Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Foltsbrook Center For Nursing And Rehabilitation during CMS and state inspections, most recent first.
The facility failed to maintain a homelike environment in the Physical Therapy gym and two resident units, with observations of patched holes and missing paint on walls. Staff interviews revealed delays in completing work orders, despite a system in place for reporting environmental issues.
The facility failed to provide residents with palatable and appropriately tempered meals, leading to complaints about food quality and temperature. Residents reported dissatisfaction with the taste and quantity of food, and staff confirmed frequent complaints about meals being cold or unappetizing. Dietary staff acknowledged that food temperatures were not maintained within the recommended range, affecting the palatability and safety of meals.
The facility's main kitchen failed to meet professional standards for food service safety, with issues such as a large puddle in the dish room, soiled areas with grease and food debris, and improper food storage. Interviews revealed lapses in cleaning frequency and adherence to policies, highlighting a need for improved infection control practices.
The facility failed to maintain an effective pest control program, leading to a persistent issue with fruit flies on the 5th floor. Despite regular pest control services, observations over several days noted fruit flies in various areas, including hallways and the dining room. Staff interviews confirmed the problem, with some attributing it to the poor condition of a specific room.
A resident with chronic kidney disease and dependent on dialysis was not provided with a meal before attending dialysis appointments, despite facility policies and physician orders. The resident expressed a preference for a hot lunch, but was not consistently offered one, leading to a deficiency in accommodating the resident's needs and preferences.
Two residents with self-care deficits were not provided necessary grooming and personal hygiene services. One resident, with PTSD and other conditions, was not shaved despite expressing a preference for being clean-shaven. Another resident, with depression and diabetes, was observed with significant facial hair and unkempt hair, despite requesting grooming services. The facility's policy required assistance with shaving and haircuts, but due to staff coordination issues, these needs were not met.
A resident with Stage 2 pressure ulcers did not receive necessary treatment and services, as there was no Comprehensive Care Plan addressing their skin impairments. The resident used an alternating air pressure mattress set incorrectly at 350 pounds, despite weighing 123 pounds, which was not monitored or documented. Staff interviews revealed confusion over responsibility for mattress setup and monitoring, leading to potential increased pressure and decreased wound healing.
The facility failed to secure medication and treatment carts and properly label insulin pens, as observed during a survey. Medication carts on multiple floors were found unlocked and unattended, and insulin pens lacked opened or expired dates. Staff interviews confirmed non-compliance with facility policies, posing risks to resident safety.
A facility failed to maintain effective infection control practices, as a CNA did not use required PPE when entering a resident's room on droplet precautions for Influenza A. Additionally, a broken soap dispenser in the basement bathroom hindered proper hand hygiene. Staff interviews emphasized the importance of these measures, but the facility's lapses in PPE adherence and hand hygiene facilities were evident.
A resident with a DNR/DNI order experienced respiratory failure during a mechanical lift transfer. Despite their advance directives, CPR was initiated by an LPN before the resident's code status was verified. A Registered Nurse Supervisor later resumed CPR due to a misunderstanding, leading to further confusion until emergency services ceased all life-saving measures upon re-confirmation of the resident's DNR/DNI status.
Deficiency in Maintaining a Homelike Environment
Penalty
Summary
The facility failed to ensure a safe, clean, comfortable, and homelike environment for residents in the Physical Therapy gym and two of the five resident units reviewed. Observations revealed several walls with patched holes and missing paint in these areas. Specifically, Unit 4 had rooms with orange-sized white patches of paint and areas of missing paint on the walls. Unit 1 had large scrapes in the sheetrock behind the bed in one of the rooms. The Physical Therapy gym had an area of white plaster in the shape of a door on the wall, which had been present for several months. Interviews with staff, including a Certified Nurse Aide, Licensed Practical Nurses, the Director of Housekeeping, and the Director of Maintenance, indicated that while there was a system in place for reporting and addressing environmental issues, there were delays in completing work orders. Staff reported that maintenance typically completed repairs within a few hours to a few days, depending on the availability of parts and the drying time for materials. However, the presence of unresolved issues such as missing paint and patched walls indicated a failure to maintain a homelike environment as per the facility's policy.
Deficiency in Food Quality and Temperature
Penalty
Summary
The facility failed to ensure that residents were provided with food and drink that were palatable, flavorful, and served at appetizing temperatures during two observed lunch meals. On two separate occasions, meals were found to be lacking in flavor and served at inappropriate temperatures. Residents expressed dissatisfaction with the taste and quantity of food provided. Specifically, during the lunch meal observations, food items such as lemon pepper fish, French fries, coleslaw, and milk were served at temperatures outside the recommended range, leading to complaints from residents about the food being cold or unappetizing. Interviews with residents and staff revealed consistent complaints about the quality and temperature of the food. Residents reported that the food lacked flavor and was often served cold, with some stating they did not receive enough food. Staff members, including Certified Nurse Aides and a Licensed Practical Nurse, confirmed that residents frequently complained about the food being cold, too salty, or lacking in flavor. They noted that alternatives were offered, but residents often refused them, which could lead to weight loss if they did not eat. The facility's dietary staff acknowledged that the food temperatures were not within the appropriate service range, which could affect the palatability and safety of the meals. The Director of Food Service and a dietary staff member confirmed that the temperatures of both hot and cold foods were not maintained as per the facility's policy, which could lead to unappetizing meals and potential bacterial growth. The report highlights the importance of serving food at the correct temperatures to ensure it is enjoyable and safe for residents, as it directly impacts their quality of life.
Deficiencies in Kitchen Cleanliness and Food Storage
Penalty
Summary
The facility failed to ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety in the main kitchen. Observations revealed several issues, including a large puddle on the floor of the dish room, soiled areas behind the cookline with grease and food debris, and a stagnant puddle of liquid on the ice machine. Additionally, the dry storage room had food debris under the shelving and opened jelly packets dried on the floor. The tray line cooler door was in disrepair with exposed insulation, and a tray of portioned pasta salad was uncovered and dried out. Interviews with the Director of Dietary and the Director of Building Services highlighted that the floors were not cleaned as frequently as required, and cleaning behind equipment was not completed as scheduled. The Director of Dietary acknowledged that prepared food should have been covered to prevent contamination. The Director of Building Services emphasized the importance of maintaining clean kitchen equipment and floors for infection control. These deficiencies indicate a failure to adhere to the facility's policies on food and supply storage and cleaning procedures.
Pest Control Deficiency on 5th Floor
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of fruit flies on the 5th floor, as observed during the recertification survey. The facility's policy, dated December 2024, stated that all reasonable measures would be taken to prevent and control pests through routine cleaning, proper food storage, and regular pest control services. Despite this, multiple observations of fruit flies were made in various locations on the 5th floor, including hallways, the nursing station, the dining room, and the elevator. These observations were made over several days, indicating a persistent issue. Interviews with staff revealed that the fruit flies were a known problem, with a Licensed Practical Nurse Manager acknowledging that pest control treatments had not been fully effective. A Certified Nurse Aide suggested that the poor condition and odor of a specific room might be contributing to the issue. The Maintenance Director noted that the problem had been more significant during the summer and mentioned recent treatments by a third-party pest control service. However, they were unaware of the current presence of fruit flies until it was pointed out during an elevator ride.
Failure to Provide Meals Before Dialysis
Penalty
Summary
The facility failed to reasonably accommodate the needs and preferences of a resident, specifically Resident #4, who was not provided with a meal before attending outside dialysis appointments. The facility's policy required that residents receive nutritious, well-balanced, and palatable meals that meet their dietary needs and preferences. Additionally, the Medical Transport Process policy stated that if a resident had an early appointment, a to-go breakfast or meal should be prepared. However, Resident #4, who had chronic kidney disease and was dependent on renal dialysis, was not provided with a lunch before their dialysis sessions, despite a physician's order indicating that a meal should be sent with the resident. Observations and interviews revealed that Resident #4 was not given a lunch before going to dialysis on multiple occasions. The resident expressed a preference for a hot lunch and stated that they were not allowed to eat at the dialysis center, making it difficult to go without food from breakfast until dinner. Staff interviews confirmed that the resident was not consistently provided with a lunch before dialysis, and there was confusion about whether a bagged or hot lunch should be offered. The dietary staff maintained a list of residents who required early or bagged lunches, but the list was not located during the survey, and it was unclear if Resident #4 was consistently included on this list. The deficiency was further highlighted by the fact that on an extra dialysis day, Resident #4 was provided with a hot lunch for the first time and expressed appreciation for it. Staff interviews indicated that it was important for residents to receive three meals a day for nutritional purposes, especially for those undergoing dialysis, which places additional stress on the body. Despite this understanding, the facility failed to ensure that Resident #4 received the necessary meals, leading to a deficiency in accommodating the resident's needs and preferences.
Failure to Provide Necessary Grooming and Hygiene Services
Penalty
Summary
The facility failed to ensure that residents who were unable to carry out activities of daily living received the necessary services to maintain grooming and personal hygiene. Specifically, Resident #116, who had diagnoses including post-traumatic stress disorder, pneumonia, and bladder cancer, was observed on multiple occasions with a significant amount of facial stubble, despite expressing a preference for being clean-shaven. The resident was cognitively intact and able to communicate their needs, yet they were not shaved during their bed bath on 1/28/2025, as per their request. Similarly, Resident #226, with diagnoses including depression, diabetes, and obesity, was observed with significant facial hair and unkempt hair on several occasions. Despite requesting a haircut and shave from multiple staff members, these grooming needs were not addressed. The facility's policy required that residents be assisted with shaving as needed and on shower days, but due to the absence of the unit clerk, appointments for haircuts were not being scheduled. Interviews with staff revealed that personal hygiene care, including shaving, was supposed to be completed daily, but the lack of coordination and follow-up led to these deficiencies.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to ensure that a resident with pressure ulcers received necessary treatment and services consistent with professional standards of practice. Specifically, there was no documented evidence of a Comprehensive Care Plan for the resident's two Stage 2 pressure ulcers. The resident, who had moderately impaired cognition and was dependent for all activities of daily living, was admitted without pressure ulcers but developed them during their stay. The resident was at moderate risk for developing pressure ulcers and required preventative measures, which were not documented or implemented. The resident was readmitted to the facility with two Stage 2 pressure ulcers, but the Comprehensive Care Plan initiated did not include interventions for these skin impairments. Additionally, the resident was using an alternating air pressure relieving mattress that was not set to their correct weight, which could exacerbate the pressure ulcers. The facility's records, including the Medication Administration and Treatment Administration Records, did not include directions for monitoring the mattress or its recommended settings, and the Kardex did not document the use of a pressure relieving mattress. Interviews with facility staff revealed a lack of clarity and responsibility regarding the setup and monitoring of the pressure relieving mattress. The mattress was observed to be set incorrectly at 350 pounds, despite the resident weighing 123 pounds. Staff interviews indicated that the mattress settings were not regularly checked or documented, which could lead to increased pressure and decreased wound healing. The Director of Nursing expected that residents with an alternating pressure mattress would have their care planned accordingly, with daily checks for functionality and correct weight settings documented every shift, which was not done in this case.
Medication and Treatment Cart Security and Labeling Deficiency
Penalty
Summary
The facility failed to ensure that drugs and biologicals were labeled and stored according to professional principles, as observed during a recertification survey. Specifically, medication carts on the 1st, 2nd, and 4th floors, as well as a treatment cart on the 1st floor, were found to be unattended and unlocked. This included the 1st and 4th floor medication carts and the 1st floor treatment cart, which were left unsecured, allowing potential unauthorized access. Additionally, the 2nd floor medication cart contained insulin pens without an opened or expired/discard date, which is against the facility's policy that requires insulin pens to be labeled with an expiration date and stored properly. Interviews with nursing staff revealed a lack of adherence to the facility's policies regarding the security and labeling of medication carts. Registered Nurse #12 acknowledged the importance of knowing when insulin pens were opened, as they are only effective for 28 days. The Director of Nursing and other staff members confirmed that medication and treatment carts should always be locked when unattended to prevent unauthorized access and ensure resident safety. The failure to secure these carts and properly label medications posed a risk of expired medications being administered and unauthorized access to medications and treatment supplies.
Infection Control Lapses in PPE Use and Hand Hygiene Facilities
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of Certified Nurse Aide #26, who did not adhere to the required personal protective equipment (PPE) protocols when entering the room of Resident #112. Resident #112 was on droplet precautions due to a positive diagnosis of Influenza A. Despite the presence of a droplet precaution sign on the doorframe, the aide entered the room without washing hands, wearing a gown, gloves, or a face shield, stating they were unaware of the need for such precautions. Additionally, the facility's infection control measures were compromised by a non-functional soap dispenser in the women's bathroom located off the basement breakroom. Observations confirmed the soap dispenser was broken, and there was no alcohol-based hand rub available, preventing proper hand hygiene. Janitorial staff were aware of the issue but were unable to fix it, and maintenance had not yet addressed the problem, leaving staff without the means to wash their hands after using the restroom. Interviews with various staff members, including the Infection Control Nurse and the Director of Housekeeping, highlighted the importance of hand hygiene and adherence to PPE protocols to prevent the spread of infections. However, the failure to ensure functional hand hygiene facilities and adherence to PPE protocols for residents on droplet precautions demonstrated significant lapses in the facility's infection control practices.
Failure to Honor Resident's Advance Directives
Penalty
Summary
The facility failed to honor the advance directive wishes of a resident, leading to inappropriate medical intervention. The resident, who had a do not resuscitate (DNR) and do not intubate (DNI) order documented in their Medical Orders for Life Sustaining Treatment (MOLST) form, experienced respiratory failure during a mechanical lift transfer. Despite the resident's advance directives, cardiopulmonary resuscitation (CPR) was initiated by a Licensed Practical Nurse (LPN) before the resident's code status was verified. The LPN performed approximately 30 chest compressions before a social worker confirmed the resident's DNR/DNI status, at which point CPR was ceased. However, upon the arrival of a Registered Nurse Supervisor, CPR was resumed due to a misunderstanding of the resident's code status. The supervisor instructed the continuation of chest compressions despite being informed of the resident's DNR status. This led to further confusion and the involvement of emergency medical services, who eventually ceased all life-saving measures upon re-confirmation of the resident's DNR/DNI status. The resident was pronounced deceased shortly thereafter. The incident highlighted a lapse in communication and adherence to the resident's advance directives, resulting in a care plan violation. The misunderstanding and miscommunication among staff members, particularly the actions of the Registered Nurse Supervisor, contributed to the failure to honor the resident's documented wishes, turning a potentially peaceful death into a chaotic situation.
Plan Of Correction
Plan of Correction: Approved January 10, 2025 FoltsBrook Center for Nursing and Rehabilitation is committed to ensuring that advance directive wishes are honored. 1. Resident #1 was discharged from the facility. The RN Supervisor was terminated. 2. All residents are at risk of this deficient practice. An audit was conducted on all residents’ Advance Directives. No further issues were identified. 3. The facility’s Advance Directives Policy and Procedure was reviewed. An audit will be conducted to ensure resident’s code status is accurate across the indicators (Order and MOLST). This audit will be conducted monthly for 3 months. The audit results will be reviewed during the facility’s monthly QA meeting. The frequency and duration of the audit will be re-evaluated at the end of the 3-month period. Also, Code Blue drills will be implemented monthly for 3 months. Those drills will be reviewed during the facility’s monthly QA meeting. The frequency and duration of the drills will be re-evaluated at the end of the 3-month period. 4. All nursing staff will be educated on the Advanced Directives Policy and Procedure including the difference between CPR and DNR; and indicators for resident’s code status (Order and MOLST). 5. Director of Nursing
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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How nearby facilities compare on the same public inspection record.
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| Valley Health Services Inc | 0.7 mi | ★★★★★ | 26 | 0 |
| The Grand Rehabilitation And Nursing At Mohawk | 3.2 mi | ★★★★★ | 3 | 1 |
| Alpine Rehabilitation And Nursing Center | 6.9 mi | ★★★★★ | 16 | 0 |
| Masonic Care Community Of New York | 11 mi | ★★★★★ | 35 | 1 |
| Charles T Sitrin Health Care Center Inc | 12.5 mi | ★★★★★ | 0 | 0 |
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