The Foley Center at Chestnut Ridge

Inspectors wroteBased on observations and staff interviews, the facility failed to label and date leftover food and failed to discard food items by the expiration or used by date for 1 of 3 nourishment room refrigerators (300/400 hall) reviewed for food storage. This practice had the potential to cause foodborne illnesses.

Inspectors wroteBased on record review, and interviews with the Medical Director and staff, the facility failed to prevent a medication error when Nurse #2 administered a medication to a resident without a physician's order. On 6/21/25, Resident #92 received a 300 milligram (mg) dose of gabapentin (nerve pain medication) that was left in a medication cup labeled with Resident #94's last name. The deficient practice occurred for 1 of 6 residents reviewed for unnecessary medications (Resident #92).

Inspectors wroteBased on observation, record review, and staff interviews, the facility failed to secure an opened tube of antifungal ointment and an opened tube of zinc oxide cream for 1 of 1 resident reviewed for medication storage (Resident #80). Resident #80 was admitted to the facility on [DATE]. The quarterly Minimum Data Set (MDS) assessment dated [DATE] coded Resident #80 with intact cognition. A review of Resident #80's medical records revealed he had never been assessed for self-administration of medication. [...]

Inspectors wroteBased on record review, staff, Social Worker (SW), Nurse Practitioner (NP), and Medical Director (MD) interviews the facility failed to notify a medical provider when Resident #278 was noted by Medication Aide (MA) #1 to have difficulty breathing, had an oxygen saturation in the high 70's/low 80's (normal oxygen saturation is 92 to 100%), and was asking for help. On [DATE] at 7:00 am MA #1 was told by Nurse #2 that Resident #278 was having issues with breathing. MA #1 checked Resident #278 and noted an oxygen saturation in the high 70's/low 80's, and got the Director of Nursing (DON). The DON advised MA #1 to place Resident #278 on oxygen and continue to monitor her oxygen saturation levels. MA #1 reported Resident #278's oxygen saturation levels remained in the 80's and she appeared to be struggling to breathe and was asking for help. [...]

Inspectors wroteBased on record reviews, and Resident Representative (RR), staff, Nurse Practitioner (NP), and Medical Director (MD) interviews the facility failed to protect a Resident's right to be free from neglect when they failed to provide effective care and services to a resident experiencing a medical emergency. On [DATE] MA #1 was told by Nurse #2 that Resident #278 was not doing well. MA #1 checked Resident #278 and noted an oxygen saturation in the high 70's/low 80's (normal oxygen saturation is 92 to 100%), and got the Director of Nursing (DON). The DON advised MA #1 to place Resident #278 on oxygen and monitor oxygen saturation levels. MA #1 continued to report breathing issues and concern about Resident #278 to the DON throughout the day until Resident #278 was removed from the facility by the RR at 4:47 pm. [...]

Inspectors wroteBased on record review, and staff, Resident Representative (RR), Social Worker (SW), Nurse Practitioner (NP), and Medical Director (MD) interviews Based on record review, and staff, Resident Representative (RR), Social Worker (SW), Nurse Practitioner (NP), and Medical Director (MD) interviews the facility failed to complete and document on-going thorough assessments for an acute change in condition and failed to respond effectively to a medical emergency. On [DATE] at 7:00 pm, Resident #278's Representative requested a chest x-ray, when Nurse #1 observed Resident #278 had a cough, congestion, and decreased appetite. Resident #278 was seen by the NP on [DATE] who ordered an oral medication for breaking up mucous/congestion every 12 hours and nebulizer breathing treatments four times a day were ordered for 7 days for a cough. [...]

Inspectors wroteBased on record review, Resident Representative (RR), staff, Nurse Practitioner (NP) interviews, the facility failed to address a resident's pain after a resident requested pain medication and was observed screaming in pain, crying, and very upset by Nurse #10 on [DATE]. The deficient practice occurred for 1 of 3 residents (Resident #279) reviewed for pain.

Inspectors wroteBased on record review and facility staff and Power of Attorney interviews, the facility failed to follow their abuse, neglect, and exploitation policies when they failed to immediately remove a nurse aide (Nurse Aide #10) from the facility following a reported allegation of potential abuse involving a resident (Resident #41). This resulted in the facility failing to protect the resident or other residents from potential further abuse. The facility also failed to thoroughly investigate an allegation of misappropriation of resident property involving Resident #26. This occurred for 2 of 4 residents reviewed for Abuse.

Inspectors wroteBased on record review and facility staff interviews, the facility failed to request a Pre-admission Screening and Resident Review (PASARR) review for a resident who was newly diagnosed with psychosis for 1 of 1 resident reviewed for level II PASARR. (Resident #50)

Inspectors wroteBased on observations, record review, Resident, staff, Nurse Practitioner (NP), and Medical Director (MD) the facility failed to have a documented diagnosis for the use of an indwelling urinary catheter (Resident #18) and facility failed to prevent urinary catheter bags from touching the floor to reduce the risk of infection (Resident #48) for 2 of 2 residents (Resident #18 and Resident #48) reviewed for urinary catheter.

Inspectors wroteBased on observations, record review, and staff interviews, the facility failed to have cautionary oxygen signage posted (Resident #15) and failed to keep an oxygen concentrator free from dust and debris (Resident #37) for 2 of 3 residents reviewed for respiratory care.

Inspectors wroteBased on observations, record review, staff, Nurse Practitioner (NP), and Medical Director (MD) interviews the facility failed to maintain a medication error rate of less than 5% by having 10 errors out of 25 opportunities which resulted in a 40% medication error rate. This affected 1 of 11 residents observed on medication pass (Resident # 286).

Inspectors wroteBased on observations and staff interviews, the facility failed to label and date open food items and discard items that were beyond their expiration date in 1 of 1 walk in refrigerators and 2 of 3 reach in refrigerators in the kitchen.

Inspectors wroteBased on record review and staff interviews, the facility failed to treat a resident with dignity and respect when a nurse aide was witnessed with her hand raised to a cognitively impaired resident's face during an interaction in the resident's room for 1 of 4 residents reviewed for dignity (Resident #41). A reasonable person would not like someone raising a hand in front of their face.

Inspectors wroteBased on record review, staff interview, and Nurse Practitioner (NP) interviews the facility failed to ensure a resident's code status election was accurate throughout the medical record for 1 of 4 residents reviewed for advanced directives (Resident # 57).

Inspectors wroteBased on observations, record reviews and interviews the facility failed to implement a care plan intervention of placing a rubbery flexible sheet used to prevent sliding to a wheelchair for 1 of 4 residents (Resident #28) reviewed for accidents.

Inspectors wroteBased on record review, staff, and Nurse Practitioner (NP) interviews the facility failed to re-order medications from the pharmacy to ensure medications were available for 1 of 3 residents (Resident # 52) reviewed for the provision of pharmaceutical medications to meet residents' needs.

Inspectors wroteBased on observations, record review, staff, Nurse Practitioner (NP), and Medical Director (MD) interviews the facility failed to verify medication rights of administration, including right resident and right medication, when a nurse attempted to administer Resident #50's medications (including apixaban, a blood thinner) to Resident #286 for 1 of 11 residents reviewed for significant medication error (Resident #286).

Inspectors wroteBased on record review and staff interviews the facility failed maintain complete and accurate medical records by not ensuring the Nurse Practitioner completed a progress note after seeing a resident related to cough congestion and decreased appetite for 1 of 2 residents (Resident #278) reviewed for medical record accuracy.

Inspectors wroteBased on observations, record reviews and interviews the facility failed to implement their handwashing/hygiene policy as part of their infection control program when Nurse #7 did not perform hand hygiene when changing gloves during wound care or change gloves after removing a soiled dressing from Resident #15. The facility also failed to implement their policy for Enhanced Barrier Precautions (EBP) regarding donning Personal Protective Equipment (PPE) to include donning gloves and gowns during high contact resident care activities. Two staff were observed checking Resident #15's brief for incontinence and were not wearing gowns or gloves during the incontinence check. These failures occurred for 1 of 3 residents (Resident #15) reviewed for infection control.