Deficiency Records for Foltsbrook Center For Nursing and Rehabilitation
Updated as of March 01, 2024
A list of the most recent deficiencies for Foltsbrook Center For Nursing and Rehabilitation. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Install an approved automatic sprinkler system. | Fire Safety | 2023-06-30 | 2023-08-21 | N |
| Install a two-hour-resistant firewall separation. | Fire Safety | 2023-06-30 | 2023-08-20 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-06-30 | 2023-08-20 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2023-06-30 | 2023-08-20 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-06-30 | 2023-08-20 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-06-30 | 2023-08-20 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2023-06-30 | 2023-08-20 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2023-06-30 | 2023-08-20 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-06-30 | 2023-08-20 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2023-06-30 | 2023-08-20 | N |
| Provide activities to meet all resident's needs. | Health | 2023-06-30 | 2023-08-09 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-06-30 | 2023-08-09 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder. | Health | 2023-06-30 | 2023-08-09 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2023-06-30 | 2023-08-09 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-06-30 | 2023-08-09 | Y |
| Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. | Health | 2023-06-30 | 2023-08-09 | Y |
| Provide or get specialized rehabilitative services as required for a resident. | Health | 2022-04-13 | 2022-05-13 | Y |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-04-13 | 2022-05-13 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-10-18 | 2021-11-19 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-10-18 | 2021-11-19 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-06-09 | 2021-07-11 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-06-09 | 2021-07-11 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2021-06-09 | 2021-07-11 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2021-06-09 | 2021-07-11 | N |
| Provide special eating equipment and utensils for residents who need them and appropriate assistance. | Health | 2021-06-09 | 2021-07-11 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-06-09 | 2021-07-11 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-06-09 | 2021-07-11 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2021-06-09 | 2021-07-11 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-06-09 | 2021-07-11 | Y |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2021-06-09 | 2021-07-05 | N |
| Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards. | Health | 2021-06-09 | 2021-06-29 | N |
| Install a two-hour-resistant firewall separation. | Fire Safety | 2021-06-03 | 2021-06-28 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2021-06-03 | 2021-06-28 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2021-06-03 | 2021-06-28 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-06-03 | 2021-06-28 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2021-06-03 | 2021-06-28 | N |
| Have proper fire barriers, ventilation and signs for the transfilling of oxygen. | Fire Safety | 2021-06-03 | 2021-06-28 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2019-07-25 | 2019-09-16 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2019-07-25 | 2019-09-16 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-07-25 | 2019-09-16 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2019-07-25 | 2019-09-16 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-07-25 | 2019-09-16 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-07-25 | 2019-09-16 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-07-25 | 2019-09-16 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-07-25 | 2019-09-16 | N |
| Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care. | Health | 2019-07-25 | 2019-09-16 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2019-07-25 | 2019-09-16 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2019-07-25 | 2019-09-16 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2019-07-25 | 2019-09-16 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-07-25 | 2019-09-16 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-07-25 | 2019-09-16 | N |
| Implement a program that monitors antibiotic use. | Health | 2019-07-25 | 2019-09-16 | N |
| Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame. | Health | 2019-07-25 | 2019-09-16 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2019-07-25 | 2019-09-16 | N |
| Install a two-hour-resistant firewall separation. | Fire Safety | 2019-07-25 | 2019-09-09 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2019-07-25 | 2019-09-09 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2019-07-25 | 2019-09-09 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-07-25 | 2019-09-09 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-07-25 | 2019-09-09 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-07-25 | 2019-09-09 | N |
| Have proper fire barriers, ventilation and signs for the transfilling of oxygen. | Fire Safety | 2019-07-25 | 2019-09-09 | N |
