Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record

COMPLETE CARE AT FOX HILL

VERNON, CT · 120 certified beds · Last Life Safety survey May 22, 2024

CMS Certification Number 075183 · first certified April 1967

Ownership

Operated by COMPLETE CARE · For profit - Limited Liability company

Ownership changed November 15, 2022 (change of ownership)to COMPLETE CARE AT FOX HILL LLC from 22 SOUTH STREET OPERATIONS LLC

Citations on file

Rolling three-year window

Life Safety surveys

In the same window

Tags cited more than once

Across separate surveys

Inspection & testing records

Of the citations on file

Position within CT

26 citations — more than 93% of the 191 certified nursing homes in CT. Compared within CT rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated

Improvingfewer citations at the latest survey than at its earlier surveys in the window.

The latest survey found 5 citations; the earlier surveys in the window averaged 10.5. With 3 surveys on file this is a direction of travel, not a conclusion.

When is the next survey likely?

Past the typical window (March 2026 to September 2026). Most CT facilities have been surveyed by November 2026. This facility’s last Life Safety survey was May 2024. Facilities in CT are typically surveyed 21–28 months after the last one (median 24), measured over 181 consecutive surveys in the last two years of CMS records.

A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured

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2 inspection-and-testing tags have been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.

Emergency preparedness

3 of the 26 citations on file are Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index

Physical environment (health survey)

4 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 26 Life Safety citations above. The Physical Environment Index

F-0880 Provide and implement an infection prevention and control program.
F-0919 Make sure that a working call system is available in each resident's bathroom and bathing area.

How that compares

Citations on file over three years

Compared with the median facility in CT, and nationally. Surveyors differ markedly between states, so the CT figure is the meaningful one.

Citations on file over three years, compared
Measure	Citations
This facility	26
Median facility in CT	10
Median facility nationally	11

Survey history

Citations at each Life Safety survey

Citations at each Life Safety survey
Survey date	Citations
July 5, 2019	5
November 19, 2021	16
May 22, 2024	5

Most-cited tags

Most-cited tags at this facility

Most-cited tags at this facility
Tag	What the surveyor checks	Times cited	Last cited
K-0918	Have generator or other power source capable of supplying service within 10 seconds.	2	2024-05-22
K-0211	Keep aisles, corridors, and exits free of obstruction in case of emergency.	2	2021-11-19
K-0223	Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.	2	2024-05-22
K-0353	Inspect, test, and maintain automatic sprinkler systems.	2	2021-11-19
K-0324	Provide properly protected cooking facilities.	1	2021-11-19
K-0345	Have approved installation, maintenance and testing program for fire alarm systems.	1	2024-05-22
E-0030	List the names and contact information of those in the facility.	1	2021-11-19
K-0363	Install corridor and hallway doors that block smoke.	1	2021-11-19

What the citations cover

Citations by CMS category

Smoke Deficiencies 9
Egress Deficiencies 5
Gas, Vacuum, and Electrical Systems Deficiencies 5
Miscellaneous Deficiencies 3
Other 4

Citations by CMS category
Category	Citations
Smoke Deficiencies	9
Egress Deficiencies	5
Gas, Vacuum, and Electrical Systems Deficiencies	5
Miscellaneous Deficiencies	3
Emergency Preparedness Deficiencies	3
Services Deficiencies	1

Every citation on file

As published by CMS, newest survey first. Descriptions are CMS’s own wording.

May 22, 2024 — 5 citations

Citations issued on May 22, 2024
Tag	What the surveyor checks	Status
K-0223	Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.	Deficient, Provider has date of correction (July 2, 2024)
K-0345	Have approved installation, maintenance and testing program for fire alarm systems.	Deficient, Provider has date of correction (July 2, 2024)
K-0914	Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.	Deficient, Provider has date of correction (July 23, 2024)
K-0918	Have generator or other power source capable of supplying service within 10 seconds.	Deficient, Provider has date of correction (July 23, 2024)
K-0921	Ensure that testing and maintenance of electrical equipment is performed.	Deficient, Provider has date of correction (July 2, 2024)

November 19, 2021 — 16 citations

Citations issued on November 19, 2021
Tag	What the surveyor checks	Status
E-0007	Address patient/client population and determine types of services needed.	Deficient, Provider has date of correction (February 1, 2022)
E-0030	List the names and contact information of those in the facility.	Deficient, Provider has date of correction (February 1, 2022)
E-0037	Establish staff and initial training requirements.	Deficient, Provider has date of correction (February 1, 2022)
K-0211	Keep aisles, corridors, and exits free of obstruction in case of emergency.	Deficient, Provider has date of correction (February 1, 2022)
K-0222	Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.	Deficient, Provider has date of correction (February 1, 2022)
K-0223	Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.	Deficient, Provider has date of correction (February 1, 2022)
K-0324	Provide properly protected cooking facilities.	Deficient, Provider has date of correction (February 1, 2022)
K-0341	Install a fire alarm system that can be heard throughout the facility.	Deficient, Provider has date of correction (February 1, 2022)
K-0351	Install an approved automatic sprinkler system.	Deficient, Provider has date of correction (February 1, 2022)
K-0353	Inspect, test, and maintain automatic sprinkler systems.	Deficient, Provider has date of correction (February 1, 2022)
K-0355	Properly select, install, inspect, or maintain portable fire extinguishes.	Deficient, Provider has date of correction (February 1, 2022)
K-0363	Install corridor and hallway doors that block smoke.	Deficient, Provider has date of correction (February 1, 2022)
K-0500	Meet other general requirements that are deficient.	Deficient, Provider has date of correction (February 1, 2022)
K-0711	Provide a written emergency evacuation plan.	Deficient, Provider has date of correction (February 1, 2022)
K-0781	Have restrictions on the use of portable space heaters.	Deficient, Provider has date of correction (February 1, 2022)
K-0920	Ensure proper usage of power strips and extension cords.	Deficient, Provider has date of correction (February 1, 2022)

July 5, 2019 — 5 citations

Citations issued on July 5, 2019
Tag	What the surveyor checks	Status
K-0211	Keep aisles, corridors, and exits free of obstruction in case of emergency.	Deficient, Provider has date of correction (September 23, 2019)
K-0321	Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.	Deficient, Provider has date of correction (September 23, 2019)
K-0353	Inspect, test, and maintain automatic sprinkler systems.	Deficient, Provider has date of correction (September 23, 2019)
K-0712	Have simulated fire drills held at unexpected times.	Deficient, Provider has date of correction (September 23, 2019)
K-0918	Have generator or other power source capable of supplying service within 10 seconds.	Deficient, Provider has date of correction (September 23, 2019)

Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.