Fox Run Village

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain best practices in the food service area resulting in the potential to spread foodborne illness to all residents that consume food from the kitchen. Findings Include:On 04/28/2026 at 9:15 AM during the kitchen tour with Dietary Manager (DM) I and Dietary Services Director (DSD) J observed in the walk-in cooler: two clear deep covered plastic containers of facility made tomato soup. The soup in each container was approximately 6 deep and was labeled as being prepared on 4/27. The temperature of the soup measured at the top of the product was in the range of 45 F-49 F. During this observation, when DM I was queried about the cooling of this product, it was confirmed that it had been cooked and cooled on the previous day more than 6 hours prior. [...]

Inspectors wroteBased on interview and record review facility staff failed to report an allegation of sexual assault to the Administrator/Abuse Coordinator and State Agency for one (R7) out of two residents reviewed for abuse.

Inspectors wroteBased on interview and record review, the facility failed to prevent an avoidable fall for one resident, (R36) of three residents reviewed for accidents, resulting in a fall requiring a transfer to the emergency room.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure appropriate infection control practices for residents on droplet precautions during an influenza outbreak, and implementation of Enhanced Barrier Precautions (EBP) affecting multiple residents reviewed for infection control, including R93, R21 and R15. This deficient practice has the likelihood to result in cross-contamination and the continued development and spread of infection and disease.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure Nursing standards of practice were followed for medication administration for one resident (R5) of five residents reviewed for medication administration.

Inspectors wroteBased on observation, interview and record review, the facility failed to consistently provide assistance with oral hygiene for one (R34) of two residents reviewed for activities of daily living (ADLs).

Inspectors wroteBased on interview and record review, the facility failed to ensure medications were available for administration for one resident (R143) of one resident reviewed for new admissions.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure Physician orders were in place and appropriate catheter care was provided for one resident (R143) of two residents reviewed for indwelling catheters.

Inspectors wroteThis citation pertains to intake # MI00144708 Based on interview and record review, the facility failed to ensure services met professional standards for medication administration and documentation of controlled substances and medication documentation according to order changes for one resident (R901) of one reviewed for professional standards, resulting in R901 not receiving medication in accordance with the physician order.

Inspectors wroteThis citation pertains to intake #MI00144708. Based on interview and record review, the facility failed to ensure adequate, and accurate assessment, investigation, and monitoring of a resident post fall with injury for two (R901 and R904) of three residents reviewed for accidents.

Inspectors wroteBased on observation and interview, the facility failed to ensure proper storage of medications in two of two medication carts reviewed resulting in the potential of dispensing expired medications and storing unidentifiable medications in the narcotic cart.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure food items were stored, dated, and discarded appropriately, failed to maintain the kitchen in a sanitary manner, and failed to ensure the dry storage room was free from pests. This deficient practice had the potential to affect all residents in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents were treated in a dignified and respectful manner. This deficient practice had the potential to affect multiple residents that resided on the Cardinal unit.

Inspectors wroteBased on observation, interview and record review, the facility failed to properly store, secure, and/or dispose medications, including controlled drugs in one of two medication carts and one of two medication rooms, resulting in increased potential for diversion and misappropriation.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure a level one OBRA screening (Omnibus Budget Reconciliation Act) was submitted to the Community Mental Health Services Program (CMHSP) for a level two evaluation for two (R's 7 and 2) of two residents reviewed for PASAR (Preadmission screening/resident review).

Inspectors wroteBased on interview and record review the facility failed to effectively collaborate with the hospice agency for one resident (R2) of one resident reviewed for hospice services.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure the required assistance level for bed mobility was provided to one (R18) of four residents reviewed for accidents.

Inspectors wroteBased on observation, interview and record review the facility failed to consistently provide a rationale for declination of the pharmacist's monthly medication regimen review for two residents (R2 and R15) of the two residents reviewed.

Inspectors wroteBased on interview and record review, the facility failed to justify the use of antibiotics in according with current practice/guidance for one (R8) of four residents reviewed for antibiotic medication use.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure gradual dose reductions (GDRs) for psychotropic medications were completed, implement a care plan that identified targeted behaviors and non-pharmacological interventions for behaviors, and maintain behavioral data for two (R's 7 and 25) of five residents reviewed for unnecessary medications.

Inspectors wroteBased on interview and record review the facility failed to maintain an antibiotic stewardship program that included consistent implementation of protocols for appropriate antibiotic use for two (R233 and R234) of four residents reviewed.