Deficiencies (last 8 years)
Deficiencies (over 8 years)
12.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
124% worse than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
36
27
18
9
0
Occupancy
Latest occupancy rate
148% occupied
Based on a October 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Complaint Investigation
Census: 92
Deficiencies: 3
Date: Oct 22, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to ensure accurate documentation and administration of narcotic medication for a sampled resident.
Complaint Details
Complaint number 2634694 triggered the investigation into narcotic medication administration and documentation discrepancies.
Findings
The facility failed to ensure the physician's orders for narcotic medication matched the narcotic sheet and Medication Administration Record (MAR), failed to accurately document narcotic administration on the MAR, and failed to follow policy for corrections on the narcotic sheet. Discrepancies were found in medication counts and documentation, including altered records and missing signatures.
Deficiencies (3)
Failure to ensure physician's order for narcotic medication was accurately shown on the narcotic sheet and MAR.
Failure to ensure nurse accurately documented narcotic medications administered on the MAR.
Failure to follow policy and procedure for corrections made on the narcotic sheet.
Report Facts
Residents Affected: 8
Facility Census: 92
Medication tablets delivered: 30
Medication tablets documented: 20
Medication tablets administered: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Medication Technician A | Certified Medication Technician | Described narcotic medication administration process and discrepancies |
| Registered Nurse A | Registered Nurse | Described in-service training and narcotic administration documentation requirements |
| Director of Nursing | Director of Nursing | Provided expectations for narcotic order verification and documentation, and discussed audit findings |
| Administrator | Administrator | Discussed narcotic sheet and MAR discrepancies and corrective expectations |
Inspection Report
Routine
Census: 82
Deficiencies: 7
Date: Jan 10, 2025
Visit Reason
A standard survey was conducted at Foxwood Springs Living Center from 1/7/25 through 1/10/25 to assess compliance with Medicare/Medicaid regulations.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations, with deficiencies related to residents' rights, safe environment, care plan timing, food safety, and quality assurance.
Deficiencies (7)
F551 Rights Exercised by Representative: The facility failed to ensure a resident lacking capacity was provided opportunities to participate in the care plan process and that decisions by the resident's representative were respected.
F582 Medicaid/Medicare Coverage/Liability Notice: The facility failed to ensure the Notice of Medicare Non-Coverage and Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage were acknowledged by the resident.
F584 Safe/Clean/Comfortable/Homelike Environment: The facility failed to maintain a safe, clean, comfortable, and homelike environment on 200 Hall, including cleanliness of carpets, common areas, and removal of dust and debris.
F657 Care Plan Timing and Revision: The facility failed to develop a comprehensive care plan within seven days after assessment for a resident with a significant change in condition.
F689 Free of Accident Hazards/Supervision/Devices: The facility failed to ensure an environment free from accident hazards by leaving an unlocked treatment cart accessible to residents.
F812 Food Procurement/Store/Prepare/Serve-Sanitary: The facility failed to maintain food service areas in a clean and sanitary manner, with food debris and grease observed in the kitchen.
F868 QAA Committee: The facility failed to maintain a quality assessment and assurance committee with required members and proper meeting attendance.
Report Facts
Resident census: 82
Resident census: 45
Resident census: 82
Inspection Report
Routine
Census: 45
Deficiencies: 7
Date: Jan 10, 2025
Visit Reason
The inspection was conducted as a routine regulatory survey to assess compliance with healthcare facility regulations, including resident rights, care planning, environment safety, medication security, food service safety, and quality assurance.
Findings
The facility was found to have multiple deficiencies including failure to ensure resident participation in care planning, inadequate notification of Medicare non-coverage, failure to maintain a clean and safe environment, untimely care plan updates, unsecured medication cart, unsanitary kitchen conditions, and incomplete attendance of required members in the Quality Assessment and Performance Improvement committee.
Deficiencies (7)
Failed to ensure a resident was provided opportunities to make decisions in their best interest for the Care Plan process.
Failed to ensure the Notice of Medicare Non-Coverage and the Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage were acknowledged by the resident.
Failed to maintain the physical environment in a safe, clean, comfortable and homelike manner on 200 Hall and shared lounge areas.
Failed to develop a Comprehensive Care Plan within 7 days of a significant change in resident's status.
Failed to ensure an environment free from accident hazards by leaving a treatment cart unlocked in a resident lounge area.
Failed to store, prepare, distribute, and serve food in accordance with professional standards due to unsanitary kitchen conditions.
Failed to maintain a Quality Assessment and Performance Improvement committee with required members present at all quarterly meetings.
Report Facts
Residents affected: 3
Residents affected: 2
Census: 45
Days late for care plan update: 26
Quarterly meetings missing required members: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Social Worker #1 | Interviewed regarding Resident #64's decision-making capacity and care planning | |
| Social Worker #2 | Interviewed regarding Resident #64's Durable Power of Attorney and care planning participation | |
| Assistant Director of Nursing (ADON) | Assistant Director of Nursing | Interviewed regarding care plan timeliness, environmental observations, and QAPI committee attendance |
| Facilities Director | Facilities Director | Interviewed regarding housekeeping policies and environmental cleanliness |
| Housekeeping Supervisor #5 | Housekeeping Supervisor | Accompanied surveyor during environmental tour and discussed cleaning expectations |
| RN Charge Nurse #4 | Registered Nurse Charge Nurse | Interviewed regarding unsecured treatment cart |
| Chef #3 | Chef | Interviewed regarding kitchen cleanliness and cleaning responsibilities |
| Director of Dining Services (DDS) | Director of Dining Services | Interviewed regarding kitchen cleanliness and importance of sanitation |
Inspection Report
Annual Inspection
Census: 82
Capacity: 108
Deficiencies: 3
Date: Jan 9, 2025
Visit Reason
An annual CMS recertification Emergency Preparedness (EP) survey and Life Safety Code (LSC) survey were conducted to assess compliance with federal regulations for long term care facilities.
Findings
The facility was found to be in compliance with Emergency Preparedness requirements but was not in compliance with Life Safety Code requirements. Deficiencies were identified related to sprinkler system supervisory signals, sprinkler system maintenance and testing, and electrical equipment power cords.
Deficiencies (3)
K352 Sprinkler System - Supervisory Signals: The facility failed to install electronic supervisory devices on all sprinkler control valves, affecting two smoke compartments, staff, and 24 residents. The Post Indicator Valve was not supervised by the fire alarm system as required by NFPA 101.
K353 Sprinkler System - Maintenance and Testing: The facility failed to maintain the sprinkler system by not providing documentation of a full flow trip test on the dry sprinkler system within the last three years, affecting six smoke compartments, staff, and all residents.
K920 Electrical Equipment - Power Cords and Extension Cords: The facility failed to prohibit improper use of electrical equipment, including use of a relocatable power tap in the Therapy Department, affecting one smoke compartment, staff, and one resident.
Report Facts
Deficient smoke compartments affected: 2
Deficient smoke compartments affected: 6
Deficient smoke compartments affected: 1
Residents affected: 82
Staff affected: 24
Staff affected: 6
Staff affected: 1
Total facility capacity: 108
Census: 82
Inspection Report
Plan of Correction
Census: 88
Deficiencies: 1
Date: Jul 9, 2024
Visit Reason
The visit was a plan of correction review related to a past non-compliance regarding notification of changes and obtaining consent prior to starting new medication for a resident.
Findings
The facility failed to notify the resident's responsible party prior to starting a new medication for one sampled resident out of three. The deficiency was corrected and no plan of correction was required for this past non-compliance.
Deficiencies (1)
§483.10(g)(15) The facility failed to notify the resident's responsible party to obtain consent prior to starting a new medication for one sampled resident out of three. The deficiency was corrected on 6/21/24.
Report Facts
Facility census: 88
Inspection Report
Complaint Investigation
Census: 88
Deficiencies: 1
Date: Jul 9, 2024
Visit Reason
The inspection was conducted due to a complaint regarding the facility's failure to notify the resident's responsible party prior to starting a new medication for a sampled resident.
Complaint Details
The complaint was substantiated. The resident's DPOA was not notified prior to administration of Memantine, a new medication. The DPOA found out about the medication from the pharmacy bill and requested discontinuation. The facility held a conference call with the DPOA to discuss the grievance.
Findings
The facility failed to notify the resident's Durable Power of Attorney (DPOA) before administering a new medication, Memantine, to Resident #2. The facility provided in-service education to nursing staff on notification responsibilities and corrected the deficiency by 6/21/24.
Deficiencies (1)
Failure to notify the resident's responsible party to obtain consent prior to starting a new medication for one sampled resident.
Report Facts
Residents present: 88
Dates of medication administration: Memantine administered between 5/10/24 and 6/17/24 as per Medication Administration Records
Date of in-service education: Nursing staff in-serviced on notification responsibilities on 6/21/24
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse A | Interviewed regarding notification responsibilities for medication changes | |
| Administrator | Interviewed regarding notification failure and staff in-service | |
| Director of Nurses | DON | Interviewed regarding verbal orders and notification procedures |
Inspection Report
Complaint Investigation
Census: 87
Deficiencies: 3
Date: Feb 6, 2024
Visit Reason
The inspection was conducted following a complaint and immediate jeopardy incident involving alleged abuse and neglect of a resident who refused care and was forcibly showered by staff.
Complaint Details
The complaint investigation was substantiated. The resident reported fear of water and refusal to shower. Staff forcibly showered the resident, causing bruises. The facility was notified and initiated corrective actions prior to the state investigation.
Findings
The facility was found noncompliant with regulations related to freedom from abuse and neglect and free of accident hazards/supervision/devices. The investigation revealed staff forcibly showered a resident against their will, causing bruising and emotional distress. The facility failed to provide safe transfer assistance, resulting in resident bruising.
Deficiencies (3)
F600 Freedom from Abuse and Neglect: The facility failed to protect a resident from physical abuse by staff who forcibly showered the resident against their will, causing bruising and emotional distress.
F689 Free of Accident Hazards/Supervision/Devices: The facility failed to provide safe transfer assistance to a resident, resulting in bruising from improper handling during transfer without a gait belt.
A4075 Nursing Care per Resident Condition: Each resident shall receive personal attention and nursing care consistent with current acceptable nursing practice. Refer to F689.
Report Facts
Facility census: 87
Number of sampled residents: 10
Number of staff assisting transfer: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse A | Licensed Practical Nurse | Named in abuse incident involving forcible showering of resident |
| Nurse Practitioner B | Nurse Practitioner | Ordered psychiatric evaluation related to abuse incident |
| Director of Nursing | Director of Nursing | Spoke regarding resident's claim of abuse and corrective actions |
Inspection Report
Complaint Investigation
Census: 87
Deficiencies: 2
Date: Feb 6, 2024
Visit Reason
The inspection was conducted following a complaint alleging that the facility failed to protect a resident from physical abuse and intimidation, specifically regarding a forced shower incident on 1/25/24.
Complaint Details
The complaint investigation was substantiated. The resident reported being forcibly showered after refusing, resulting in bruises. Staff interviews confirmed the forced shower and improper transfer without a gait belt. The facility acknowledged the abuse and corrected the immediate jeopardy before the investigation.
Findings
The facility failed to protect one resident from physical abuse when staff forcibly gave the resident a shower after the resident refused, resulting in bruising. Additionally, the facility failed to use a gait belt during a transfer, which was against policy and best practice. The immediate jeopardy was corrected prior to the investigation.
Deficiencies (2)
Failed to protect a resident from physical abuse by forcibly showering the resident against their will, causing bruising.
Failed to provide safe transfer assistance by not using a gait belt during transfer of the resident, resulting in bruising.
Report Facts
Residents affected: 1
Facility census: 87
Staff involved: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN A | Licensed Practical Nurse | Involved in forcibly showering the resident and transfer without gait belt. |
| CNA A | Certified Nurses Aide | Assisted in showering the resident and transfer without gait belt. |
| CNA B | Certified Nurses Aide | Assisted in showering the resident and transfer without gait belt. |
| CNA C | Certified Nurses Aide | Assisted in showering the resident and transfer without gait belt. |
| Administrator | Notified of immediate jeopardy and acknowledged abuse. | |
| Director of Nursing | Director of Nursing | Involved in investigation and acknowledged abuse. |
| NP A | Nurse Practitioner | Ordered psychiatric evaluation and stated expectation that residents not be forced to shower. |
Inspection Report
Routine
Census: 80
Deficiencies: 11
Date: Jul 3, 2023
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements including resident rights, care, medication administration, infection control, food service, safety, and other aspects of facility operations.
Findings
The facility was found deficient in multiple areas including failure to document resident consent for wandering safety devices, inadequate dental care offerings, improper medication administration including a significant medication error, failure to maintain resident privacy during care, inadequate infection control practices, unsafe transfer practices, failure to maintain food temperatures, and environmental cleanliness issues.
Deficiencies (11)
Failure to provide supporting documentation for use of wandering safety device and resident consent for one resident.
Failure to ensure privacy during blood glucose testing and insulin administration for one resident.
Failure to notify residents or representatives in writing about bed hold policies upon hospital transfer for three residents.
Failure to aspirate or flush IV catheter prior to medication administration for one resident.
Failure to lock wheels on mobile devices prior to transferring and repositioning one resident.
Failure to monitor, clean, and assess ability to perform self-care of suprapubic catheter for one resident.
Significant medication error by administering incorrect antibiotic for three days to one resident.
Failure to offer and provide dental services for one resident without teeth.
Failure to maintain hot food temperatures on room trays for two residents and failure to maintain food safety and cleanliness in kitchen and dining areas.
Failure to implement infection prevention and control practices including hand hygiene and sterile technique during IV medication administration and resident care.
Failure to maintain clean, safe, and comfortable environment including dust buildup, unsecured vent screens, damaged commode seat, lack of negative air flow in shower rooms, and high temperatures in kitchenette.
Report Facts
Resident census: 80
BIMS score: 15
BIMS score: 13
BIMS score: 6
Temperature: 110.4
Temperature: 108.2
Temperature: 93.3
Temperature: 90.9
Urine volume: 300
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN A | Licensed Practical Nurse | Administered IV medication without flushing line; involved in medication error |
| CNA F | Certified Nursing Assistant | Failed to perform proper hand hygiene during resident care |
| CNA G | Certified Nursing Assistant | Failed to perform proper hand hygiene during resident care |
| Pharmacist A | Pharmacist | Notified facility of medication transcription error |
| DON | Director of Nursing | Provided multiple interviews regarding deficiencies and facility practices |
| RN A | Registered Nurse | Provided interview on dental care and catheter care |
| CNA A | Certified Nursing Assistant | Provided interview on food temperature and catheter care |
| Assistant Director of Dining Services | Assistant Director | Provided interview on food service deficiencies |
| Maintenance Worker B | Maintenance Worker | Provided interview on environmental deficiencies |
Inspection Report
Plan of Correction
Census: 83
Deficiencies: 1
Date: Nov 29, 2022
Visit Reason
The visit was conducted to address a past noncompliance related to licensing and staff qualifications, specifically concerning a graduate practical nurse passing medications without proper certification.
Findings
The facility failed to comply with licensing requirements by allowing a graduate practical nurse (GPN) to pass medications without an approval letter or a Certified Medication Technician certificate. The facility took corrective actions including suspension and termination of the nurse and provided education to staff.
Deficiencies (1)
F836: The facility allowed a graduate practical nurse to pass medications without an approval letter or a current Certified Medication Technician certificate. This was a violation of federal, state, and local laws and professional standards.
Report Facts
Facility census: 83
Inspection Report
Routine
Deficiencies: 0
Date: Nov 29, 2021
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted to assess compliance with CMS and CDC recommended practices related to COVID-19.
Findings
The facility was found to be in compliance with 42 CFR 483.73 and CMS and CDC recommended practices for COVID-19 preparedness and infection control.
Inspection Report
Annual Inspection
Census: 84
Deficiencies: 9
Date: Oct 29, 2021
Visit Reason
The inspection was conducted as an annual survey to assess compliance with federal regulations regarding quality of care, pharmacy services, medication management, and psychotropic drug use at Foxwood Springs Living Center.
Findings
The facility was found deficient in coordinating hospice care, maintaining accurate controlled substance records, ensuring psychotropic drug use was properly documented, and maintaining medication error rates below 5 percent. Multiple deficiencies were cited related to medication storage, labeling, and administration practices.
Deficiencies (9)
F684 Quality of care: The facility failed to ensure coordination of care with hospice services for a sampled resident, including lack of a coordinated hospice care plan and hospice book documentation.
F755 Pharmacy services: The facility failed to ensure narcotic counts were completed and signed by two staff each shift for multiple medication carts and rooms, with numerous missed signatures documented.
F758 Psychotropic drugs: The facility failed to document behaviors warranting PRN anti-anxiety medication use and failed to ensure proper behavioral assessment and monitoring.
F759 Medication errors: The facility failed to maintain a medication error rate below 5 percent, with an observed error rate of 16.67 percent involving crushing medications and improper administration.
F761 Labeling of drugs and biologicals: The facility failed to properly label and date opened medications, including insulin pens and controlled substances, and failed to maintain proper storage conditions.
A4054 Safe/effective medication system: The facility failed to maintain a safe and effective medication distribution and administration system as evidenced by deficiencies in narcotic reconciliation and medication error rates.
A4083 Medication storage: The facility failed to store medications at appropriate temperatures and maintain secure storage for controlled and discontinued medications.
A4070 Controlled substance reconcile/record: The facility failed to maintain accurate records of receipt and disposition of controlled drugs, with incomplete narcotic counts and missing signatures.
A4074 Nursing care per resident condition: The facility failed to provide personal attention and nursing care consistent with residents' conditions, including coordination of hospice care and psychotropic drug monitoring.
Report Facts
Facility census: 84
Medication error rate: 16.67
Medication error sample size: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joyce A. Leffert | Health Care Administrator | Signed the Statement of Deficiencies and Plan of Correction |
Inspection Report
Routine
Census: 84
Deficiencies: 5
Date: Oct 29, 2021
Visit Reason
The inspection was conducted to evaluate the facility's compliance with regulatory requirements related to resident care, medication management, and facility operations.
Findings
The facility was found deficient in coordinating hospice care for a resident, ensuring narcotic counts were properly completed and signed, documenting behaviors and non-pharmacological interventions prior to PRN anti-anxiety medication administration, preventing medication errors including crushing medications not approved for crushing and improper eye drop administration, and properly dating multi-dose medications including insulin pens and liquid narcotics.
Deficiencies (5)
Failed to ensure coordination of care with hospice services for one resident; no hospice book or coordinated care plan was maintained.
Failed to ensure narcotic counts were completed and signed by two staff each shift for medication carts and rooms, with multiple missed or improper signatures.
Failed to document behaviors and non-pharmacological interventions prior to administration of PRN anti-anxiety medication for one resident.
Medication errors including crushing medications not approved for crushing and failure to apply pressure to inner corner of eyes after eye drop administration for glaucoma.
Multi-dose medications including insulin pens and liquid narcotics were not dated when opened.
Report Facts
Facility census: 84
Medication error rate: 16.67
Narcotic count missed signatures: 28
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN J | Licensed Practical Nurse | Interviewed regarding hospice care coordination and narcotic counts |
| RN B | Registered Nurse, Unit Manager | Interviewed regarding hospice care coordination and narcotic counts |
| MDS Coordinator A | Mentioned in relation to hospice care plan monitoring | |
| Social Worker A | Social Worker | Interviewed regarding hospice care plan documentation |
| DON | Director of Nursing | Interviewed regarding hospice care, narcotic counts, PRN medication documentation, and medication dating |
| ADON | Assistant Director of Nursing | Interviewed regarding hospice care, narcotic counts, PRN medication documentation, and medication dating |
| LPN K | Licensed Practical Nurse | Observed crushing medications not approved for crushing and interviewed about medication crushing |
| LPN L | Licensed Practical Nurse | Observed administering eye drops without applying pressure and interviewed about eye drop administration |
| LPN G | Licensed Practical Nurse | Interviewed regarding narcotic counts and medication dating |
| LPN B | Licensed Practical Nurse | Interviewed regarding narcotic counts and medication dating |
Inspection Report
Routine
Deficiencies: 0
Date: Dec 29, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted to assess compliance with related federal regulations and CDC recommended practices.
Findings
The facility was found to be in compliance with 42 CFR 483.73 and CMS and CDC recommended practices for COVID-19 preparedness and infection control.
Inspection Report
Routine
Deficiencies: 0
Date: Nov 13, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted to assess compliance with relevant federal regulations and CDC recommended practices.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended infection control practices for COVID-19.
Inspection Report
Routine
Deficiencies: 0
Date: Aug 24, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted to assess compliance with relevant federal regulations and CDC recommended practices.
Findings
The facility was found to be in compliance with 42 CFR 483.73 and CMS and CDC recommended practices for COVID-19 preparedness and infection control.
Inspection Report
Routine
Deficiencies: 0
Date: Aug 4, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness survey and a COVID-19 Focused Infection Control Survey were conducted to assess compliance with related regulations and CDC recommended practices.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control.
Inspection Report
Routine
Deficiencies: 0
Date: Jul 16, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness survey and a COVID-19 Focused Infection Control Survey were conducted to assess compliance with related federal regulations and CDC recommended practices.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control.
Inspection Report
Routine
Deficiencies: 0
Date: May 22, 2020
Visit Reason
A COVID-19 focused infection control and emergency preparedness survey was conducted to assess compliance with CMS and CDC recommended practices and 42 CFR 483.73 related regulations.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices for COVID-19 infection control and with 42 CFR 483.73 related to emergency preparedness.
Inspection Report
Annual Inspection
Census: 94
Deficiencies: 5
Date: Oct 21, 2019
Visit Reason
Annual inspection survey conducted at Foxwood Springs Living Center to assess compliance with federal and state regulations.
Findings
The facility was found deficient in multiple areas including quality of care, accident hazards/supervision, parenteral/IV fluids, psychotropic medication management, infection prevention and control, and safe medication systems. Deficiencies were documented with specific resident cases and policy reviews.
Deficiencies (5)
F684 Quality of care: The facility failed to notify the physician of a significant weight gain and obtain orders for a specialized arm sleeve for edema for Resident #29. Documentation and notification regarding weight changes were inadequate.
F689 Free of Accident Hazards/Supervision/Devices: The facility failed to ensure a safe transfer for Resident #10, requiring assistance of two staff members, resulting in unsafe transfer practices.
F694 Parenteral/IV Fluids: The facility failed to ensure intravenous services were provided consistent with professional standards, including documentation and securing of PICC lines for Resident #75.
F758 Free from Unnecessary Psychotropic Meds/PRN Use: The facility failed to limit PRN psychotropic drug orders to 14 days and document rationale for extensions for Residents #26, #29, #56, and #64 receiving hospice services.
F880 Infection Prevention & Control: The facility failed to maintain an effective infection prevention program, including proper use of PPE, hand hygiene, and PICC line dressing changes, affecting Resident #75 and others.
Report Facts
Facility census: 94
Sampled residents: 19
PRN psychotropic drug order limit: 14
Random audits frequency: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joyce Zippert | Health Care Administrator | Signed the statement of deficiencies and plan of correction |
| Director of Nursing | Named in interviews and responsible for staff education and monitoring compliance | |
| Registered Nurse (RN) A | Registered Nurse | Observed wound care and PICC line dressing changes |
| Licensed Practical Nurse (LPN) B | Licensed Practical Nurse | Interviewed regarding weight monitoring and PICC line measurements |
| Certified Nursing Assistant (CNA) C | Certified Nursing Assistant | Interviewed regarding resident care and weight gain observations |
| Registered Dietician (RD) | Registered Dietician | Interviewed regarding resident weight changes and notifications |
| Licensed Practical Nurse (LPN) C | Licensed Practical Nurse | Interviewed regarding PICC line measurements and documentation |
| Certified Medication Technician (CMT) A | Certified Medication Technician | Interviewed regarding resident anxiety and medication observations |
| Certified Nursing Assistant (CNA) E | Certified Nursing Assistant | Interviewed regarding isolation precautions |
| Certified Nursing Assistant (CNA) F | Certified Nursing Assistant | Interviewed regarding isolation precautions |
Inspection Report
Life Safety
Census: 135
Capacity: 170
Deficiencies: 7
Date: Oct 21, 2019
Visit Reason
Life Safety Code survey conducted to assess compliance with fire safety regulations and emergency preparedness requirements.
Findings
The facility failed to meet several Life Safety Code requirements including kitchen range hood fire suppression connection, annual inspection and testing of fire doors, and electrical system maintenance. Deficiencies affect all residents, staff, and visitors in the facility's smoke compartments.
Deficiencies (7)
K324 Cooking Facilities: The facility's kitchen range hood fire suppression system was not documented as connected to the main fire alarm system, affecting all residents and staff.
K761 Maintenance, Inspection & Testing - Doors: The facility failed to conduct annual visual and functional assessments of smoke barrier and corridor doors, risking fire spread in smoke compartments.
K918 Electrical Systems - Essential Electric System: The facility failed to complete comprehensive testing and maintenance of electrical main and circuit breaker panels, potentially affecting all residents and staff.
A2003 No Fire Hazard: The building presented a fire hazard due to deficiencies referenced in K761 and K918.
A2018 Complete Fire Alarm System Requirements: The facility lacked a complete fire alarm system as required by NFPA 101 and related standards.
A2046 Corridor Requirements: Corridors were obstructed or had doors swinging into them, violating fire safety corridor requirements.
A3030 Electrical Wiring & Equipment Maintained: Electrical wiring and equipment were not maintained in accordance with NFPA 70 standards.
Report Facts
Skilled Nursing Facility census: 94
Skilled Nursing Facility licensed capacity: 108
Assisted Living Facility census: 41
Assisted Living Facility licensed capacity: 62
Total census: 135
Total licensed capacity: 170
Inspection Report
Annual Inspection
Census: 89
Deficiencies: 5
Date: Oct 25, 2018
Visit Reason
Annual survey inspection of Foxwood Springs Living Center to assess compliance with federal regulations and state requirements.
Findings
The facility was found to have multiple deficiencies including failure to ensure safe transfer of residents, inadequate nutrition and hydration interventions, improper medication labeling and storage, infection control lapses, and environmental safety issues such as poor airflow and dust buildup.
Deficiencies (5)
F689: The facility failed to safely transfer a resident using a mechanical lift by not locking the resident's wheelchair, risking falls and injury.
F692: The facility failed to provide adequate nutrition and hydration interventions, resulting in significant weight loss for a sampled resident.
F761: The facility failed to ensure proper labeling and storage of drugs and biologicals, including opened medication bottles without dates and missing resident names.
F880: The facility failed to maintain an effective infection prevention and control program, including improper catheter care and cross-contamination risks.
F921: The facility failed to maintain negative airflow in required areas, resulting in heavy dust buildup affecting at least 30 residents.
Report Facts
Facility census: 89
Sampled residents: 31
Weight loss: 26
Medication errors: 13
Medication errors: 11
Residents affected: 30
Inspection Report
Life Safety
Census: 89
Capacity: 108
Deficiencies: 26
Date: Oct 25, 2018
Visit Reason
The inspection was conducted to assess compliance with the 2012 National Fire Protection Association (NFPA) 101 Life Safety Code and related fire safety regulations at Foxwood Springs Living Center.
Findings
The facility failed to meet several fire safety requirements including sprinkler system penetrations, means of egress obstructions, illumination of exit pathways, exit signage, fire alarm system maintenance, and emergency preparedness. Multiple deficiencies were identified that potentially affected residents and staff.
Deficiencies (26)
K161: The facility failed to ensure there were no penetrations in walls and ceilings in multiple areas, potentially allowing smoke to spread. This affected an unknown number of residents in six resident smoke zones.
K211: One exit door from the dining room did not open easily during fire alarm testing, potentially affecting at least 46 residents in one smoke zone.
K271: Exit discharge walkways were obstructed by dietary carts and damaged areas, potentially affecting dietary employees and at least 47 residents in four smoke zones.
K281: The facility failed to place additional emergency lights at exit discharges in multiple areas, potentially affecting 62 residents and one non-resident use smoke zone.
K293: Exit signs were not placed at both entrances from the courtyard into the facility, potentially affecting residents in seven smoke zones.
K300: The facility failed to prevent lint buildup in clothes dryers, potentially affecting at least 36 residents in two smoke zones.
K324: Two baffle vents in the range hood were damaged and loose, and two baffle vents were replaced. Re-education was provided to maintenance and dining staff.
K341: The facility failed to ensure a heat detector in the 600 Hall kitchenette was properly attached, potentially affecting 17 residents in two smoke zones.
K345: The facility failed to conduct a semi-annual fire alarm inspection, affecting all residents in the facility.
K354: The sprinkler system was out of service for more than four hours without proper notification and fire watch procedures, potentially affecting all residents.
K372: The facility failed to ensure smoke barriers were properly constructed and maintained, potentially affecting 27 residents in four smoke zones.
K914: The facility failed to perform required electrical system maintenance and testing, potentially affecting 89 residents in the Skilled Nursing Facility and 41 residents in the Assisted Living Facility.
K918: The facility failed to ensure a door with a 90-minute fire rating was maintained, potentially affecting residents in three smoke zones.
A2003: The facility failed to maintain fire extinguishers with proper labeling and accessibility, potentially affecting residents in two smoke zones.
A2010: The facility failed to maintain oxygen storage in accordance with NFPA 99, potentially affecting residents in the Skilled Nursing and Assisted Living Facilities.
A2016: The facility failed to maintain range hood certification and fire alarm system inspections, potentially affecting residents in the Skilled Nursing and Assisted Living Facilities.
A2024: The facility failed to correct fire alarm system faults, potentially affecting residents in the Skilled Nursing and Assisted Living Facilities.
A2036: The sprinkler system was out of service for more than four hours without proper notification, potentially affecting all residents.
A2037: The facility failed to maintain required exit sign illumination and emergency lighting, potentially affecting residents in multiple smoke zones.
A2049: The facility failed to maintain emergency lighting and exit signage, potentially affecting residents in multiple smoke zones.
A2050: The facility failed to maintain emergency lighting intensity and automatic transfer switches, potentially affecting residents in multiple smoke zones.
A2054: The facility failed to maintain smoke section walls and doors, potentially affecting residents in multiple smoke zones.
A3001: The facility failed to maintain building construction and fire protection systems in good repair, potentially affecting residents in multiple smoke zones.
A3030: The facility failed to maintain electrical wiring and equipment in accordance with NFPA 70, potentially affecting residents in multiple smoke zones.
A4013: The facility failed to maintain policies and procedures for personnel, potentially affecting all residents.
A4015: The facility failed to inform personnel of policies and duties, potentially affecting all residents.
Report Facts
Facility census: 89
Total capacity: 108
Total capacity: 62
Number of smoke zones: 16
Inspection Report
Life Safety
Census: 94
Capacity: 108
Deficiencies: 2
Date: May 31, 2018
Visit Reason
The inspection was conducted to assess compliance with the 2012 edition of the Life Safety Code of the National Fire Protection Association (NFPA) and related reference documents, specifically focusing on fire safety and evacuation plans following a fire incident.
Findings
The facility failed to include a policy for conducting hourly fire watches for 24 hours after a fire, which potentially affected all residents. The fire watch policy was missing directions for hourly checks after a fire, and staff were not instructed to conduct these checks.
Deficiencies (2)
K711 Evacuation and Relocation Plan is missing a policy for conducting hourly fire watches for 24 hours after a fire, potentially affecting all residents. Staff were not instructed to conduct hourly fire watches in the affected area after the fire.
A2005 19 CSR 30-85.022(2)(G) Fire-24hr Monitor, Hourly Checks regulation is not met as the facility failed to monitor the area for 24 hours following the fire with documented hourly visual checks.
Report Facts
Facility census: 94
Licensed capacity: 108
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joyce Ann Leffert | Administrator | Signed the plan of correction and was interviewed regarding fire watch policy |
| LPN A | Licensed Practical Nurse who extinguished the fire and was interviewed about the incident |
Report
Jul 3, 2023
Viewing
Loading inspection reports...
