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Deficiency Records for Complete Care at Fox Hill
A list of the most recent deficiencies for Complete Care at Fox Hill. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Complete Care at Fox Hill. 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? |
|---|---|---|---|---|
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2024-05-21 | 2024-07-23 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-05-21 | 2024-07-23 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-05-22 | 2024-07-03 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2024-05-22 | 2024-07-03 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-05-22 | 2024-07-03 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2024-05-22 | 2024-07-03 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-05-22 | 2024-07-03 | N |
| Respond appropriately to all alleged violations. | Health | 2024-05-22 | 2024-07-03 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2024-05-22 | 2024-07-03 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2024-05-22 | 2024-07-03 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-05-22 | 2024-07-03 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-05-22 | 2024-07-03 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-05-22 | 2024-07-03 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-05-22 | 2024-07-03 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-05-22 | 2024-07-03 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2024-05-22 | 2024-07-03 | 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 | 2024-05-22 | 2024-07-03 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2024-05-22 | 2024-07-03 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-05-22 | 2024-07-03 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-05-22 | 2024-07-03 | N |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2024-05-22 | 2024-07-03 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2024-05-21 | 2024-07-02 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-05-21 | 2024-07-02 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2024-05-21 | 2024-07-02 | N |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2024-02-01 | 2024-02-01 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-07-12 | 2023-08-21 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-07-12 | 2023-08-21 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-07-12 | 2023-06-15 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-10-25 | 2022-12-01 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2022-02-01 | 2022-03-28 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2022-02-01 | 2022-03-28 | Y |
| Address patient/client population and determine types of services needed. | Fire Safety | 2021-11-03 | 2022-02-01 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2021-11-03 | 2022-02-01 | N |
| Establish staff and initial training requirements. | Fire Safety | 2021-11-03 | 2022-02-01 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2021-11-03 | 2022-02-01 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2021-11-03 | 2022-02-01 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2021-11-03 | 2022-02-01 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2021-11-03 | 2022-02-01 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2021-11-03 | 2022-02-01 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2021-11-03 | 2022-02-01 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-11-03 | 2022-02-01 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2021-11-03 | 2022-02-01 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-11-03 | 2022-02-01 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2021-11-03 | 2022-02-01 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2021-11-03 | 2022-02-01 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2021-11-03 | 2022-02-01 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-11-03 | 2022-02-01 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2021-11-19 | 2021-12-30 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-11-19 | 2021-12-30 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-11-19 | 2021-12-30 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2021-11-19 | 2021-12-30 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-11-19 | 2021-12-30 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-11-19 | 2021-12-30 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-11-19 | 2021-12-30 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-11-19 | 2021-12-30 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-11-19 | 2021-12-30 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-11-19 | 2021-12-30 | Y |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2021-11-19 | 2021-12-30 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2021-11-19 | 2021-12-30 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-11-19 | 2021-12-30 | Y |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2021-11-19 | 2021-12-30 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-07-08 | 2019-09-23 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2019-07-08 | 2019-09-23 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-07-08 | 2019-09-23 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-07-08 | 2019-09-23 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-07-08 | 2019-09-23 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2019-07-05 | 2019-08-16 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2019-07-05 | 2019-08-16 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2019-07-05 | 2019-08-16 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-07-05 | 2019-08-16 | N |
| Provide activities to meet all resident's needs. | Health | 2019-07-05 | 2019-08-16 | N |
| Ensure that residents are free from significant medication errors. | Health | 2019-07-05 | 2019-08-16 | N |
| Provide or obtain dental services for each resident. | Health | 2019-07-05 | 2019-08-16 | N |
| Keep all essential equipment working safely. | Health | 2019-07-05 | 2019-08-16 | N |
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