Deficiency Records for Aurelia Osborn Fox Memorial Hospital
Updated as of March 01, 2024
A list of the most recent deficiencies for Aurelia Osborn Fox Memorial Hospital. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2022-05-26 | 2022-07-21 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-05-26 | 2022-07-21 | Y |
| Establish staff and initial training requirements. | Fire Safety | 2022-05-26 | 2022-07-15 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2022-05-26 | 2022-07-15 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-05-26 | 2022-07-15 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2022-05-26 | 2022-07-08 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2022-05-26 | 2022-07-01 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-05-26 | 2022-07-01 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-10-29 | 2021-12-11 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-10-29 | 2021-12-11 | Y |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2019-10-31 | 2020-01-16 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-10-31 | 2020-01-07 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-10-31 | 2019-12-30 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-10-31 | 2019-12-30 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-10-31 | 2019-12-30 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2019-10-31 | 2019-12-30 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2019-10-31 | 2019-12-30 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2019-10-31 | 2019-12-30 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-10-31 | 2019-12-20 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2019-10-31 | 2019-12-20 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-10-31 | 2019-12-20 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-10-31 | 2019-12-20 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2019-10-31 | 2019-12-20 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2019-10-31 | 2019-12-20 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-10-31 | 2019-12-20 | N |
| Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2019-10-31 | 2019-12-20 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2018-05-04 | 2018-07-03 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-05-04 | 2018-07-03 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-05-04 | 2018-07-03 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2018-05-04 | 2018-07-03 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2018-05-04 | 2018-07-03 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2018-05-04 | 2018-07-03 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2018-05-04 | 2018-07-03 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2018-05-04 | 2018-07-03 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-05-04 | 2018-07-03 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-05-04 | 2018-07-03 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2018-05-04 | 2018-07-03 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2018-05-04 | 2018-07-03 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2018-05-04 | 2018-07-03 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2018-05-04 | 2018-07-03 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2018-05-04 | 2018-07-03 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2018-05-04 | 2018-07-03 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2018-05-04 | 2018-07-03 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-05-04 | 2018-07-03 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2018-05-04 | 2018-07-03 | N |
| Ensure precautions for handling oxygen cylinders and equipment are correctly followed. | Fire Safety | 2018-05-04 | 2018-07-03 | N |
