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? |
|---|---|---|---|---|
| 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 |
| Establish an Emergency Preparedness Program (EP). | Fire Safety | 2018-05-01 | 2018-07-17 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-05-01 | 2018-07-17 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2018-05-03 | 2018-06-14 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2018-05-03 | 2018-06-14 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-05-03 | 2018-06-14 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2018-05-03 | 2018-06-14 | N |
| Provide activities to meet all resident's needs. | Health | 2018-05-03 | 2018-06-14 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2018-05-03 | 2018-06-14 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2018-05-03 | 2018-06-14 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2018-05-03 | 2018-06-14 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2018-05-03 | 2018-06-14 | N |
