Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Complete Care At Fox Hill during CMS and state inspections, most recent first.
Three residents with orders for oxygen therapy did not have their care plans updated to include required interventions and monitoring for oxygen use, despite clinical documentation and physician orders indicating the need. The omission was identified through record review, observation, and staff interviews, and was not addressed in the care plans until after surveyor inquiry.
A resident with acute respiratory failure and congestive heart failure was discharged without a medically necessary walker, despite therapy and physician recommendations. Facility documentation did not show that a walker was ordered, and post-discharge follow-up revealed the resident experienced falls at home before a walker was obtained by family.
A resident with significant cardiac conditions and an implantable defibrillator did not receive a timely cardiology follow-up as ordered after hospital discharge. Although the care plan and physician's order required a cardiology appointment within one week, the appointment was not scheduled or documented, and the cardiology office confirmed no recent visits. The lapse was attributed to a lack of review and action by the covering nurse during the admission process.
The facility failed to provide a dignified dining experience for residents, with delays in providing utensils and beverages, and inadequate assistance for those dependent on feeding. Additionally, a resident's urinary device was left uncovered, compromising dignity and infection control. Staff shortages contributed to these deficiencies.
A resident missed a scheduled shower due to inadequate staffing, as confirmed by nursing assistants who reported being unable to provide basic care due to being short-staffed. The facility faced challenges with staff call-outs and insufficient availability, particularly on weekends, affecting the care of residents requiring assistance with daily activities.
The facility failed to ensure proper food safety and hygiene practices in the kitchen. Dietary staff were observed without beard restraints due to inaccessibility, and opened food items were not labeled or dated. Personal items were found in the refrigerator, and frozen foods were not properly sealed. Facility policies require proper food storage and staff to wear hair restraints.
The facility failed to maintain updated COVID-19 testing logs for staff and residents, with the last update in September 2023, despite a recent outbreak. Additionally, a nurse aide did not perform hand hygiene or sanitize equipment after exiting a resident's room on transmission-based precautions, contrary to facility policies.
The facility failed to document COVID-19 vaccine education and consent for three residents who received the vaccine and did not document education or consent/refusal for two other residents during the 2023/2024 season. This was confirmed by interviews with RNs who could not locate the necessary records, indicating non-compliance with facility policies.
The facility failed to notify resident representatives of changes in condition and new physician orders for two residents. One resident with dementia experienced agitation, an eye infection, and a bruise, but their representative was not informed of new medication orders. Another resident with diabetes developed cellulitis and received new orders for antibiotics and diuretics, yet their representative was not notified. The facility's policy requires immediate notification and documentation, which was not followed.
A resident with dementia and behavioral disturbances was involved in an altercation with a nursing assistant during care, resulting in bruising and a skin tear. The incident was not reported as abuse by the RN who witnessed it, nor was it investigated by the DNS until the resident's family raised concerns. The facility failed to adhere to its abuse prevention policies, allowing the NA to continue working without investigation.
The facility failed to follow its policy in investigating allegations of abuse and an injury of unknown origin for two residents. One resident, with dementia, was involved in an incident where a nursing assistant held the resident's arms down during care, resulting in a skin tear. The incident was not reported or investigated as potential abuse. Another resident, with severe cognitive impairment, had a bruise of unknown origin, but the investigation was delayed, with no staff interviews conducted on the day of discovery. The facility's policy requires immediate reporting and investigation of abuse allegations, which was not adhered to in these cases.
The facility failed to report allegations of abuse, injuries of unknown origin, and a fall from a mechanical lift to the state agency in a timely manner for three residents. A resident with dementia was involved in an incident where a NA was observed holding the resident's arms down, leading to skin tears and bruising, which was reported six days later. Another resident with severe cognitive impairment was found with a bruise of unknown origin, reported a day late. A third resident fell from a mechanical lift and was diagnosed with a hip fracture five days later, but the incident was not reported promptly.
The facility failed to investigate an allegation of abuse for a resident with dementia who was found with bruising after a combative incident during care. The nursing supervisor did not consider the incident as potential abuse and did not initiate an investigation. In another case, the facility did not investigate a bruise of unknown origin on a resident's heel, as required by policy. Both incidents highlight a failure to adhere to the facility's policies on investigating abuse and injuries.
A facility failed to timely complete a PASRR rescreen for a resident with an intellectual disability. The resident, admitted with a diagnosis affecting normal physiological development and moderately impaired cognition, required a Level II PASRR evaluation. Despite the care plan's directive to coordinate necessary evaluations, the facility did not complete a rescreen after the resident's 60-day approval ended, identifying the oversight only after the period had lapsed.
A facility failed to document a resident's need for continuous oxygen in the baseline care plan upon admission, despite the resident being on oxygen due to respiratory conditions. The resident's hospital discharge summary and nursing assessment indicated the need for oxygen, but the care plan and physician's orders did not reflect this. Observations showed the resident on oxygen with undated tubing, and interviews revealed a lack of a proper baseline care plan for oxygen use.
A resident with cognitive impairment and a history of falls did not receive a comprehensive care plan to prevent further falls. Despite multiple falls and injuries, interventions were not effectively implemented or revised. Communication failures between staff led to necessary equipment modifications not being made, contributing to the resident's continued falls.
Two residents did not receive their scheduled weekly showers due to staffing shortages and miscommunication in a facility. One resident, admitted with a right ankle fracture and diabetes, did not receive a shower for the first 33 days, while another resident with multiple health issues also missed several scheduled showers. The facility's Bathing/Shower Policy was not followed, leading to the deficiency.
The facility failed to complete required neurological assessments for a resident after multiple falls and did not perform an RN assessment for a new bruise on another resident. Despite policies mandating these assessments, documentation was incomplete or missing, indicating lapses in care processes.
The facility failed to ensure proper air mattress settings and treatment for pressure ulcers for two residents. One resident with a stage 3 ulcer had an air mattress set incorrectly, and another developed a new ulcer without proper treatment. The facility did not provide a policy for pressure ulcer care.
A resident admitted with respiratory issues was on oxygen therapy without a valid physician's order specifying the flow rate or frequency of checks. Facility staff confirmed the lack of proper documentation and labeling of oxygen equipment, contrary to the facility's policy.
A resident experienced delays in receiving preferred pain medication, Naproxen, due to pharmacy delivery issues and lack of facility stock. Despite a physician's order, the medication was not available, leading to prolonged wait times for pain relief. The resident initially refused Hydromorphone, preferring Naproxen, but later agreed to take it until Naproxen was available. Facility staff were unaware of the extent of the delays, and the ADNS noted that Naproxen could have been obtained locally.
A facility failed to ensure a timely response to a pharmacy medication review for a resident with diabetes. The resident was on sliding scale insulin without orders for a long-acting insulin. Despite a pharmacy recommendation to adjust the insulin regimen, no changes were made, and the APRN did not document a response. The facility's policy required a documented response within 7-14 days, which was not met.
Failure to Include Oxygen Therapy in Resident Care Plans
Penalty
Summary
The facility failed to ensure that the care plans for three residents receiving oxygen therapy included specific interventions and focus areas for oxygen use, as required by facility policy. For each resident, physician orders and clinical assessments documented the need for oxygen therapy, including prescribed flow rates and monitoring requirements. However, the corresponding Resident Care Plans (RCPs) did not address oxygen therapy, omitting necessary details such as the type of delivery system, administration instructions, equipment settings, and monitoring protocols. This omission was identified through review of clinical records, facility documentation, and direct observation of residents receiving oxygen. Specifically, one resident with acute respiratory failure and heart failure was admitted with an order for oxygen but had no care plan interventions for oxygen therapy. Another resident with acute respiratory failure had a physician's order for continuous oxygen, was observed receiving oxygen, but the care plan did not include oxygen therapy until after surveyor inquiry. A third resident with chronic obstructive pulmonary disease had an order for oxygen and was receiving it, but the care plan failed to address oxygen therapy until prompted by surveyors. Interviews with facility staff confirmed that oxygen use should have been included in the care plans, in accordance with facility policy.
Failure to Provide Medically Necessary Walker at Discharge
Penalty
Summary
A deficiency occurred when the facility failed to provide a medically necessary walker for a resident upon discharge. The resident, who had diagnoses including acute respiratory failure and congestive heart failure, was identified in the care plan as having potential for discharge with interventions to evaluate the need for assistive devices. Both occupational and physical therapy discharge summaries recommended a walker for safe functional mobility. The physician's discharge note also listed a walker as required durable medical equipment. However, the social services documentation did not indicate that a walker was ordered for the resident at discharge. Post-discharge assessments revealed problems with both oxygen and the walker, with no documented follow-up or resolution. An interview with a family member confirmed that the resident was discharged without a walker or wheelchair and experienced two falls at home before a walker was purchased independently. Facility policy required that discharge care plans address equipment needs and document referrals, but there was no evidence that a walker was provided or ordered for the resident at discharge.
Failure to Schedule Cardiology Follow-Up for Cardiac Resident
Penalty
Summary
A deficiency occurred when a resident with multiple cardiac diagnoses, including ventricular tachycardia, congestive heart failure, hypertensive heart disease with heart failure, and an automatic implantable cardiac defibrillator, was not provided with a timely cardiology follow-up as ordered by the physician and directed in the hospital discharge paperwork. The resident was assessed as having intact cognition and required assistance with activities of daily living. The care plan included monitoring for cardiovascular symptoms and following up with cardiology, as specified in both the hospital after-visit summary and a physician's order, which directed a cardiology appointment to be scheduled within one week of admission. Despite these clear directives, there was no documentation that the resident was scheduled for or transported to a cardiology appointment during the relevant period. Interviews revealed that the process for scheduling such appointments involved several staff roles, but due to the absence of the usual unit manager and a lack of follow-through by the covering nurse, the appointment was not made. The cardiology office confirmed that the resident had not been seen since a prior date, and the facility was unable to provide a policy for scheduling and transporting residents to outside provider appointments.
Deficiencies in Dining Experience and Resident Dignity
Penalty
Summary
The facility failed to ensure a dignified dining experience for several residents, as observed during breakfast service. Residents were not provided with necessary eating utensils, beverages, or condiments for up to 35 minutes after their meals were delivered. This delay resulted in residents eating with their fingers and consuming cold food, which was reported by two residents who expressed dissatisfaction with their dining experience. The issue was attributed to a shortage of nurse aide staff, as confirmed by interviews with the nursing staff, who were occupied with other duties such as answering call lights and providing care to soiled residents. Additionally, the facility did not provide adequate assistance to residents who were dependent on staff for feeding. Observations revealed that some residents were left unattended with their meals for extended periods, leading to delays in feeding. The care plans for these residents did not accurately reflect their need for assistance, contributing to the oversight. Interviews with staff indicated that the facility was short-staffed, particularly on weekends, which affected the timely provision of care and assistance during meals. Furthermore, the facility failed to maintain the dignity and privacy of a resident with a urinary device. The device was observed lying on the floor without a privacy cover, visible from the hallway. This was acknowledged by the charge nurse and the DNS, who noted that the device should have been covered and not in contact with the floor for infection control reasons. The facility's catheter care policy mandates that privacy bags be used to cover drainage bags, which was not adhered to in this instance.
Inadequate Staffing Leads to Missed Resident Care
Penalty
Summary
The facility failed to ensure sufficient nurse staffing levels to meet the needs of its residents, as evidenced by multiple interviews and documentation. A resident reported that their scheduled shower was missed due to being out for an appointment, and the staff did not reschedule it appropriately. A nursing assistant confirmed that on the day in question, she was the only aide on the unit and could not provide showers due to short staffing. Another nursing assistant reported that staffing was particularly inadequate on weekends, leading to prioritization of care tasks and sometimes resulting in residents not receiving basic care such as getting out of bed, mouth care, or showers. The staff scheduler and the Director of Nursing Services (DNS) acknowledged challenges with staffing, particularly due to call-outs and insufficient staff availability, especially on weekends. The facility assessment indicated a significant number of residents requiring assistance with daily activities, highlighting the need for adequate staffing. Despite attempts to manage the schedule, the facility struggled to maintain sufficient staffing levels, impacting the quality of care provided to residents.
Food Safety and Hygiene Deficiencies in Kitchen
Penalty
Summary
The facility failed to ensure proper food safety and hygiene practices in the kitchen, as observed during an initial tour. Dietary staff were found not wearing beard restraints while preparing breakfast, which was attributed to the restraints being stored in a locked office, inaccessible until the manager's arrival. Additionally, opened food and beverage items in the refrigerator were not labeled or dated, including containers of sour cream, cottage cheese, milk, orange juice, chocolate milk, and iced tea. Personal items such as a water bottle and a coffee cup were also found in the kitchen refrigerator. Further observations revealed that frozen food items, including breaded chicken patties, dinner rolls, and fish fillets, were not properly sealed and were exposed to air. The facility's policies require that all food be stored in a manner that prevents contamination, with proper labeling and dating, and that staff wear hair restraints to prevent hair from contacting food. The food services district manager confirmed these expectations and noted that an in-service on labeling and dating had been provided to the dietary staff.
Deficiencies in COVID-19 Testing Surveillance and Infection Control Practices
Penalty
Summary
The facility failed to maintain ongoing surveillance of COVID-19 testing for staff and residents, as evidenced by the lack of updated testing logs since September 2023. During an interview, the Infection Control Nurse (RN #2) acknowledged that the logs had not been updated with information from the current outbreak that began on May 12, 2024. The Regional Clinical Manager (RN #9) and the Director of Nursing Services (DNS) both indicated that it was the facility's expectation to maintain documentation of routine COVID-19 testing, including surveillance and contact tracing. However, prior to the surveyor's inquiry, there was no evidence that such logs were maintained, which is contrary to the facility's policies on infection prevention and control. Additionally, the facility failed to ensure proper hand hygiene and sanitization of resident-care equipment. An observation revealed that a nurse aide (NA #11) exited the room of a resident on transmission-based precautions without performing hand hygiene or sanitizing the vital sign machine. NA #11 admitted to not washing her hands after removing personal protective equipment and transporting the unsanitized vital sign machine to the nurse's station due to the unavailability of sanitizing wipes on the isolation cart. The facility's policies require staff to perform hand hygiene after exiting isolation rooms and to sanitize equipment after each use, which was not adhered to in this instance.
Failure to Document COVID-19 Vaccine Education and Consent
Penalty
Summary
The facility failed to ensure that three residents were provided with education and consented to receive the COVID-19 vaccine. The clinical records for these residents did not contain documentation of education or consent for the COVID-19 vaccine, despite the vaccine being administered. Additionally, two other residents were not documented as having been educated about the COVID-19 vaccine or having consented or refused the vaccine during the 2023/2024 season. This lack of documentation was confirmed during interviews with RN #2 and the regional clinical manager, RN #9, who were unable to locate the necessary records. The facility's policies require that residents be educated about the COVID-19 vaccine and that consent be documented in the clinical record. However, the facility was unable to provide evidence of compliance with these policies for the residents in question. The absence of documentation for both education and consent indicates a failure to adhere to the facility's COVID-19 Prevention, Response, and Reporting policy, as well as the Vaccination of Residents policy, which mandates that residents be informed about the benefits and potential side effects of vaccinations before administration.
Failure to Notify Resident Representatives of Changes in Condition
Penalty
Summary
The facility failed to notify the resident representatives of changes in condition and new physician orders for two residents. Resident #100, who was admitted with dementia and hypertension, experienced several changes in condition, including agitation, an eye infection, and a bruise on the left heel. Despite these changes, there was no documentation indicating that the resident's representative was informed of new orders for medications such as Trazodone and Ativan, or treatments for the eye infection and heel bruise. Interviews with the Director of Nursing Services (DNS) and Assistant Director of Nursing Services (ADNS) confirmed that the facility's policy requires notification of the resident's representative in such cases, but this was not done. Resident #160, admitted with diabetes, atrial fibrillation, and acute kidney fracture, also experienced a failure in communication regarding changes in condition. The resident developed cellulitis in the right lower extremity, and new orders were issued for antibiotics and diuretics. However, there was no documentation that the resident's representative was notified of these changes. The DNS confirmed that the licensed staff are responsible for notifying the resident and their representative of any change in condition, but this was not reflected in the records. The facility's Change in Condition Policy, last revised in May 2021, mandates immediate consultation with the resident, if competent, and notification of the physician and designated representative when there is a significant decline in a resident's status or a need to alter treatment. The policy also requires documentation of the notification in the nurse's notes, including the name of the person notified and the details of the change in condition or treatment. The lack of adherence to this policy resulted in deficiencies in communication for both residents.
Failure to Protect Resident from Abuse During Care
Penalty
Summary
The facility failed to protect a resident from abuse, as evidenced by an incident involving a resident with dementia and behavioral disturbances. The resident, who required extensive assistance with activities of daily living due to conditions such as cellulitis, COPD, and pressure ulcers, was involved in an altercation with a nursing assistant (NA) during care. The NA attempted to provide incontinent care, during which the resident became combative, yelling, thrashing, and physically resisting. The NA restrained the resident's arms to prevent harm, which was observed by a registered nurse (RN) who did not consider the incident as abuse and failed to report it. The incident was documented in an Accident/Incident report, noting bruising on the resident's arms and a skin tear on the right hand. The RN involved did not initiate an investigation or report the incident to the Director of Nursing Services (DNS) or the State Agency, as required by the facility's abuse policy. The DNS was unaware of the incident until the resident's family representative raised concerns about the bruising. The facility's policies on abuse and restraints emphasize the need for immediate reporting and appropriate actions when abuse is suspected, which were not followed in this case. The facility's failure to recognize and report the incident as potential abuse resulted in the NA continuing to work without investigation. The facility's policies require staff to identify underlying causes of resistance to care and to approach residents differently if they resist care, which was not adhered to during this incident. The lack of immediate reporting and investigation highlights a deficiency in the facility's adherence to its abuse prevention policies.
Failure to Investigate Allegations of Abuse and Injury
Penalty
Summary
The facility failed to implement its policy when investigating an allegation of abuse and an injury of unknown origin for two residents. Resident #7, who had dementia and required extensive assistance, was involved in an incident where a nursing assistant (NA #15) was observed holding the resident's arms down during care. The resident became combative, resulting in a skin tear on the right hand. Despite the incident, the nursing supervisor (RN #10) did not consider it as potential abuse, did not initiate an investigation, or report it to the Director of Nursing Services (DNS). The DNS was unaware of the incident until a resident representative reported bruising on the resident's body days later. For Resident #24, who had severe cognitive impairment and required a walker for mobility, a bruise of unknown origin was discovered on the resident's finger. The RN supervisor (RN #5) identified the bruise and completed an incident report, notifying the DNS. However, the investigation was delayed, with no staff interviews conducted on the day the bruise was discovered. Interviews with staff began two days later, which was not in accordance with the facility's policy. The facility's policy mandates immediate reporting and investigation of abuse allegations, including obtaining witness statements and suspending the accused employee. However, in both cases, the facility did not adhere to these procedures. The policy also emphasizes the right of residents to be free from abuse and the need for staff to approach residents with cognitive impairments in a manner that identifies underlying causes of resistance to care, which was not followed in these incidents.
Failure to Timely Report Abuse and Injuries
Penalty
Summary
The facility failed to report allegations of abuse, injuries of unknown origin, and a fall from a mechanical lift to the state agency in a timely manner for three residents. Resident #7, who had dementia and other health issues, was involved in an incident where a nursing assistant (NA) was observed holding the resident's arms down during care, which led to skin tears and bruising. The incident was not reported to the state agency until six days later, despite the facility's policy requiring immediate reporting of suspected abuse. Resident #24, who had severe cognitive impairment and other health conditions, was found with a bruise of unknown origin on the left hand. The bruise was identified by a registered nurse (RN) and reported to the Director of Nursing Services (DNS), but the state agency was not notified until the following day, contrary to the facility's policy of reporting within two hours of suspicion. Resident #25, with a history of epilepsy and cerebral palsy, fell from a mechanical lift during a seizure-like episode and was initially cleared of fractures at the hospital. However, five days later, the resident was diagnosed with a right hip fracture. The DNS did not report the fall or the subsequent fracture to the state agency within the required timeframe, failing to comply with the facility's policy on reporting unknown injuries.
Failure to Investigate Allegations of Abuse and Injury
Penalty
Summary
The facility failed to investigate an allegation of abuse in a timely manner for Resident #7, who was admitted with diagnoses including dementia with behavioral disturbance and muscle weakness. On a specific date, a resident representative reported bruising on the resident's arms and left temporal area. The incident involved a nursing assistant (NA) attempting to provide care, during which the resident became combative, resulting in a skin tear on the right hand. The nursing supervisor witnessed the NA holding the resident's arms down but did not consider the incident as potential abuse, nor did she initiate an investigation or report it to the Director of Nursing Services (DNS). The DNS acknowledged that the investigation should have started immediately after the incident, but it was only initiated six days later when the resident's representative raised concerns. In another case, the facility failed to conduct an investigation for an injury of unknown origin for Resident #100, who was admitted with dementia and hypertension. The resident was at risk for pressure ulcers, and a bruise was noted on the left heel during a skin check. The Licensed Practical Nurse (LPN) who identified the bruise did not recall reporting it to the RN supervisor or completing a reportable event form, which is required for new bruises. The Advanced Practice Registered Nurse (APRN) was not informed of the bruise, and the DNS confirmed that no reportable event form or investigation was completed for the bruise. The facility's policies require immediate investigation of any suspicion of abuse, neglect, or exploitation, including physical marks such as bruises. The policies also state that residents with cognitive impairments should be approached differently if they resist care. In both cases, the facility did not adhere to its policies, resulting in a lack of timely investigations into the incidents involving Resident #7 and Resident #100.
Failure to Timely Complete PASRR Rescreen for Resident with Intellectual Disability
Penalty
Summary
The facility failed to ensure timely completion of a Level of Care rescreen or PASRR Level II for a resident with an intellectual disability. The resident was admitted with a diagnosis of unspecified lack of expected normal physiological development in childhood and had moderately impaired cognition. The admission MDS assessment confirmed the resident had been evaluated by Level II PASRR and was determined to have a condition of mental retardation. The care plan indicated the need for coordination with the appropriate agency to conduct the PASRR evaluation and obtain results if the PASRR was not completed or was incorrect. Despite these requirements, the facility did not complete a PASRR rescreen after the resident's 60-day short-term approval ended. The gap in the rescreening process was identified on May 3, 2024, after which a Level of Care rescreen was completed, and a request for retroactive approval was made. The facility's policy mandates that staff ensure appropriate pre-admission screening for mental illness and/or intellectual/developmental disability per federal and state regulations, which was not adhered to in this instance.
Failure to Document Oxygen Use in Baseline Care Plan
Penalty
Summary
The facility failed to ensure that a baseline care plan for a resident, who was admitted with respiratory conditions including pneumonia, acute respiratory failure, asthma exacerbation, and sepsis, reflected the use of oxygen. Upon admission, the resident was on oxygen at 2 liters per minute via nasal cannula, as indicated in the hospital discharge summary and the admission nursing assessment. However, the baseline care plan did not document the resident's need for continuous oxygen, and the physician's orders did not reflect this requirement either. Observations and interviews revealed that the resident was on oxygen, but the oxygen tubing and bubbler were not dated, and there was no clear record of when they were last changed. Interviews with the LPN and the DNS highlighted that the facility did not have a proper baseline care plan in place for the resident's oxygen use upon admission. The DNS acknowledged that the oxygen use should have been included in the care plan from the start. The facility's policy requires a baseline care plan to be developed within 48 hours of admission to address the resident's immediate needs, including treatments and services. However, this was not done for the resident, leading to a deficiency in meeting the resident's respiratory care needs as per the facility's policy.
Failure to Implement Comprehensive Fall Prevention Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a resident who experienced multiple falls. Resident #22, admitted with diagnoses including urinary retention and depression, had moderately impaired cognition and required maximum assistance with daily activities. Despite having no falls prior to admission, the resident experienced several falls after admission, including unwitnessed falls in the bathroom and from a wheelchair, resulting in injuries such as lacerations and abrasions. The care plan for Resident #22 identified a risk for falls and included interventions such as offering toileting assistance and encouraging the use of a call light. However, these interventions were not effectively implemented or revised after each fall. For instance, the resident was found wearing regular socks instead of non-skid socks, despite a physician's order for non-skid footwear. Additionally, interventions like educating the resident on using the call light were repeated, even though the resident's cognitive impairment made such education ineffective. Communication breakdowns further contributed to the deficiency. The Occupational Therapist identified the need for an adaptive wheelchair and an anti-lock braking system but failed to communicate these needs effectively to the Director of Maintenance or the Director of Nursing Services. As a result, necessary equipment modifications were not made, and the resident continued to experience falls. The facility's falls management policy, which requires the interdisciplinary team to implement appropriate interventions and revise care plans after falls, was not adequately followed, leading to repeated incidents and injuries for Resident #22.
Failure to Provide Scheduled Showers Due to Staffing Shortages
Penalty
Summary
The facility failed to provide weekly showers to two residents, Resident #14 and Resident #160, as required by their care plans. Resident #14, who was admitted with a right ankle fracture and diabetes, required moderate assistance with bathing. Despite being scheduled for showers on Tuesdays during the 3:00 PM to 11:00 PM shift, Resident #14 did not receive a shower for the first 33 days of their stay. Interviews revealed that staffing shortages and miscommunication about shower schedules contributed to the failure to provide showers. Resident #14 expressed frustration and distress over the lack of showers, and there was no documentation of any shower refusals. Resident #160, admitted with diabetes, atrial fibrillation, and an acute kidney fracture, also did not receive scheduled showers. The care plan indicated a need for extensive assistance with personal hygiene, yet there was no documentation of showers being provided or refused on multiple scheduled days across several months. Interviews with staff indicated that staffing shortages and failure to communicate refusals to charge nurses were contributing factors. The facility's Bathing/Shower Policy emphasizes the importance of showers for cleansing, skin observation, and circulation. However, the lack of adequate staffing and communication led to the failure to adhere to this policy, resulting in the deficiency noted in the report.
Failure to Complete Neurological and RN Assessments
Penalty
Summary
The facility failed to ensure that neurological assessments were completed following falls for Resident #22, as per the facility's policy. Resident #22, who was admitted with diagnoses including urinary retention and depression, experienced multiple falls, both witnessed and unwitnessed, between March and May 2024. Despite the facility's policy requiring neurological assessments for unwitnessed falls or falls with head injuries, the Director of Nursing Services (DNS) confirmed that there were 11 missing or incomplete neurological assessment forms for Resident #22's falls. The DNS was unable to verify that these assessments had been completed, indicating a significant lapse in following the facility's fall management and neurological assessment policies. Additionally, the facility failed to perform an RN assessment following the discovery of a new bruise on Resident #100. This resident, admitted with dementia and hypertension, was identified as having a bruise on the left heel during a skin check by LPN #3. However, there was no documentation of an RN assessment or a reportable event form for this new bruise, as required by the facility's procedures. Interviews with the DNS and ADNS revealed that any new bruise should have prompted an RN assessment and a reportable event form, neither of which were completed in this case. The lack of adherence to the facility's policies for both neurological assessments after falls and RN assessments for new bruises highlights deficiencies in the facility's care processes. These deficiencies were identified through interviews with staff and a review of clinical records, which showed incomplete documentation and a failure to follow established protocols for resident safety and care.
Deficiencies in Pressure Ulcer Care and Air Mattress Settings
Penalty
Summary
The facility failed to ensure proper settings for air mattresses for two residents, leading to deficiencies in pressure ulcer care. Resident #95, who had a stage 3 pressure ulcer, was observed lying on an air mattress set incorrectly at 85 lbs, despite the physician's order to set it at 160 lbs. The resident's weight had decreased to 146 lbs, but the air mattress was still not adjusted accordingly. The Assistant Director of Nursing Services (ADNS) acknowledged that the air mattress settings were not aligned with the resident's weight, which is crucial for preventing and assisting in wound healing. Resident #100, who was on hospice care and at risk for pressure ulcers, was also found on an air mattress set at 80 lbs, while the last known weight was 152 lbs. The resident developed a new pressure ulcer on the left heel, which was not present upon admission. The care plan did not initially reflect the use of an air mattress, and the ADNS could not confirm when the air mattress was provided. The resident's representative noted the air mattress appeared deflated, and the ADNS confirmed the settings were not appropriate for the resident's weight, which could hinder wound prevention. Additionally, the facility failed to implement a treatment plan for Resident #100's new pressure ulcer. A physician's order for Xeroform dressing was not documented in the treatment administration record, and the treatment was not provided as prescribed. The APRN confirmed the absence of the treatment order in the records, and the ADNS acknowledged the oversight. The wound physician later identified the ulcer as unstageable with necrotic tissue, indicating a lack of timely and appropriate intervention. The facility's policy on pressure ulcer treatment and prevention was not provided upon request.
Failure to Ensure Proper Respiratory Care and Physician Orders
Penalty
Summary
The facility failed to ensure proper respiratory care for a resident, identified as Resident #210, who was admitted with a history of pleural effusion, asthma exacerbation, and acute hypoxic respiratory failure. Upon admission, the resident was on supplemental oxygen at 2 liters per minute via nasal cannula. However, the physician's order from 5/9/24 to 5/20/24 did not reflect that the resident was on continuous oxygen. Observations on 5/19/24 revealed that the resident was on 1 liter of oxygen via nasal cannula, but the oxygen tubing and humidifier canister were not labeled or dated, and there was no valid physician's order specifying the oxygen administration details. Interviews with facility staff, including an LPN and the ADNS, confirmed the lack of a valid physician's order for oxygen therapy since the resident's admission. The LPN noted that the existing order to 'titrate oxygen' was not sufficient, as it did not specify the oxygen flow rate or the frequency of pulse oximetry checks. The ADNS acknowledged that oxygen is considered a medication and requires a physician's order, which was missing in this case. The facility's Oxygen Administration Policy mandates verification of physician orders for oxygen, which was not adhered to, leading to the deficiency.
Failure to Provide Timely Pain Management
Penalty
Summary
The facility failed to provide timely and appropriate pain management for a resident who preferred Naproxen over Hydromorphone for pain relief. The resident, who was admitted with a right femur fracture and post-surgery pain, expressed a preference for Naproxen, which had been effective during their hospital stay. Despite a physician's order for Naproxen, the medication was not available at the facility due to pharmacy delivery issues, and the resident experienced delays in receiving pain relief. The resident reported having to wait up to six hours for pain medication, despite requesting it every four hours as prescribed. The facility's pharmacy, located out of state, did not deliver the Naproxen promptly, and the facility did not have it in stock as an over-the-counter medication. The resident initially refused Hydromorphone, preferring Naproxen, but later agreed to take Hydromorphone until Naproxen was available. However, the resident continued to experience delays in receiving pain medication. Interviews with facility staff revealed communication issues with the pharmacy and a lack of awareness of the resident's prolonged wait times for pain medication. The Assistant Director of Nursing Services (ADNS) acknowledged that the Naproxen could have been obtained locally as an over-the-counter medication, but this option was not pursued. The facility's pain management policy emphasizes the importance of timely and effective pain relief, but this was not achieved for the resident in question.
Failure to Address Pharmacy Medication Review in a Timely Manner
Penalty
Summary
The facility failed to ensure a timely response to a pharmacy medication review for a resident with a diagnosis of diabetes and a right ankle fracture. The resident was receiving sliding scale insulin without orders for a long-acting or basal insulin. A pharmacy progress note recommended changes to the insulin regimen, including discontinuing the sliding scale insulin and adjusting the frequency of blood sugar monitoring. However, there were no changes made to the physician orders from the date of the pharmacy recommendation until the survey date. Interviews with facility staff revealed that the pharmacist expected a response to the medication review within 24-72 hours, while the facility's policy required a response within 7-14 days. The APRN responsible for the resident did not document a response to the pharmacy's recommendation, and the DNS confirmed that the APRN did not address the recommendation. The facility's policy required the attending physician or designee to document agreement or disagreement with the pharmacist's recommendations and provide a rationale if no changes were made, which was not done in this case.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Vernon
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Woodlake At Tolland | 1.3 mi | — | 2 | 0 |
| Vernon Rehabilitation And Healthcare Center | 2.3 mi | — | 0 | 0 |
| Evergreen Center For Health & Rehabilitation | 8.5 mi | — | 0 | 0 |
| Manchester Rehabilitation And Healthcare Center | 8.6 mi | — | 3 | 0 |
| Westside Care Center | 8.9 mi | — | 2 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.