Complete Care at Fox Hill

In the surveyor’s words

From the most serious findings on record at Complete Care at Fox Hill, in the surveyor’s own words.

• Immediate jeopardy, isolatedF678Feb 29, 2024

  Based on review of the clinical record, facility documentation, facility policy, and interviews for one (1) of one (1)residents reviewed for Cardiopulmonary Resuscitation (CPR), (Resident #1), the facility failed to provide continuous (CPR) once initiated for a resident who was found pulseless and not breathing, and had a full code status (a full code identifies that all resuscitative efforts will be provided) resulting in a finding of Immediate Jeopardy. The findings include: Resident #1 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD) with acute exacerbation, acute respiratory failure and was dependent on supplemental oxygen. […]

• Actual harm, isolatedF689Jul 12, 2023

  Based on clinical record review, facility documentation, and interviews, for one (1) of three (3) residents reviewed for accidents, (Resident #1), the facility failed to ensure that the resident was transferred in accordance with the plan of care resulting in an injury. The findings include: Resident #1 had a diagnosis of Alzheimer's disease, diffuse osteopenia, and osteoarthritis. A Minimum Data Set, dated dated dated [DATE] identified that Resident #1 had severe cognitive impairment, required total care for Activities of Daily Living (ADL's), including assistance of two (2) with transfers. […]

• Actual harm, isolatedF684Nov 19, 2021

  Based on a review of clinical records, review of manufacturer's directions for use, review of facility documentation, interviews, and policy review, for two of five residents reviewed for non-pressure related impaired skin integrity (Resident #301 and #304), the facility failed to notify the physician when the wound vacuum was not operational and failed to perform wound assessments in accordance with facility policy and failed to ensure wound monitoring was completed. The findings include: 1. Resident #301's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission MDS assessment dated [DATE] identified intact cognition, requiring extensive assistance of one staff for ADLs, and an unstageable pressure ulcer. […]

• Actual harm, isolatedF686Nov 19, 2021

  Based on clinical record review, facility documentation review and interview for one of five residents (Resident #305), reviewed for impaired skin integrity, the facility failed to ensure that pressure ulcers were treated and measured in accordance with facility policy and physician orders. The findings include: 1. Resident #305 diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] A quarterly Minimum Data Set, dated dated dated [DATE] identified that the resident was cognitively intact, required extensive assistance with activities of daily living, was at risk for skin breakdown, and had intact skin integrity. A Resident care plan dated 12/13/21 identified that the resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• No harm, potential for more than minimal, patternF803Mar 3, 2026

  Based on observations of dining and interviews, the facility failed to ensure that substitutions made during the noon meal were posted on the daily menu prior to mealtime. The findings include: An observation and interview with the Regional Dietary Manager on 2/24/2025 at 12:10 PM indicated the kitchen was out of peas and they were substituting cabbage and spinach because their delivery was not received the day prior due to the snowstorm. Outside the main dining room, the daily meal list was posted but the substitutions had not been added to the menu. The Regional Dietary Manager indicated when the residents were served in the dining room they would be notified of the change. […]