Fox Hollow Post Acute

In the surveyor’s words

From the most serious findings on record at Fox Hollow Post Acute, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Jun 4, 2026

  Based on observation, interview, and record review, the facility failed to ensure each resident receives adequate supervision and assistance devices to prevent accidents for 1 (Residents #1) of 5 residents reviewed for accidents and supervision. The facility failed to ensure Resident #1 who had a previous history of elopement, received adequate supervision to prevent elopement. Resident #1 exited from the facility front entrance on 05/02/26 at around 8:40 PM. Resident was found roughly 2 miles from facility on a busy 2-way street that did not have a sidewalk and returned to the facility about 5 hours after he eloped. The non-compliance was identified as past non-compliance. The Immediate Jeopardy began on 05/02/26 and ended on 05/04/26. […]

• Immediate jeopardy, isolatedF684May 2, 2026

  Based on interview and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered- care plan, and the resident's choices for 1 (Resident #1) of 3 residents reviewed for quality of care. The facility failed to treat a confirmed infection despite two provider orders, resulting in septic shock and death, with no evidence of clinical follow-up or intervention An Immediate Jeopardy (IJ) was identified on [DATE]. […]

• Immediate jeopardy, isolatedF755May 2, 2026

  Based on interview and record review, the facility failed to ensure residents were free of significant medication errors for 1 of 3 Residents (Resident #1) reviewed for antibiotic medication. Facility failed to acquire and administer physician ordered antibiotics to treat Resident #1's identified UTI. On [DATE] R#1was sent to hospital, admitted with septic shock and expired on [DATE]. An Immediate Jeopardy (IJ) was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of isolated with a potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. […]

• Immediate jeopardy, isolatedF689Oct 14, 2025

  Based on observations, interviews, and record reviews the facility failed to ensure the resident environment remains as free of hazards as is possible; and each resident received adequate supervision and assistance devices to prevent accidents for 1 (Residents #1) of 4 residents reviewed for accidents and supervision. On 8/29/25 Resident #1, while being transferred by CNA A and CNA B via mechanical lift from bed to wheelchair, hit her left foot against the mast of the mechanical lift. CNA A failed to protect Resident #1's feet during the mechanical lift transfer. Resident #1's x-ray results: acute third digit proximal phalanx shaft and neck fracture (The largest and longest phalanx bone, it is the base of the toe.) An Immediate Jeopardy was identified on 10/10/2025. […]

• No harm, potential for more than minimal, patternF812Jan 22, 2026

  Based on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for kitchen sanitation. The facility failed to ensure food was properly labeled and dated.The facility failed to clean the equipment properly.This failure placed all residents who ate food served by the kitchen at risk of cross contamination and food-borne illness.Findings Include:Observation of the juice machine on 01/20/26 at 8:27 AM revealed one of the spouts had a green substance around the entire rim.Observation of the walk-in refrigerator on 01/20/26 at 8:31 AM revealed a plastic container of tomatoes and a plastic container of oranges, not labeled or dated indicating when… […]