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Inspection visit

Inspection

AURELIA OSBORN FOX MEMORIAL HOSPITALCMS #33520423 citations on this visit
23 citations recorded

Citations

23 citations recorded*CMS

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

  • 0006GeneralS&S Fpotential for harm

    Conduct risk assessment and an All-Hazards approach.

  • 0029GeneralS&S Fpotential for harm

    Develop a communication plan.

  • 0037GeneralS&S Fpotential for harm

    Establish staff and initial training requirements.

  • 0271GeneralS&S Fpotential for harm

    Have exits that are accessible at all times.

  • 0281GeneralS&S Fpotential for harm

    Install proper backup exit lighting.

  • 0363GeneralS&S Dpotential for harm

    Install corridor and hallway doors that block smoke.

  • 0372GeneralS&S Epotential for harm

    Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

  • 0511GeneralS&S Epotential for harm

    Have properly installed electrical wiring and gas equipment.

  • 0761GeneralS&S Fpotential for harm

    F761 - Labeling of Drugs and Biologicals

    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.

  • 0901GeneralS&S Fpotential for harm

    Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel.

  • 0550GeneralS&S Epotential for harm

    F550 - Resident Rights

    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

  • 0600SeriousS&S Gactual harm

    F600 - Freedom from Abuse, Neglect, and Exploitation

    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

  • 0610GeneralS&S Dpotential for harm

    F610 - In response to allegations of abuse, neglect, exploitation, or mistreatment, the

    Respond appropriately to all alleged violations.

  • 0645GeneralS&S Dpotential for harm

    F645 - Preadmission Screening for individuals with a mental disorder and individuals

    PASARR screening for Mental disorders or Intellectual Disabilities

  • 0656GeneralS&S Dpotential for harm

    F656 - Comprehensive Care Plans

    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

  • 0657GeneralS&S Epotential for harm

    F657 - Comprehensive Care Plans

    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

  • 0679GeneralS&S Dpotential for harm

    F679 - Activities

    Provide activities to meet all resident's needs.

  • 0725GeneralS&S Fpotential for harm

    F725 - Nursing Services

    Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

  • 0759GeneralS&S Dpotential for harm

    F759 - Medication Errors

    Ensure medication error rates are not 5 percent or greater.

  • 0804GeneralS&S Fpotential for harm

    F804 - Food and drink

    Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

  • 0812GeneralS&S Dpotential for harm

    F812 - Food safety requirements

    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

  • 0880GeneralS&S Fpotential for harm

    F880 - Infection Control

    Provide and implement an infection prevention and control program.

  • 0921GeneralS&S Fpotential for harm

    F921 - Other Environmental Conditions

    Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

FAQ · About this visit

Common questions about this visit

What happened during the April 22, 2025 survey of AURELIA OSBORN FOX MEMORIAL HOSPITAL?

This was a inspection survey of AURELIA OSBORN FOX MEMORIAL HOSPITAL on April 22, 2025. The surveyor cited 23 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at AURELIA OSBORN FOX MEMORIAL HOSPITAL on April 22, 2025?

Yes, 23 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Conduct risk assessment and an All-Hazards approach."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

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Next steps

Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.

Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.

Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.