FOX SUBACUTE AT SOUTH PHILADELPHIA

1930 SOUTH BROAD STREET, PHILADELPHIA, PA 19145 (215) 709-4000
Non profit - Corporation 53 Beds Independent Data: November 2025
Trust Grade
75/100
#172 of 653 in PA
Last Inspection: February 2025

Within standard 12-15 month inspection cycle. Federal law requires annual inspections.

Overview

Fox Subacute at South Philadelphia has received a Trust Grade of B, indicating it is a good choice among nursing homes. It ranks #172 out of 653 facilities in Pennsylvania, placing it in the top half of the state, and #8 out of 46 in Philadelphia County, meaning only seven local facilities are rated higher. The facility's trend is stable, with six issues noted in both 2024 and 2025, which suggests consistency in their performance. Staffing is a notable strength, with a 2/5 star rating and a turnover rate of 37%, which is better than the state average of 46%, but still below average; however, there is good RN coverage, exceeding that of 91% of Pennsylvania facilities. On the downside, there were no fines reported, but recent inspections revealed concerning practices, such as failure to provide appropriate respiratory care for multiple residents and issues with the use of restraints without proper consent or evaluations, highlighting areas that need improvement.

Trust Score
B
75/100
In Pennsylvania
#172/653
Top 26%
Safety Record
Low Risk
No red flags
Inspections
Holding Steady
6 → 6 violations
Staff Stability
○ Average
37% turnover. Near Pennsylvania's 48% average. Typical for the industry.
Penalties
✓ Good
No fines on record. Clean compliance history, better than most Pennsylvania facilities.
Skilled Nurses
✓ Good
Each resident gets 96 minutes of Registered Nurse (RN) attention daily — more than 97% of Pennsylvania nursing homes. RNs are the most trained staff who catch health problems before they become serious.
Violations
⚠ Watch
20 deficiencies on record. Higher than average. Multiple issues found across inspections.
★★★★☆
4.0
Overall Rating
★★☆☆☆
2.0
Staff Levels
★★★☆☆
3.0
Care Quality
★★★★☆
4.0
Inspection Score
Stable
2024: 6 issues
2025: 6 issues

The Good

  • Full Sprinkler Coverage · Fire safety systems throughout facility
  • No fines on record
  • Staff turnover below average (37%)

    11 points below Pennsylvania average of 48%

Facility shows strength in fire safety.

The Bad

Staff Turnover: 37%

Near Pennsylvania avg (46%)

Typical for the industry

The Ugly 20 deficiencies on record

Feb 2025 6 deficiencies
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0604 (Tag F0604)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, a review of select facility's policy, clinical records review, and staff interviews, it was determined tha...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, a review of select facility's policy, clinical records review, and staff interviews, it was determined that the facility failed to ensure the evaluation of resident's need and use of restraints, including evaluation of the least restrictive measure needed to treat the resident's medical symptom and failed to timely obtain informed consent prior to the use of restraint for one of one sampled residents with restraints. (Residents R5) Findings include: A review of a facility policy titled Restraints - revised on September 1, 2016, revealed Physical restraints include, but are not limited to leg restraints, arm restraints, hand mitts, soft ties or vests, lap cushions and lap trays the resident cannot remove. To provide guidelines for appropriate use of restraints to prevent injury to the patient or other patients only as necessary. A. An initial assessment will be completed whenever the use of a physical device is considered. 1. Included in the assessment will be a. To determine the need for any device b. To determine what is the appropriate and least restrictive device. 2. The use of restraints will be deemed appropriate only if a specific medical condition/symptoms are present and documented and presented on the initial restraint assessment. B. Less restrictive alternatives are considered/attempted and documented. Review of facility documentation Restraint notification and Consent Information revealed that the facility had a process of obtaining informed consent prior to the use of restraints including documentation of benefits, potential negative outcome, recommendation and the written acknowledgement of resident representative of the understanding of benefits and negative outcome of restraint use. Observation Resident R5 on February 9, 2025, at 10:37 a.m. revealed that the resident was using hand mitt (a thumbless mitten device is used to restrain a patient's hands) to the both hands. Clinical record review revealed that Resident R5 was admitted to the facility on [DATE], with the diagnosis of chronic respiratory failure and tracheostomy (a surgical procedure that creates an opening (stoma) in the front of the neck into the trachea (windpipe)) status. A review of the admission Minimum Data Set Assessment (MDS) - a federally mandated standardized assessment process conducted periodically to plan resident care) dated December 25, 2024, revealed Resident 5's BIMS interview (Brief Interview for Mental Status- a tool to assess cognitive function) was not completed, which indicated that the resident was unable to provide or did not provide answers to complete this section). Further review of the MDS revealed that the resident used limb restraint daily. A physician order for Resident R5 dated December 18, 2024, revealed an order for hand mitt to both hands and remove every 2 hours for skin integrity check. Review of clinical record for Resident R5 revealed no evidence that the resident was evaluated of resident's need and use of restraints, including evaluation of the least restrictive measure needed to treat the resident's medical symptom when the facility started using restraint for Resident R5 on December 18, 2024. Further review of clinical record for Resident R5 revealed no evidence that the facility obtained informed consent prior to the use of restraint. There was no consent available in the clinical record. An undated restraint consent provided during the survey provided no indication of the date the consent was obtained. Interview with Director of Nursing on February 12, 2025, at 10:00 a.m. confirmed that the facility did not evaluate Resident R5 of residents' need and use of restraints, including evaluation of the least restrictive measure needed to treat the resident's medical symptom when the facility started using restraint and obtained documented informed consent prior to the use of restraint. 28 Pa. Code 211.8 (c.1)(f) Use of restraints 28 Pa. Code 211.12(d) Nursing services
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0688 (Tag F0688)

Could have caused harm · This affected 1 resident

Based on the observations, review of clinical records, and interview with staff, it was determined that the facility failed to ensure that a resident with limited range of motion, received appropriate...

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Based on the observations, review of clinical records, and interview with staff, it was determined that the facility failed to ensure that a resident with limited range of motion, received appropriate services to prevent further decline in range of motion and maintain appropriate positioning for two of 13 resident s reviewed. (Resident R26 and Resident R33). Finding Include: Review of physician order for Resident R26 dated May 9, 2024, revealed an order for hand grip splint to be alternated right to left every 4 hours with a schedule of 12 AM, 4AM, 8AM, 12PM, 4PM and 8PM. Review of physician order for Resident R26 dated July 31, 2024, revealed an order for elbow positioning wedges to be applied bilaterally 4 hours then removed 4 hours with a schedule of 12 AM, 4AM, 8AM, 12PM, 4PM and 8PM. Review of MDS (Minimum Data Set- Assessment of resident care needs) for Resident R26 dated January 14, 2025, revealed that the resident's range of motion was limited on both sides on both upper and lower extremities. Observation of Resident R26 on February 9, 2025, at 10:20 a.m. revealed that the resident was lying in the bed. It was observed that residents appeared to be contracture to her upper extremities. Residents was not wearing any devices or splints to the affected area. There was a white colored hand splint and blue elbow splint on the windowsill. Further observation of Resident R26 on February 9, 2025, at 12:46 p.m. revealed that the resident was lying in the bed. Residents was not wearing any devices or splints to the hands or elbow. The white colored hand splint and blue elbow splint was on the windowsill at the same location. Interview with Employee E8, Licensed Practical Nurse, on February 9, 2025, at 12:46 p.m. stated Resident R26 should wear splint as ordered by the physician every 4 hours Review of clinical record for Resident R33 revealed that the resident had diagnosis of muscle wasting, atrophy and abnormal posture Review of physician order for Resident R33 dated November 15, 2024, revealed an order for Abductor wedge to be positioned between legs at all times as tolerated. Review of physician order for Resident R33 dated December 28, 2024, revealed an order for bilateral upper extremity splint to be applied for 4 hours and remove for 4 hours. Observation of Resident R33 on February 9, 2025, at 10:25 a.m. revealed that the resident was lying in the bed. Residents was not wearing any devices or splints. There was no splint or devices in resident's room. Further observation of Resident R33 on February 9, 2025, at 12:44 p.m. revealed that the resident not wearing any devices or splints. There was no splint or devices in resident's room. Interview with Employee E8, Licensed Practical Nurse, on February 9, 2025, at 12:46 p.m. stated she was not sure if resident should be wearing splint or any devices, the employee searched the room and could not locate splint or devices. 28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services 28 Pa. Code: 201.18 (b)(2) Management 28 Pa. Code: 211.10 (d) Resident care policies
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical record, facility policy, facility documentation, and interviews with staff, it was determined that t...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical record, facility policy, facility documentation, and interviews with staff, it was determined that the facility failed to ensure that adequate assistance was provided to prevent a fall for one of two sampled residents reviewed for falls (Resident R33). This deficiency was identified as past non-compliance. Findings include: Review of Resident R33's comprehensive Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated November 14, 2024, revealed Resident R33 had severe cognitive impairment and diagnosis that included but not limited to chronic respiratory failure, anoxic brain damage (brain deprived of oxygen), and muscle wasting and atrophy. Further review of Resident R33's MDS dated [DATE], revealed Resident R33 was dependent (helper does all the effort) for all activities. Resident R33 required assistance of two or more helpers for bed mobility (how resident moves to and from lying position, turns side to side, and positions body while in bed or alternate sleep furniture). Review of Resident R33's comprehensive care plan dated September 11, 2024, revealed Resident R33 had ADL (activities of daily living) deficit related to chronic illness as evidenced by: transfer dysfunction, decreased strength, decreased bed mobility, decreased cognitive and physical function. Further review of Resident R33's comprehensive care plan revealed interventions dated September 12, 2024, Resident R33 required assistance of two staff members for bed mobility. Review of facility documentation submitted to the State Survey Agency on December 05, 2024, revealed on December 05, 2024 Resident R33 had a witnessed fall from bed while one staff member attempted to reposition Resident R33. Review of facility documentation revealed an incident report dated December 05, 2024, that revealed nurse aide, Employee E7, was preparing to provide care for Resident R33. Nurse aide, Employee E7, raised Resident R33's bed to knee height and moved the floor mat. Nurse aide, Employee E7, then removed the other floor mat to allow for another caregiver to stand on opposite side of bed. Nurse aide, Employee E7, then removed the pillow from under Resident R33's hip, turned to put the pillow on the mat, and Resident R33 rolled on to the floor. No other staff members were present to assist nurse aide, Employee 7, to turn/reposition Resident R33 in bed. Review of nurse aide, Employee E7, statement dated December 05, 2024 revealed during patient care the nurse aide, Employee E7, removed side pillow from Resident R33 and then turned away from Resident R33's bed to put pillow on matt behind his/her self. Nurse aide, Employee E7, then heard a bump and saw Resident R33 on the floor. Interview on February 10, 2025, at 10:15 a.m. with Director of Nursing, Employee E2, confirmed Resident R33 should have been assisted with two staff members during turning and repositioning in bed. On December 05, 2024, following the incident, the facility immediately implemented the following corrective actions: -On 12/05/24 [Resident R33] care plan immediately updated to include fall incident and bilateral fall mats. - On 12/05/24 Director of Nursing, Employee E7, provided direct education to Employee E7 and nurse who was assigned to Resident R33 on bed mobility orders and the required assistance when turning/ repositioning resident. -Starting on 12/05/24 and completed on 12/10/2024, Director of Nursing, Employee E2, re-educated all nursing staff on understanding bed mobility orders and where to find what assistance is required for residents. -Starting on 12/09/24 and completed on 12/10/2024, Director of Nursing, Employee E2, re-educated all nursing staff on understanding floor mats and the removal of floor mats when the required assistance is present and ready to assist. -Starting on 12/06/2024 and continuous auditing through 01/29/25, Director of Nursing, Employee E2, conducted safety audit bed mobility/floor mats to ensure bed mobility orders were followed accordingly and floor mats were in place for residents who required them. Interviews with nursing staff on February 11, 2024 at 9:45 a.m. confirmed that they had all been in-serviced on reviewing bed mobility orders and ensuring proper assistance is being provided during care. Review of clinical records and observations revealed proper assistance was being provided for bed mobility orders and floor mats were in placed as ordered for residents. This deficiency was identified as past non-compliance. 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(d)(1) Nursing services
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Incontinence Care (Tag F0690)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records, observations, and staff interviews, it was determined that the facility failed to ensure th...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records, observations, and staff interviews, it was determined that the facility failed to ensure that adequate catheter care was provided for two of two sampled residents with urinary catheters reviewed (Residents R4, and R39). Findings include: Review of Resident R4's clinical record revealed Resident R4 was admitted to the facility on [DATE] for a diagnosis that included but not limited to chronic respiratory failure, anoxic brain damage (complete lack of oxygen to the brain), and retention of urine. Observation on February 10, 2024 at 12:22 p.m. revealed Resident R4's indwelling urinary catheter drainage bag (a flexible catheter used to drain urine from the bladder into a drainage collection bag) lying flat on floor on the right side of Resident R4's bed. Interview on February 10, 2025 at 12:26 p.m. with Employee E5, Nurse Aide, confirmed Resident R4's indwelling urinary catheter drainage bag should not be on the floor. Review of Resident R39's clinical record revealed Resident R39 was admitted to the facility on [DATE] for a diagnosis that included but not limited to chronic respiratory failure, muscle weakness, and retention of urine. Observation on February 10, 2025 at 1:00 p.m. revealed Resident R39's indwelling urinary catheter drainage bag lying flat on floor on the right side of Resident R39's bed. Interview on February 10, 2025 at 1:05 p.m. with Employee 6, Registered Nurse, confirmed Resident R39's indwelling urinary catheter drainage bag should not be on the floor. 28 Pa. Code 211.12(d)(3)(5) Nursing Services.
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, review of facility policy, and interviews with staff, it was determined that the facility failed to prope...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, review of facility policy, and interviews with staff, it was determined that the facility failed to properly date medication vials upon opening and failed to discard expired medication for two of three medication carts (Medication Cart Four and Medication Cart Five) and and two of two medication rooms (Room Two). Findings include: Review of facility policy titled Storage of Medication, dated 2016, revealed insulin products should be stored in the refrigerator until opened. Note the date on the label for insulin vials and pens when first used. The opened insulin vial may be stored in refrigerator or at room temperature. Outdated, contaminated, discontinued, or deteriorated medications and those in containers that are cracked, soiled or without secure closures are immediately removed from stock, disposed of according to procedures for medication disposal. Observation conducted on February 11, 2025 at 11:43 a.m. in medication storage Room Two revealed two tuberculin (TB) vials (used to diagnosis tuberculosis). TB vial one was opened and undated and vial two had an opened date of [DATE]. Instructions listed on TB vial manufacturing package was to discard after 30 days upon opening. Interview on February 11, 2025 at 11:50 a.m. with Employee E3, Registered Nurse, confirmed TB vial one was opened and not dated and TB vial two was expired. Observation on February 11, 2025 at 11:57 a.m. on Medication Cart Five revealed five insulin vials that were opened and undated, which included two Humalogs, two Novalogs, and one Lantus. Interview on February 11, 2025 at 12:00 p.m. with Employee E3, Registered Nurse, confirmed the five insulin vials were opened and undated. Observation on February 11, 2025 at 12:10 p.m. on Medication Cart Four revealed two opened insulins, Novalog opened [DATE] and Humalog opened [DATE], exceeding the recommended 28 days to discard after vial opening date. Interview on February 11, 2025 at 12:15 p.m. with Employee E5, License Practical Nurse, confirmed both insulin vials were expired. 28 Pa Code 211.9(a)(1) Pharmacy services 28 Pa Code 211.12(d)(5) Nursing services
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Food Safety (Tag F0812)

Could have caused harm · This affected 1 resident

Based on observations, interviews with staff, and a review of facility policies and documentation, it was determined that the facility did not ensure that food was stored, prepared, distributed, and s...

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Based on observations, interviews with staff, and a review of facility policies and documentation, it was determined that the facility did not ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. Findings include: Review of facility policy Food and Nutritional Services Administration and Requirement dated September 1, 2016, revealed Refrigerators freezers and dry storage areas will be checked for temperature twice daily (at opening and closing times) and temperature will be recorded on the log, Review of facility policy Kitchen Dishwasher temperature dated September 1, 2016, revealed, All temperatures are to be recorded on the dishwasher temperature log once per meal service, An initial tour of the Food Service Department was conducted on February 9, 2025, at 12:00 a.m. with Employee E13, Food Service Manager, which revealed the following: The facility dish machine temperature log for February 2025, revealed that the temperature recording was available only up to February 3, 2025. There was no temperature available for February 4, 5, 6, 7, 8, and February 9 breakfast time. The Refrigerator temperature log for one of the refrigerators revealed that the last recorded temperature was on December 29, 2025. There was no temperature available on or after December 30, 2024. The three compartment sink log for February 2025, revealed that the Sanitizer recording was available only up to February 3, 2025. There was no sanitizer recording available for February 4, 5, 6, 7, 8, and February 9 breakfast time. Observation of the walk-in refrigerator with Employee E13 revealed that there were boiled eggs in the refrigerator with no expiration date. There was a container of dessert without open date, package date or expiration date. There were also 3 boxes of breads without any date or labels. 28 PA Code: 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(3) Management
Apr 2024 6 deficiencies
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Notification of Changes (Tag F0580)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records and a staff interview, it was determined that the facility failed to ensure that the residen...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records and a staff interview, it was determined that the facility failed to ensure that the resident's representative was notified timely about a hospital transfer for one of three discharge records reviewed (Residents R49). Findings include: A review of clinical records revealed that Resident R47 was admitted to the facility on [DATE], with diagnosis to include Chronic Respiratory Failure (is a serious condition that affects your lungs and blood oxygen levels which may require a ventilator). Further review revealed a progress note dated January 10, 2024, which stated, Labs were drawn this am because they were ordered. PT (physical therapist) noted that the patient's abdomen was distended, called the doctor and got an order for BMP and abdominal X-ray. The labs were done and am waiting for X-Ray . I sent labs to attendings and took a verbal order. to send patient out to ER 9emergency room) for Eval. I called [hospital] and gave report to . 911 was called to transport patient to local ER. Continued review revealed no documentation that the responsible party was notified of the transfer to the hospital. Interview with the Administrator and Director of Nursing on April 12, 2024, at 11:00 a.m., confirmed that Resident R47's responsible party and/or power of attorney was not notified of the resident need for hospitalization. 28 Pa. Code 211.12(d)(5) Nursing services.
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, a review of clinical records, facility documentation and staff interviews, it was determined that the faci...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, a review of clinical records, facility documentation and staff interviews, it was determined that the facility failed to develop and implement a comprehensive person-centered care plans regarding the use of hand mitt restraints for one of 13 residents reviewed. (Resident R37). Findings include: A review of clinical records revealed that Resident R37 was admitted to the facility on [DATE], with diagnosis to include Chronic Respiratory Failure (is a serious condition that affects your lungs and blood oxygen levels which may require a ventilator). Further review revealed an April 4, 2024, physician's order for please place hand mitts for safety and preventing dislodgement of new midline every shift for safety. Observation of Resident R37 in the Activity Room adjacent to the nursing station on April 9, 2024, at 11:45 a.m. revealed that the resident was wearing the hand mitts while sitting at the table with several other resident during an activity program. Observation of Resident R37 in room [ROOM NUMBER] on April 10, 2024, at 11:32 a.m. revealed that the resident was wearing the hand mitts while in bed. Review of Resident R37's care plan revealed no care plan for the use of hand mitt restraints. Further review of Resident R37's Medication Administration Record for April 1, 2024 to April 30, 2024, revealed that the hand mitts were placed each shift starting April 5, 2024. An interview on April 12, 2024, at 11:30 a.m. with the Director of Nursing confirmed that the resident did not have a comprehensive care plan regarding the use of hand mitt restraints. 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(d)(5) Nursing services
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Pharmacy Services (Tag F0755)

Could have caused harm · This affected 1 resident

Based on observation, clinical record review and interview with staff, it was determined that the facility did not ensure that medications were discarded according to manufacturer instructions for 1 o...

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Based on observation, clinical record review and interview with staff, it was determined that the facility did not ensure that medications were discarded according to manufacturer instructions for 1 of 3 medication carts reviewed (Medication Cart Main B). Findings include: Review of medications stored in the Medication Cart Main B, conducted on April 11, 2024, at 1:19 p.m., in the presence of Licensed Nurse, Employee E6, revealed the following expired medications: Oxycodone HCl (IR) 5 mg tablet, 17 tablets, expired on March 2024, marked for Resident R17; Tramadol HCl 50 mg tablet, 25 tablets, expired on March 2024, marked for Resident R17; and Lorazepam 1 mg tablet, 23 tablets, expired on December 2023, marked for Resident R5. Interview with the of Licensed Practical Nurse, Employee E6, at the time of the finding, confirmed that the expired medications should have been discarded according to manufacturer instructions, and facility policy. 28 Pa Code 211.9(a)(1) Pharmacy services 28 Pa Code 211.12(d)(5) Nursing services
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Unnecessary Medications (Tag F0759)

Could have caused harm · This affected 1 resident

Based on observations, review of clinical records, and interviews with facility staff, it was determined that the facility failed to ensure that it was free of medication error rate of five percent or...

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Based on observations, review of clinical records, and interviews with facility staff, it was determined that the facility failed to ensure that it was free of medication error rate of five percent or greater, in two out of twenty-five medications reviewed. Findings include: On April 9, 2024, at 9:41 a.m., observed that Employee E11, a Licensed Nurse, administered to Resident R16, Vitamin D3 (Cholecalciferol), 1000 unit (25 mcg), one tablet, by mouth. Review of physician order for R16, dated April 3, 2024, revealed an order to administer Vitamin D3 Tablet (Cholecalciferol), 2000 unit (50 mcg), by mouth, one time a day, for Nutritional Deficiency. At the time of the observation, interviewed Employee E11, Licensed Nurseand confirmed the findings. On April 9, 2024, at 12:02 p.m., observed that Employee E10, a Registered Nurse, prepared to administer to Resident R25, Aspirin Enteric Coated 81 mg tablet, via G-Tube, but its administration was averted, as, Enteric Coated tablets should not be crushed. (Enteric coated tablets are tablets that are coated with an enteric coating. Crushing enteric coated tablets may result in the drug being released too early, destroyed by stomach acid, or irritating the stomach lining. Review of medical literature, in, https://newsnetwork.mayoclinic.org/discussion, revealed that with enteric-coated aspirin, research indicated that bloodstream absorption may be delayed and reduced, compared to regular aspirin absorption. Regular aspirin is quickly dissolved and absorbed in the stomach. As a result, enteric-coated aspirin may not be as effective as regular aspirin at reducing blood clot risk). Review of physician order for Resident R25, dated July 10, 2023, revealed an order to administer Aspirin Tablet, 81 mg, via G-Tube one time a day. At the time of the observation, interviewed E10, and confirmed the findings. This erroneous medical administration incurred a medication error rate of 8%. The facility incurred a medication error rate of 8 %. Pa Code:211.12(d)(1)(2)(5) Nursing Services.
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Food Safety (Tag F0812)

Could have caused harm · This affected 1 resident

Based on observations, interviews with staff, and a review of facility policies and documentation, it was determined that the facility did not ensure that food was stored, prepared, distributed, and s...

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Based on observations, interviews with staff, and a review of facility policies and documentation, it was determined that the facility did not ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. Findings include: The untitled and undated policy for food storage states, Food is stored in compliance with applicable Federal, State and Local regulations regarding sanitary food storage. An initial tour of the Food Service Department was conducted on April 8, 2024, at 11:00 a.m. with Employee E3, Food Service Director, which revealed the following: Observation in the walk-in freezer revealed a box of carrots that was open with the inner plastic liner open to the circulating air. Observation in the reach-in freezer revealed a bag of breaded chicken tenders that was open to the circulating air. Interview with Food Service Director on April 8, 2024, at 11:15 a.m., confirmed the above findings. Observation of the resident storage refrigerator on April 9. 2024 at 11:50 a.m. revealed several items that were expired or not labeled. The refrigerator and freezer had several spills that were not cleaned. In the refrigerator there was a carton of milk that was expired on March 14, 2024. A container of tuna salad with no date and no label. A container of yogurt and granola labeled April 2, 2024. A container of yogurt and blueberries with no date and no label. A container of peaches labeled March 27, 2024. A contained of macaroni salad labeled April 4, 2024. A salad with tuna with no date and no label that appeared soggy. Interview with the Registered Dietician, Employee E7 on April 9, 2024 at 12:20 p.m. confirmed the findings and the refrigator and stated that the kitchen is in charge of cleaning out the refrigerator once a week. 28 PA Code: 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(3) Management
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0947 (Tag F0947)

Could have caused harm · This affected 1 resident

Based on review of facility documentation and staff interview, it was determined that the facility failed to ensure nurse aide staff received in-service training to be proficient and competent and tha...

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Based on review of facility documentation and staff interview, it was determined that the facility failed to ensure nurse aide staff received in-service training to be proficient and competent and that the training be no less than 12 hour annually for two of three nurse aide staff. (Employee 16 and Employee 17). Findings Include: A request for nurse aides annual in-service training record for nurses' aides was requested on April 10, 2024. Review of nurses' aides training records revealed that nurse aides, Employee E16 and Employee E17 did not have the required 12 hours of annual in-service training as required. Interview with Director of Nursing, Employee E2 on April 11, 2024 at 1:02 p.m. confirmed there was no further record on in-service trainings for nurse aides' Employee E16 and Employee E17. 28 Pa. Code 201.14 (a) Responsibility of licensee.
Jun 2023 8 deficiencies
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Grievances (Tag F0585)

Could have caused harm · This affected 1 resident

Based on observations, review of facility policy, interviews with residents and staff, and review of facility documentation, it was determined the facility failed to ensure residents were informed and...

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Based on observations, review of facility policy, interviews with residents and staff, and review of facility documentation, it was determined the facility failed to ensure residents were informed and had access to grievance/concern forms for two of 44 residents reviewed (Resident R7 and R9) Findings Include: Review of policy Abuse Complaint and Grievance Policy revised on, November 2018 revealed there is no part of the procedure that states how residents can obtain and file a grievance anonymously. Further review of the same policy states, all complaints/grievances are cited on paper, thoroughly investigated and all necessary and appropriate corrective actions are taken. During interviews with Resident R9 and Resident R7, on June 6, 2023, at 1:15 p.m. and June 7, 2023, at 11:00 a.m. respectively, the residents revealed they were unaware how to file a grievance and/or an anonymous grievance at the facility. A tour of the facility on June 8, 2023, at approximately 10:00 a.m., with the Nursing Home Administrator and the Activity Director confirmed there were no postings throughout the facility of the right to file grievances orally or in writing, the right to file grievances anonymously, or the contact information of the grievance official with whom a grievance can be filed. 28 Pa. Code: 201.29(i) Resident Rights.
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0602 (Tag F0602)

Could have caused harm · This affected 1 resident

Based on observations, review of clinical records, review of facility policies and staff interviews, it was determine that the facility failed to prevent misappropriation of resident's medications for...

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Based on observations, review of clinical records, review of facility policies and staff interviews, it was determine that the facility failed to prevent misappropriation of resident's medications for two of two residents observed (Resident R13) Finding include: Review of the facility's abuse police updated November 28, 2015 states the facility must protect its residents to the fullest extent possible from physical, verbal, sexual or mental abuse, acts of neglect, corporal punishment, seclusion and misappropriation of residents property, which includes medications. Review of the facility medication administration policy updated November 30, 2018, states The purpose of this policy is to ensure the proper medication administration, dosage and patient route . assure the administration accuracy, the nurse shall cross check the following reference points; physician order, medicine administration record and label on the medication container. Review of Residents R28's May 2023 Medication Administration Record reveled that Resident R28 has a diagnosis of left knee wound and was ordered the antibiotic medication Clindamycin Phosphate External Gel 1% ointment to be applied every shift to the right inner knee on May 24, 2023. Review of Resident R28's May 2023 Medication Treatment Record reveled that resident did not receive Clindamycin Phosphate External Gel 1% ointment on May 26, 27, 28, 29 and 30, 2023 due to the medication not being available. Further review of Resident R28's nursing note dated May 29, 2023 revealed that the Director of Nursing was made aware and placed a call to Nurse Practitioner requesting a hold be placed on this medication. Interview with the Director of Nursing on June 7, 2023 at 11:50 a.m. confirmed that she was made aware of the medicated ointment not having been administered to Resident R28 and because the medication was misplaced. Observations conducted during a medication administration pass, June 8, 2023 at 8:15 a.m. revealed that Licensed nurse, Employee E6 proceeded to prepare medications for Resident R13. Review of the resident's electronic medication record revealed that the resident was ordered Levetracetan (Keppra is an anticonvulsant used primarily to treat seizures) 10 milliters enterally (via gastrostomy tube). The medication Levetracetan was missing from medication. Licensed nurse, Employee E6 took the medication Levetraceten prescribed to Resident R34 and dispensed the medication into medicine cup to be given to Resident R13. Licensed nurse, Employee E6, confirmed that Resident 13 did not have avaible for administration Levetracetan on the cart and that she intended to give Resident 34's Levetraceten to Resident 13. Continued observation on June 8, 2023 8:22 a.m. revealed that Licensed nurse, Employee E6 administered the medication Levetracetan through a syringe enterally to Resident R13. 28 Pa. Code 211.10 (c) Resident care policies 28 Pa. Code 211.12 (d)(1) Nursing services 28 Pa. Code 211.12(5) Nursing services
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0688 (Tag F0688)

Could have caused harm · This affected 1 resident

Based on the review of clinical records, observation and interview with the staff, it was determined that the facility did not ensure that a resident with limited range of motion received appropriate ...

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Based on the review of clinical records, observation and interview with the staff, it was determined that the facility did not ensure that a resident with limited range of motion received appropriate services according to the professional standards of practice for one of one resident reviewed for positioning and mobility. (Resident R30) Findings Include: Review of care plan for Resident R30 dated April 25, 2023, revealed that Activities of Daily Living (ADL) deficit related to transfer dysfunction, decreased strength, and decreased cognitive and physical function. Review of physician order for Resident R30 dated April 28, 2023, revealed an order for bilateral hand splints 4 hours every shift as tolerated. Further review of the physician order dated April 25, 2023, revealed that husband would like hands elevated all times secondary to edema. Observation of Resident R30 on June 6, 2023, at 10:45 a.m. revealed that the resident had limited range of motion and the resident was not wearing her splints. Resident's hands were not elevated. Observation of Resident R30 on June 6, 2023, at 12:23 p.m. revealed that the revealed that the resident was not wearing her splint. Interview with Resident R30's husband revealed that staff not consistently applying the splint as ordered, it always sits at the bed side. Husband also stated he complained about the issue multiple times. Observation of Resident R30 on June 8, 2023, at 10:45 a.m. revealed that the resident was not wearing her splint. Observation of Resident R30 on June 8, 2023, at 12:45 p.m. revealed that the resident was not wearing her splint. Interview with nursing assistant, Employee E10, revealed that the splints were to be applied by restorative nursing assistant. She was not sure who is the assigned restorative nursing assistant. Nursing assistant also stated she was not aware that the resident should wear a splint. Interview with Director of Nursing, on June 8, 2023, at 1:13 p.m. stated there was no assigned nursing assistant for restorative, providing range of motion or applying splints, it was completed by assigned nursing assistants. 28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services 28 Pa. Code: 201.18 (b)(2) Management 28 Pa. Code: 211.10 (d) Resident care policies
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Incontinence Care (Tag F0690)

Could have caused harm · This affected 1 resident

Based on observations, review of facility policy and interview with staff, it was determined that the facility failed to provide appropriate nephrostomy tube care for one of one resident reviewed. (Re...

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Based on observations, review of facility policy and interview with staff, it was determined that the facility failed to provide appropriate nephrostomy tube care for one of one resident reviewed. (Resident R2). Findings Include: Review of facility policy interventional Radiology Drainage System: dated November 30, 2018, revealed that To provide appropriate care for the patients who have an interventional radiology placed drainage tube in place, may include an abscess tube or nephrostomy tube. Emptying the drain-To be done q (every shift): 1. Place waterproof pad or towel under the drain to soak upa ny spills. Place the bag lower than the site to prevent fluid from flowing back to patient's body. Checks the bag for any holes or cracks. Observation of Resident R2 on June 6, 2023, 11:06 a.m., revealed that resident's nephrostomy bags which was connected to nephrostomy was placed at the lower half of the bed. Foot of the bed was elevated, and the catheter bag was above residents body level. Observation of Resident R2 on June 8, 2023, at 11:43 a.m. revealed that resident's nephrostomy bags which was connected to nephrostomy was placed on pillow at the lower half of the bed. Foot of the bed was elevated, and the catheter bag was higher than residents body level. Interview with Employee E10, Nursing Assistant. on June 8, 2023, at 11:43 a.m. confirmed that the drainage bag was above residents body level. Employee E10 then placed the bag below the nephrostomy site. Review of care plan for Resident R2, initiated on December 1, 2022 revealed no documented evidence that the facility developed a care plan for nephrostomy care with appropriate interventions. 28 Pa Code 211.12 (a)(c)(d)(1)(5) nursing services
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Pharmacy Services (Tag F0755)

Could have caused harm · This affected 1 resident

Based on clinical record review and interview with staff, it was determined that facility failed to enure timely availability of medication from pharmacy and disposition of unwanted medications to two...

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Based on clinical record review and interview with staff, it was determined that facility failed to enure timely availability of medication from pharmacy and disposition of unwanted medications to two out of 6 residents observed. (Resident R28 and Resident R152) Findings include: Review of the facility's medication disposal policy, updated November 30, 2015 described the proper disposal of medication is to be removed from original container and funnel the medication into the Drug Buster or an undesirable substance locked in the med room. Observation of the medication administration pass on June 7, 2023 8:50 a.m. with Employee E5, revealed that Employee E5 was preparing the following prescribed medications for Resident R 152. Diazepam 2 milligrams (mg) 1 tablet (tab), Carbidopa Levodopa 25-100 mg 1 tab, Apixaban tab 5mg, Protonix tab 40 mg, Magnesium oxide tab 400 mg 1 tab; Famotidine tab 20 mg 1 tab; Gabapentin 300 mg; Bisacodyl oral tab 5 mg; Cholecalciferol oral tab 25 mcg (1000ut); Dextromethorophan guaifenesin oral syrup 5 ml every 6 hours as needed; Duloxetine oral capsule 30 mg; Acidophilus oral cap 2 capsules; Senna tab 8.6, 2 tabs once daily; Polyethylene Glycol oral powder 34g. Continued observation on June 7, 2023 at 9:05 a.m. of Licensed nurse, Employee E5 revealed that Resident R152 took the medication cup, the resident then extracted 3 pills; Apixaban, Fametidine, and Protonix, then refused the other medications. Resident R152 requested pain medication and cough syrup. Employee E5 collected the unused medications brought it to the medication cart then prepared Resident R152's Hydromorphen and Dexrothorophan syrup. Employee E5 then was observed discarding the unused medications into trash on side of medication cart. The medication pills were visible on top of trash. During interview with Licensed nurse, Employee E5 on June 7, 2023 at 9:15 a.m. the employee was question of how she disposed of the medications that Resident R152 refused. Employee E5 stated that she threw them in the trash. Review of Residents R28's May 2023 Medication Administration Record reveled that Resident R28 has a diagnosis of left knee wound and was ordered on May 24, 2023 the antibiotic medication Clindamycin Phosphate External Gel 1% apply to right inner knee topically every shift for wound treatment for 14 days. Review of Resident R28's May 2023 Medication Treatment Record revealed that resident did not receive Clindamycin Phosphate gel on May 26, 27, 28, 29 and 30, 2023 due to the medication not being available from pharmacy. Review of nursing documentation dated May 27, 28, 29, 2023 noted that the facility was waiting for pharmacy to deliver the medication Clindamycin ointment. Further review of Resident R28's nursing note dated May 29, 2023 reveled that the Director of Nursing was made aware that the medication has not been delivered from pharmacy and placed a call to Nurse Practitioner requesting a hold be placed on this medication. Interview with the Director of Nursing on June 7, 2023 at 11:50 a.m. confirmed that she was made aware of the medication not having been administered to Resident R28 and because the medication was misplaced. The Director of Nursing stated that she placed a new order for the Clindamycin gel on May 30, 2023 and it was never received by the facility. The medication was reordered on June 7, 2023 by wound care physician Employee E3. 28 Pa. Code 211.9(j) Pharmacy services 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(d)(1) Nursing services 28 Pa. Code 211.12(5) Nursing services
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected 1 resident

Based on observation and interview, it was determined that the facility failed to ensure all drugs and biologicals were labeled in accordance with the professional standards, including marking of open...

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Based on observation and interview, it was determined that the facility failed to ensure all drugs and biologicals were labeled in accordance with the professional standards, including marking of opened dates in two of two medication carts observed. (Medication cart 2 and Medication cart 3) Findings: Observation of medication cart 2 on June 8, 2023 at 9:28 a.m. reveled two of 4 boxes of Refresh and Gentle Tears eye drops were not dated with the date of open on the vial or box. Interview with Licensed nurse, Employee E7 at time of observation confirmed that the opened boxes were missing dates. Observation of medication cart 3 on June 8, 2023 at 8:40 a.m. reveled 3 of 4 boxes of opened eye drops without any labeling of date opened. These eye drops included Polvinyl solution and Carboxymethylcellulose ophthalmic solution. Interview with Licensed nurse, E6 confirmed they did not have the dates labeled. 28 Pa. Code 211.12(d)(1) Nursing services 28 Pa. Code 211.12(5) Nursing services
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Infection Control (Tag F0880)

Could have caused harm · This affected 1 resident

Based on observation, review of manufactures recommendations, facility policy and interview with staff, it was determined that the facility failed to ensure appropriate infection control practices rel...

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Based on observation, review of manufactures recommendations, facility policy and interview with staff, it was determined that the facility failed to ensure appropriate infection control practices related to staff COVID 19 testing and management of biohazard waste. Findings Include: Review of facility policy, Infectious Waste and Sharps Disposal dated November 30, 2018, revealed that infectious waste any items contaminated with blood, infectious stool, or any infectious body fluids. Equipment needed: B. Appropriately marked infectious waste containers. C. Red plastic liners. Review of manufacture's recommendation of facility COVID-19 testing kit revealed that treat all specimens as potentially infectious. Follow universal precautions when handling samples, this kit and its contents. Observation of facility hallway on June 8, 2023, at 10:00 a.m. revealed that the staff was performing rapid COVID-19 test on the hallway between two resident room. After collecting the nasal swab, staff placed the test on an overhead table in the hallway. The area was not contained. Observation of facility hallway on June 8, 2023, at 12:00 p.m. revealed that the test materials, used infectious swabs, test kit, gloves were placed in a small open trash container in the hallway. There was no infectious waste container or red plastic liners available. Interview with Nursing Home Administrator and Directo of Nurising on June 8, 2023, at 12:00 p.m. confirmed that the staff did not use biohazard containers for disposing COVID 19 test kit, swabs or gloves. Also performed testing on resident hallway. 28 Pa. Code 211.01(d) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services
CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Respiratory Care (Tag F0695)

Could have caused harm · This affected multiple residents

Based on observations and interviews with staff, it was determined that the facility failed to provide appropriate respiratory care services related to changing and labelling respiratory equipment's f...

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Based on observations and interviews with staff, it was determined that the facility failed to provide appropriate respiratory care services related to changing and labelling respiratory equipment's for seven of 12 residents reviewed. (Resident R14, R30, R6, R4, R41, R10, R40). Findings Include: Review of an undated facility protocol Respiratory care shift duty assignments, revealed that on Day shift (7am to 7pm shift, Sunday: Change suction tubing and canisters and portables. Please make sure all equipment is dated with initial. Observation of Resident R14's suction canister revealed that the canister was last changed on May 7, 2023. There was no date on suction tubing. Observation of Resident R30's suction canister and tubing revealed that the canister and tubing was last changed on May 7, 2023. Observation of Resident R6's suction canister revealed that the canister was last changed on May 7, 2023. Observation of Resident R4's suction canister revealed that the canister and tubing had no date. Observation of Resident R41's suction canister and tubing revealed that the canister and tubing had no date. Observation of Resident R10's suction canister revealed that the canister was last changed on May 7, 2023. Observation of Resident R40's suction canister revealed that the canister was last changed on April 2, 2023. Above observations were confirmed wtth Employee E11, Respiratory Lead Technician on June 6, 2023 at 1:55 p.m. 28 Pa. Code 211.12(d)(1) Nursing services 28 Pa. Code 211.12(d)(5) Nursing services
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated K - Pattern L - Widespread
Actual Harm
G - Isolated H - Pattern I - Widespread
Potential for Harm
D - Isolated E - Pattern F - Widespread
No Harm (Minor)
A - Isolated B - Pattern C - Widespread

Questions to Ask on Your Visit

  • "Can I speak with families of current residents?"
  • "What's your RN coverage like on weekends and overnight?"

Our Honest Assessment

Strengths
  • • No major safety red flags. No abuse findings, life-threatening violations, or SFF status.
  • • No fines on record. Clean compliance history, better than most Pennsylvania facilities.
  • • 37% turnover. Below Pennsylvania's 48% average. Good staff retention means consistent care.
Concerns
  • • 20 deficiencies on record. Higher than average. Multiple issues found across inspections.
Bottom line: Generally positive indicators. Standard due diligence and a personal visit recommended.

About This Facility

What is Fox Subacute At South Philadelphia's CMS Rating?

CMS assigns FOX SUBACUTE AT SOUTH PHILADELPHIA an overall rating of 4 out of 5 stars, which is considered above average nationally. Within Pennsylvania, this rating places the facility higher than 99% of the state's 100 nursing homes. This rating reflects solid performance across the metrics CMS uses to evaluate nursing home quality.

How is Fox Subacute At South Philadelphia Staffed?

CMS rates FOX SUBACUTE AT SOUTH PHILADELPHIA's staffing level at 2 out of 5 stars, which is below average compared to other nursing homes. Staff turnover is 37%, compared to the Pennsylvania average of 46%. This relatively stable workforce can support continuity of care.

What Have Inspectors Found at Fox Subacute At South Philadelphia?

State health inspectors documented 20 deficiencies at FOX SUBACUTE AT SOUTH PHILADELPHIA during 2023 to 2025. These included: 20 with potential for harm.

Who Owns and Operates Fox Subacute At South Philadelphia?

FOX SUBACUTE AT SOUTH PHILADELPHIA is owned by a non-profit organization. Non-profit facilities reinvest revenue into operations rather than distributing to shareholders. The facility operates independently rather than as part of a larger chain. With 53 certified beds and approximately 48 residents (about 91% occupancy), it is a smaller facility located in PHILADELPHIA, Pennsylvania.

How Does Fox Subacute At South Philadelphia Compare to Other Pennsylvania Nursing Homes?

Compared to the 100 nursing homes in Pennsylvania, FOX SUBACUTE AT SOUTH PHILADELPHIA's overall rating (4 stars) is above the state average of 3.0, staff turnover (37%) is near the state average of 46%, and health inspection rating (4 stars) is above the national benchmark.

What Should Families Ask When Visiting Fox Subacute At South Philadelphia?

Based on this facility's data, families visiting should ask: "Can you walk me through typical staffing levels on day, evening, and night shifts?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?" These questions are particularly relevant given the below-average staffing rating.

Is Fox Subacute At South Philadelphia Safe?

Based on CMS inspection data, FOX SUBACUTE AT SOUTH PHILADELPHIA has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 4-star overall rating and ranks #1 of 100 nursing homes in Pennsylvania. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.

Do Nurses at Fox Subacute At South Philadelphia Stick Around?

FOX SUBACUTE AT SOUTH PHILADELPHIA has a staff turnover rate of 37%, which is about average for Pennsylvania nursing homes (state average: 46%). Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.

Was Fox Subacute At South Philadelphia Ever Fined?

FOX SUBACUTE AT SOUTH PHILADELPHIA has no federal fines on record. CMS issues fines when nursing homes fail to meet care standards or don't correct problems found during inspections. The absence of fines suggests the facility has either maintained compliance or corrected any issues before penalties were assessed. This is a positive indicator, though families should still review recent inspection reports for the full picture.

Is Fox Subacute At South Philadelphia on Any Federal Watch List?

FOX SUBACUTE AT SOUTH PHILADELPHIA is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.