Fox Run Manor

Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY.Based on closed medical record review, interviews, review of hospital records and review of the facility policy, the facility failed to adequately and accurately assess Resident #64's skin and further failed to identify a pressure ulcer (localized injury of the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) until it had reached an advanced stage. Additionally, the facility failed to timely identify and implement interventions to prevent the deterioration of the pressure ulcer. [...]

Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY.Based on closed medical record review, hospital record review, interviews, review of the Emergency Medical Services (EMS) run report and review of the facility's skills competency checklist, the facility failed to ensure an indwelling urinary catheter was medically necessary and further failed to ensure proper catheter insertion. This resulted in Actual Harm to Resident #64 when on 07/15/26 the facility obtained a physician order to place an indwelling urinary catheter to promote wound healing and Registered Nurse (RN) #200 incorrectly inserted the indwelling urinary catheter. Consequently, Resident #64 was admitted to the hospital on [DATE] with a urethral injury tear obstruction (damage to the urethra). [...]

Inspectors wroteBased on observation, medical record review, interviews and review of the facility policy, the facility failed to ensure water was readily available to residents. This affected three (#51,#54, and #56) of four residents reviewed for hydration. The facility census was 63.

Inspectors wroteBased on closed medical record review, hospital record review and interviews, the facility failed to ensure residents who required the use of a Continuous Positive Airway Pressure (CPAP) machine had physician orders for use and further failed to ensure the CPAP was used per physician orders once received. This affected one (#64) of one resident reviewed for respiratory care. The facility census was 63.

Inspectors wroteBased on observation, resident and staff interview, and policy review, the facility failed to ensure temperatures in the facility were maintained between 71 and 81 degrees Fahrenheit. This affected all 28 residents who resided on the C hall (#54, #43, #13, #48, #53, #69, #39, #44, #55, #37, #32, #51, #30, #8, #52, #6, #67, #64, #41, #63, #66, #3, #16, #15, #60, #50, #27 and #28) of 63 residents reviewed for temperature. Additionally, the facility failed to ensure a clean environment related to dust in resident rooms in the facility. This affected five residents (#36, #37, #52, #50, and #3). The facility census was 63.

Inspectors wroteBased on medical record review, staff interview, and review of facility policy, the facility failed to ensure adequate monitoring for psychotropic medication effectiveness, side effects, and adverse effects. This affected five (#1, #23, #8, #52, and #6) of five residents reviewed for unnecessary medications. The facility identified 42 residents receiving psychotropic medications. The facility census was 63. Findings Include: 1. Review of Resident #1's medical record revealed an admission date of 03/07/26. Diagnoses included fracture of lower femur subsequent encounter, chronic kidney disease, depression, cellulitis, and pneumonia. Review of Resident #1's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15. Resident #1 was dependent on staff for toilet use, bathing, dressing and transfer. [...]

Inspectors wroteBased on observation, staff interview, review of a handwritten document, and policy review, the facility failed to ensure medications were properly stored. This had the potential to affect all residents. The facility census was 63.

Inspectors wroteBased on observation, medical record review, staff interview, and review of the facility policy, the facility failed to ensure residents were provided a dignified dining experience. This affected three (Residents #50, #37 and #66) out of three residents reviewed for assistance with meals. The facility census was 63. Findings Included: 1. Review of Resident #50's medical record revealed an admission date of 04/22/21. Diagnoses included Alzheimer's disease, anxiety disorder, major depressive disorder, peripheral vascular disease, osteoarthritis and chronic pain. Review of Resident #50's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of zero indicating Resident #50 was rarely or never understood. Resident #50 was dependent on staff for eating, toilet use, bathing, dressing, bed mobility and transfer. [...]

Inspectors wroteBased on medical record review, review of the admission authorizations document, staff interview, and policy review, the facility failed to notify a resident's representative of a change in condition. This affected one (Resident #78) out of three residents reviewed for representative notification. The facility census was 63.

Inspectors wroteBased on record review, interview, and form instructions for the Notice of Medicare Non-Coverage (NOMNC) CMS-10095, and Skilled Nursing Facility (SNF) Beneficiary Protection Notification Review, the facility failed to ensure notices were given appropriately. This affected one (Resident #69) of three residents reviewed for NOMNCs and Advance Beneficiary Notice of Noncoverage (ABN). The facility census was 63.

Inspectors wroteBased on record review, discharge notice, interview, and policy review the facility failed to issue a 30-day discharge. This affected one (Resident #77) of three residents reviewed for discharge. The facility census was 63.

Inspectors wroteBased on record review and interview, the facility failed to ensure care conference notices were sent out timely and care conferences were attended by appropriate Interdisciplinary Team (IDT) members. This affected three (Resident #31, #47, and #77) of four residents reviewed for care conferences. The facility census was 63.

Inspectors wroteBased on observation, medical record review, staff interview and review of the facility policy, the facility failed to provide repositioning for dependent residents. This affected one (Resident #50) of four dependent residents reviewed for activities of daily living. The facility census was 63. Findings Include: Review of Resident #50's medical record revealed an admission date of 04/22/21. Diagnoses included Alzheimer's disease, anxiety disorder, major depressive disorder, peripheral vascular disease, osteoarthritis and chronic pain. Review of Resident #50's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of zero indicating Resident #50 was rarely or never understood. Resident #50 was dependent on staff for eating, toilet use, bathing, dressing, bed mobility and transfer. [...]

Inspectors wroteBased on medical record review, staff interview, and policy review, the facility failed to send a resident to the hospital as ordered for a change in condition. This affected one (Resident #78) of three residents reviewed for changes in condition. The facility census was 63.

Inspectors wroteBased on record review, observations, interview, and policy review, the facility failed to ensure fall investigations included a root cause and intervention. This affected one (Resident #47) of four residents reviewed for falls. The facility census was 63.

Inspectors wroteBased on record review, interview, and policy review, the facility failed to ensure residents were seen by the physician timely. This affected one (#49) of three residents reviewed for physician visits. The facility census was 63.

Inspectors wroteBased on observation, medical record review, and staff interview, the facility failed to ensure resident dietary orders were followed. This affected one Resident (#50) of three residents reviewed for provision of meals. The facility census was 64. Findings Include: Review of Resident #50's medical record revealed an admission date of 04/22/21. Diagnoses included Alzheimer's disease, anxiety disorder, major depressive disorder, peripheral vascular disease, osteoarthritis and chronic pain. Review of Resident #50's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of zero indicating Resident #50 was rarely or never understood. Resident #50 was dependent on staff for eating, toilet use, bathing, dressing, bed mobility and transfer. Resident #50 displayed no behavior and was receiving hospice services at the time of the review. [...]

Inspectors wroteBased on medical record review, staff interview, review of a investigation, and review of the facility policy, the facility failed to ensure residents were not physically restrained in a wheelchair. This affected one (Resident #39) of three residents reviewed for restraints. The facility census was 72.

Inspectors wroteBased on medical record review, review of the facilities Self-Reported Incidents (SRI), staff interview, and review of the facility policy, the facility failed to report an allegation of abuse when a resident was found to be physically restrained by a gait belt in her wheelchair to the State Survey Agency, the Ohio Department of Health. This affected one (Resident #39) of three residents reviewed for restraints. The facility census was 72.

Inspectors wroteBased on medical record review, observation, staff interview, and review of the facility policy, the facility failed to ensure urinary catheter care was performed with proper infection control procedures. This affected one (Resident # 42) of three residents reviewed for catheter care. The facility census was 72.

Inspectors wroteBased on medical record review, observation, resident interview, and staff interview, the facility failed to clarify and implement a physician order. This affected one (#70) of three residents reviewed for wound care. The facility census was 76.

Inspectors wroteBased on medical record review, observation, staff interview, and review of facility policy the facility failed to ensure adequate infection control measures for indwelling catheters. This affected one (#22) of three residents reviewed for infection control. The facility census was 76.

Inspectors wroteBased on observation and staff interview, the facility failed to ensure a resident was provided dignity during meal service. This affected one resident (#12) of one resident reviewed for meal assistance. The facility census was 78.

Inspectors wroteBased on observations, resident and staff interviews, and review of the facility assessment, the facility failed to ensure there was sufficient staff to timely meet the resident's needs. This affected 13 residents (#1, #12, #15, #21, #31, #38, #56, #62, #65, #70, #72, #73, and #82) and had the potential to affect all 77 residents residing in the facility.

Inspectors wroteBased on observations, staff interview, and review of facility policy, the facility failed to ensure adequate hand hygiene was performed during food service and failed to monitor food temperatures before serving meals. This had the potential to affect all residents in the facility except Resident #40 identified to receive no food from the kitchen.

Inspectors wroteBased on observations, resident interview and staff interview, the facility failed to serve residents in the dining room in a dignified manner. This affected five residents (#6, #8, #18, #39, and #66) of 23 residents in the dining room. The facility census was 76.

Inspectors wroteBased on review of resident council minutes and staff and resident interviews, the facility failed to ensure resident concerns were resolved timely. This affected four residents (#12, #15, #21, and #62) who regularly attended the resident council meetings. The facility census was 77.

Inspectors wroteBased on observation and staff interview, the facility failed to ensure call lights were installed in every stall in a common restroom. This had the potential to affect 13 ambulatory residents (#5, #9, #15, #17, #21, #37, #47, #48, #59, #66, #67, #75 and #232) who could self-transfer. The facility census was 76.

Inspectors wroteBased on observation, medical record review, resident interview, and staff interview, the facility failed to timely respond to the resident's call light. This affected one (#70) of 18 residents observed for call lights. The facility census was 77.

Inspectors wroteBased on record review, staff interview, and policy review, the facility failed to ensure the physician was notified of the resident's significant weight change. This affected one (Resident #27) of two residents reviewed for nutrition. The facility census was 77.

Inspectors wroteBased on record review and staff interview, the facility failed to develop a baseline care plan with the minimum necessary information to include activities of daily living (ADL) information for two residents (Resident #57 and #332), skins concerns, psychotropic medications and anticoagulation medication information for one resident (Resident #332). This affected two residents (Resident #57 and #332) of two residents reviewed for baseline care plan. The facility census was 77.

Inspectors wroteBased on record review, observation, staff interview, and policy review, the facility failed to ensure Resident #57 had a complete comprehensive care plan. This affected one (Resident #57) of 18 residents reviewed for comprehensive care plans. The facility census was 77.

Inspectors wroteBased on resident and staff interview, record review, and review of the facility policies, the facility failed to ensure comprehensive care plans were updated timely. This affected two (#56 and #67) of 18 residents reviewed for comprehensive care plans. The facility census was 77.

Inspectors wroteBased on medical record review, observation, resident and resident representative interview, and staff interview, the facility failed to ensure residents who were dependent on staff for activities of daily living (ADL) had their personal care needs met. This affected two (#10 and #64) of seven residents reviewed for ADL. The facility census was 77.

Inspectors wroteBased on staff interview, record review, and review of the facility policies, the facility failed to ensure the interdisciplinary team reviewed falls timely, and interventions were developed and implemented timely. This affected one (#67) of two residents reviewed for falls. The facility census was 76.

Inspectors wroteBased on medical record review, observation, resident interview and staff interview, the facility failed to ensure the residents were provided incontinence care timely. This affected two (#56 and #72) of three residents reviewed for incontinence care. The facility census was 77.

Inspectors wroteBased on record review, observation, staff interviews, and policy review, the facility failed to ensure staff used appropriate personal protective equipment (PPE) while in Resident #332's room who was positive for extended spectrum beta lactamase (ESBL) resistance. Additionally, the facility failed to ensure a resident's catheter bag was not on the floor. The affected two residents (Resident #34 and #332) observed during the annual survey. The facility census was 77.

Inspectors wroteBased on observation and interview, the facility failed to ensure nurse staffing data was posted on a daily basis and failed to maintain historical staffing data. This had the potential to affect all 76 residents residing in the facility.

Inspectors wroteBased on medical record review, review of resident fluid intakes, review of physician orders, staff interview, review of physician communication sheets, review of a hospital history and physical, review of hospital consultation notes, and review of facility policy, the facility failed to ensure a resident's hydration status was maintained to decrease the risk of dehydration. This resulted in actual harm when Resident #58 had a decrease in oral fluid intake for three days and was subsequently hospitalized with acute kidney injury, severe dehydration, and severe sepsis. This affected one (#58) of three residents reviewed for hydration status. The facility census was 71.

Inspectors wroteBased on medical record review, call light response log review, and resident and staff interview, the facility failed to ensure call lights were answered in a timely manner. This affected two (#8 and #14) of three residents reviewed for call light response times. The facility census was 75.

Inspectors wroteBased on medical record review, observation, review of infection control signage, and review of a facility policy, the facility failed to follow infection control precautions for a resident placed on enhanced barrier precautions. This affected one (#8) of three residents reviewed for infection control measures. The facility census was 75.

Inspectors wroteBased on observations, medical record review, resident and staff interviews, and policy review, the facility failed to assist residents who required assistance with activities of daily living (ADL) with showers and personal hygiene needs. This affected two (#19 and #39) of three residents reviewed for ADLs. The facility identified 70 residents who required assistance with bathing. The facility census was 73.

Inspectors wroteBased on medical record review, observation, staff interview, review of facility policy, and review of Centers for Disease Control and Prevention (CDC) guidance the facility failed to implement transmission based precautions for a resident when positive for a multi-drug resistant organism (MDRO) and receiving wound care. This affected Resident #4 of seven reviewed for transmission based precautions. The census was 73.