Foxdale Village

In the surveyor’s words

From the most serious findings on record at Foxdale Village, in the surveyor’s own words.

• Actual harm, isolatedF600Jan 23, 2024

  Based on observation, clinical record review, review of facility documents, and staff interview, it was determined that the facility failed to protect the rights of a resident to be free from neglect by not providing the services necessary to avoid physical harm resulting in fractures for one of two residents reviewed (Resident 1). Findings include: An observation of Resident 1 on January 23, 2024, at 11:35 AM revealed she was in an activity with her head down. An alarm box was noted on her wheelchair. Clinical record review for Resident 1 revealed that the facility admitted her on September 8, 2023. A progress note date December 29, 2023, at 9:15 PM revealed that the nurse aide (NA) notified the registered nurse (RN) that Resident 1 fell and hit the back of her head. […]

• No harm, potential for more than minimal, patternF690Nov 1, 2024

  Based on a review of select facility policies and procedures, clinical record review, and staff interview, it was determined that the facility failed to provide treatment and services based on current standards of practice for the use of indwelling catheters for two of three residents reviewed for catheter concerns (Residents 30 and 3). Findings include: The facility policy entitled, Infection Control with Indwelling Foley Catheters, last reviewed without changes on March 26, 2024, revealed that if an indwelling Foley catheter (flexible tubing inserted through the urethra into the bladder to drain urine) must be utilized, the facility would implement appropriate interventions to reduce the risk of Catheter Associated Urinary Tract Infections (CAUTI). […]

• No harm, potential for more than minimal, patternF695Nov 1, 2024

  Based on clinical record review, observation, and staff interview, it was determined that the facility failed to ensure the application of physician ordered supplemental oxygen consistent with professional standards of practice for three of three residents reviewed for supplemental oxygen concerns (Residents 9, 16, and 30). Findings include: Clinical record review for Resident 9 revealed an active physician order dated October 1, 2024, for staff to apply supplemental oxygen at two liters per minute (lpm) as needed for hypoxia (too little oxygen delivered to body tissues), SPO2 (pulse oximeter, or pulse ox, works by shining a light through the skin and determining the amount of oxygen based on how the light travels through the skin and blood vessels) of less than 90 percent. […]

• No harm, potential for more than minimal, patternF756Dec 2, 2022

  Based on clinical record review, review of select facility policies and procedures, and staff interview, it was determined that the facility failed to ensure that the resident's attending physician addressed pharmacy recommendations for four of five residents reviewed (Residents 3, 10, 21, and 30). Findings include: Review of the policy entitled Pharmacy Monthly Drug Regimen Review, last reviewed on March 22, 2022, indicates that the Director of Nursing or designee will assure that recommendations associated with drug irregularities are communicated to the attending physician within three days from the receipt of the report. […]

• No harm, potential for more than minimal, isolatedF625Nov 1, 2024

  Based on clinical record review and staff interview, it was determined that the facility failed to provide written notice regarding the facility's bed-hold policy for one of one resident reviewed for hospitalization concerns (Resident 16). Findings include: Clinical record review for Resident 16 revealed nursing documentation dated August 3, 2024, at 5:00 PM that Resident 16 had a fall, hit the back of her head, sustained a head laceration, and was sent to the hospital emergency room for evaluation. Nursing documentation dated August 3, 2024, at 9:04 PM revealed that the hospital admitted Resident 16 for observation and hypoxia (low oxygen levels). […]