Foltsbrook Center for Nursing and Rehabilitation

In the surveyor’s words

From the most serious findings on record at Foltsbrook Center for Nursing and Rehabilitation, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Jun 9, 2021

  Based on observation, record review and interview during the recertification and abbreviated surveys (NY 612 and NY 726) 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 [CONDITION(S)] (paralysis), sustained [CONDITION(S)] 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. […]

• Actual harm, isolatedF689Oct 18, 2021

  Based on observation, record review, and interview during the abbreviated surveys (NY 768 and NY 093) conducted on 10/18/21, the facility failed to provide adequate supervision to prevent accidents (resident to resident incidents) for 3 of 5 (Resident #2, 3 and 4) residents reviewed. Specifically, - Residents #2 was not protected from physical abuse from Resident #1 when Resident #1 hit Resident #2 over the head with a wheelchair leg rest causing a head laceration. - Resident #1 was moved to a different unit and a plan was not implemented to prevent abuse. Resident #1 struck Resident #3, causing a sprained finger, a contusion of the chest wall, and injury of the head. - Resident #4 exhibited behaviors in the dining room and was physically abusive towards Resident #5. […]

• No harm, potential for more than minimal, widespreadF804Jun 9, 2021

  Based on observation, interview, and record review during the recertification and abbreviated surveys (NY 434) 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. Findings include: The undated Food Temperature Policy documented once food was placed in the steam table staff would take and record the temperature of the items on the Temperature Log Sheet. The undated Temperature Log Sheet documented the following acceptable temperatures: - Entrees 160 degrees Fahrenheit (F); and - All cold foods should be 45 degrees F or below. […]

• No harm, potential for more than minimal, widespreadF812Jun 9, 2021

  Based on observation, interview, and record review conducted during the recertification and abbreviated (NY 434) 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. […]

• No harm, potential for more than minimal, patternF584Jan 29, 2025

  Based 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. Findings include: The facility policy, Homelike Environment, revised 12/2024, documented the residents were provided a safe, clean, comfortable, and homelike environment. […]