 of 5 medication carts (1st, 2nd, and 4th floor medication carts), and 1 of 5 treatment carts (1st floor treatment cart). Specifically, the 1st and 4th floor medication carts and the 1st floor treatment cart were left unattended and unlocked; and the 2nd floor medication cart contained 3 insulin pens without an opened or expired/discard date.

Inspectors wroteBased on observations, record review, and interviews during the recertification survey conducted 1/23/2025-1/29/2025, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 4 residents (Resident #112) reviewed, and for 1 of 1 staff bathroom (the basement breakroom bathroom) reviewed. Specifically, Certified Nurse Aide #26 did not use appropriate personal protective equipment when providing care to Resident #112 who was on transmission based precautions (droplet precautions) for influenza; and the soap dispenser in the women's bathroom located off the facility breakroom in the basement was not functional.

Inspectors wroteBased on record review and interviews during the abbreviated survey (NY00365213), the facility failed to honor advance directive wishes for 1 of 3 residents (Resident #1) reviewed. Specifically, cardiopulmonary resuscitation (attempt to restart the heart) was implemented on Resident #1 when it was established they were unresponsive and without a pulse before their advance directive wishes were determined; once their advance directives were determined to be do not resuscitate (withhold cardiopulmonary resuscitation and allow a natural death) based on their Medical Orders for Life Sustaining Treatment, cardiopulmonary resuscitation ceased, only to be resumed due to staff appearing on scene and misunderstanding the resident's advance directives. [...]

Inspectors wroteBased on observation, record review, and interview during the recertification and abbreviated (NY00290691) surveys conducted 6/22/23-6/30/23, the facility did not ensure residents had the right to a safe, clean, comfortable, and homelike environment for 5 of 5 occupied resident floors (1st, 2nd, 3rd, 4th, and 5th floors) and for 1 of 1 resident (Resident #53) reviewed. Specifically, there were unclean floors, unclean surfaces, damaged walls, damaged floors on the 1st, 2nd, 3rd, 4th, and 5th floors; resident room [ROOM NUMBER] was cluttered with various items; Resident #53's call light was not within their reach; and there were unacceptable noise levels on the 4th floor.

Inspectors wroteBased on observation, record review, and interview during the recertification survey conducted 6/22/23-6/30/23, the facility did not ensure they provided each resident with a nourishing, palatable, well-balanced diet that meets daily nutritional and special dietary needs, taking into consideration the preferences of each resident for 3 of 8 residents (Residents #5, 7, and 80) reviewed, and 2 of 2 meal test trays (1 lunch and 1 dinner tray) observed. Specifically: - 1 lunch tray and 1 dinner tray had hot and cold food items that were not maintained at safe temperatures and the food did not taste appetizing or palatable; - Resident #80 did not receive food items listed on their meal ticket and had food items they were not supposed to have; - Resident #7 did not receive food items listed on their meal ticket; [...]

Inspectors wroteBased on observation, interview, and record review during the recertification survey conducted 6/22/23-6/30/23, the facility did not ensure residents were provided an ongoing program to support their choice of activities, designed to meet their interests and support their physical, mental, and psychosocial well-being for 1 of 1 resident (Resident #62) reviewed. Specifically, Resident #62 was not offered meaningful activities that included their interests and preferences.

Inspectors wroteBased on observation, record review and interview during the recertification survey conducted 6/22/23-6/30/23, the facility did not ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 1 resident (Resident #90) reviewed. Specifically, Resident #90's urinary catheter (removes urine from the bladder into a collection bag) was observed hanging above the level of their bladder for multiple observations, potentially causing urine backflow and risk of infection.

Inspectors wroteBased on observation, record review, and interview during the recertification and abbreviated (NY00317917) surveys conducted 6/22/23-6/30/23, the facility did not ensure a resident who needed respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 1 resident (Resident #27) reviewed. Specifically, Resident #27 was administered oxygen (O2) without a medical order.

Inspectors wroteBased on observation, interview, and record review during the recertification survey conducted 6/22/23-6/30/23, the facility did not ensure that residents who displayed or were diagnosed with a mental disorder or psychosocial adjustment difficulty, received appropriate treatment and services to correct the assessed problem to attain the highest practicable mental and psychosocial well-being for 1 of 1 resident (Resident #12) reviewed. Specifically, Resident #12 exhibited symptoms of depression and grief following the death of their spouse and continued need for long-term care and did not receive routine psychiatric evaluations or mental health counseling as planned.

Inspectors wroteBased on observation, record review and interview during the recertification and abbreviated surveys (NY00269612 and NY00272726) conducted on 6/1/21- 6/9/21, the facility did not ensure the environment remained as free of accident hazards as possible and that each resident received adequate supervision and assistive devices to prevent accidents for 2 of 4 residents (Residents #93 and #141) reviewed. Specifically, - Resident #93, who had intact cognition and a diagnosis of quadriplegia (paralysis), sustained burns from food/beverages on multiple occasions. On 1/2/21, the resident microwaved soup and spilled it on their leg causing a 9.5 by 5.5 centimeter second-degree burn, which is currently a non-healing wound. On 1/9/21, Resident #93 microwaved a beverage and spilled it, sustaining a cluster of blisters on their abdomen. [...]

Inspectors wroteBased on observation, interview, and record review during the recertification and abbreviated surveys (NY00250434) ending on 6/9/21, the facility did not provide food and drink that was palatable, attractive, and at a safe and appetizing temperature for 4 of 4 meal trays tested. Specifically, food was not served at palatable and safe temperatures.

Inspectors wroteBased on observation, interview, and record review conducted during the recertification and abbreviated (NY00250434) surveys completed on 6/9/21, the facility did not store, prepare, distribute and serve food in accordance with professional standards for 1 of 1 commercial dishwasher and for 1 of 8 meals (6/6/21 lunch meal) observed Specifically, the commercial dishwasher was not functioning as designed and needed to be used as a low temperature machine versus a high temperature machine. The sanitizer was not being pumped into the machine to complete the sanitization step for the dishes and utensils used in the facility. Additionally, the 4th floor lunch meal on Sunday 6/6/21 was served 45 minutes late due to insufficient staffing.

Inspectors wroteBased on observation, record review, and interview during the recertification survey completed on 6/9/2021, the facility did not ensure that residents received treatment and care in accordance with professional standards of practice for 1 of 4 residents (Resident #84) reviewed. Specifically, Resident #84 had a change in condition including a swollen tongue and dysphagia (difficulty swallowing) that was not addressed timely.

Inspectors wroteBased on observation, interview, and record review during a recertification survey conducted from 6/1/2021 to 6/9/2021, the facility did not ensure that residents maintained acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible for 2 of 8 residents (Residents #52 and #80) reviewed. Specifically, Residents #52 and #80 had significant weight loss and were not reassessed timely by clinical nutrition staff and there was no documented evidence the medical provider was made aware of the weight loss when it occurred.

Inspectors wroteBased on observation, interview, and record review during the recertification survey ending on 6/9/21, the facility did not ensure drugs and biologicals were stored and labeled in accordance with currently accepted professional standards, and the expiration date when applicable for 2 of 4 medication rooms (Units 3 and 4) and 2 of 4 medication carts (Units 3 and 5) reviewed. Specifically, on Unit 3 the medication cart had an opened expired stock medication bottle and the medication room refrigerator had an opened expired biological vial. The Unit 4 medication room had 2 expired unopened stock medications and the Unit 5 medication cart had 2 expired opened stock medications.

Inspectors wroteBased on observation, interview and record review during the recertification survey ending 6/9/21, the facility did not ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences for 2 of 3 residents (Residents #62 and138) reviewed. Specifically, Resident #138 did not like tuna fish and was served tuna fish sandwiches at multiple meals and Resident #62 was not provided their choice of salad dressing.

Inspectors wroteBased on observation, interview, and record review during the recertification survey ending on 6/9/21, the facility did not provide special eating equipment for residents who need them and appropriate assistance to ensure that the resident can use the assistive devices when consuming meals and snacks for 1 of 1 resident (Resident #77) reviewed. Specifically, Resident #77 was not provided a Dycem mat (a non-slip material used to stabilize items) when eating as ordered.

Inspectors wroteBased on record review and interview during the recertification survey ending [DATE], the facility did not ensure services were provided in compliance with all applicable Federal, State, and local laws, regulations, and codes for 1 of 1 resident (Resident #99) reviewed. Specifically, the facility did not follow requirements for completing Resident #99's Medical Orders for Life-Sustaining Treatment (MOLST).

Inspectors wroteBased on observation, record review and interview during the recertification survey completed on 6/9/2021, the facility did not establish and maintain an infection prevention and control program to ensure the health and safety of residents and to prevent the transmission of COVID-19 for 12 residents (Residents #20, 29, 35, 43, 44, 60, 88, 108, 109, 123, 125, and 136) observed during a meal service. Specifically, a certified nurse aide (CNA) was observed serving residents their beverages during the lunch meal at a distance closer than 6 feet with their surgical mask not covering their nose and mouth.

Inspectors wroteBased on interview and record review during the recertification survey ending on 6/9/21, the facility did not inform each resident before, or at the time of admission, and periodically during the resident's stay, of services available in the facility and of charges for those services, including any charges for services not covered under Medicare for 2 of 3 residents (Residents #56 and 60) reviewed. Specifically, Resident #56 and 60 did not receive CMS (Centers for Medicare and Medicaid Services) Form 10055 (Skilled Nursing Facility Advance Beneficiary notice of Non-coverage, SNF-ABN) at the end of their Medicare A stay. This is evidenced by: The 9/2020 Form CMS-10055 documents the resident's care may not be covered by Medicare and they may have to pay out of pocket for care. The following options are listed: 1) I want the care listed above. [...]