Aurelia Osborn Fox Memorial Hospital

Inspectors wroteBased on record review and interview conducted during a recertification and complaint (Case # NY00345612) survey from [DATE] to [DATE], the facility failed to ensure residents were free from neglect for one (1) (Resident #109) of 23 residents reviewed. Specifically, Resident #109 was assessed by physical therapy on [DATE] as having total dependence on staff and required maximum assistance of two (2) staff members for bed mobility. As a result of the facility's lack of communication for updating the care plan to incorporate the physical therapy assessment, Resident #109 rolled out of bed and suffered a fractured (broken) hip while receiving care from one (1) staff member on [DATE] at 5:05 PM. The failure to provide required staff services and oversight to meet the resident's needs resulted in actual harm to Resident #109 that was not Immediate Jeopardy. This is evidenced by: [...]

Inspectors wroteBased on observation, record review, and interviews conducted during a recertification survey, the facility did not ensure the provision of sufficient nursing staff to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident throughout the facility. Specifically, residents were not assisted with care when requested, staff complained of not able to complete all the required tasks assigned and provide resident care, and the staffing sheets provided while on site did not accurately reflect the needs of the facility population. This is evidenced by: Facility Assessment The facility assessment dated 8/2024 documented that the staffing plan was based on the resident population and their needs for care and support. The staffing plan documented the following daily staffing needs: Average daily census: [...]

Inspectors wroteBased on observation, record review, and interviews conducted during the recertification survey, the facility did not ensure drugs and biologicals were labeled and stored in accordance with professional standards of practice for two (2) (Unit 100 and Unit 300) of two (2) Medication Rooms; and three (3) (Unit 100, 200 and 300) of three (3) Medication Carts reviewed. Specifically, (a.) two medications had expired; (b.) one open bottle of tuberculin Purified Protein Derivative (PPD) solution had expired; (c.) one Humalog Kwik pen had an illegible open date; (d.) four open inhalers had no open or expiration date; one unopened inhaler had an open date; (e.) one bottle of eye drops had no open and or expiration date (f.) two bottles of eye drops had open and or expiration date discrepancies; (g.) an unopened Solostar Kwik insulin pen was in medication cart unrefrigerated. This is evidenced by: [...]

Inspectors wroteBased on observations, record reviews, and interviews during the recertification survey, the facility did not ensure that food was prepared by methods that conserved the food ' s nutritive value, flavor and appearance and were palatable for 18 (Resident #s 1, 2, 4, 9, 21, 23, 31, 32, 39, 48, 59, 63, 64, 68, 90, 91, 92, and 94) of 22 residents who were reviewed for palatable and attractive food and drink. Specifically, (a.) During an interview during Resident Council held on 4/15/2025, six (6) residents complained that the food was inedible and cold, that drinks were warm, vegetables were hard and under cooked, and that the meat was tough. (b.) Resident # ' s 1, 9, 21, 23, 31, 32, 63, 64, 68, 90, 91, 92, and 94 complained of food being of not palatable with meat being overcooked and vegetables undercooked, tasteless and without variety. [...]

Inspectors wroteBased on observation, record review, and interviews conducted during the recertification survey, the facility did not ensure they established and maintained an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for five (5) (Resident # ' s 21,35,92, 95, and 99) of 15 residents reviewed for infection control. Specifically, (a.) Resident #s 21, 35, 92, and 95 had wounds that required dressing changes and were not placed on Enhanced Barrier Precautions; and (b.) for Resident #99, infection control practice was not maintained during a dressing change and skin treatment. This is evidenced by: The facility policy, Nursing Home Infection Prevention and Control Program, revised 1/2023, documented the following: • Under Policy: [...]

Inspectors wroteBased on observations and interviews conducted during a recertification survey from 4/14/2025 - 4/22/2025, the facility did not ensure the environment was functional, sanitary, and comfortable for residents, staff, and the public. Specifically, all three units (100, 200 and 300) had foul smelling odors of urine and feces. Unit 100 carpet was soiled with multiple stains throughout; Unit 200 had dirty linens under sink and Unit 300 had smelled consistent with cannabis. This is evidenced by: The Facility ' s Policy and Procedure titled, Personal Appearance, revised 3/17/2025, documented the policy intends to provide a general expectation for personal appearance for facility ' s employees and is not meant to capture all necessary dress and appearance requirements nor represent a complete listing of clothing or items of apparel acceptable throughout the facility. [...]

Inspectors wroteBased on observations and interviews conducted during a recertification survey, the facility did not ensure each resident was treated with respect and dignity in a manner and environment that promoted maintenance or enhancement of their quality of life for five (5) (Resident #s 21, 31, 32, 64, and 99) of 23 residents reviewed for dignity and respect. Specifically, (a.) Resident #s 31 and 32 had Foley catheters that were fully visible from the hallway, outside resident rooms and in common areas, and not in cover bags; (b.) Resident #64 reported that staff spoke to them 'like they were retarded' and ignored their requests to open the room dividing curtain when their roommate was not in the room; (c.) Resident #99's repeated request to be toileted was ignored by staff while the surveyor was on the resident's unit; [...]

Inspectors wroteResident #109 Resident #109 was admitted to the facility with diagnoses of generalized osteoarthritis (when the cartilage that cushions the ends of bones in the joints gradually wears away), transient ischemic attacks (a short period of symptoms similar to those of a stroke), and repeated falls. The Minimum Data Set (an assessment tool) dated 2/09/2024 documented the resident could understand and be understood by others. The comprehensive care plan titled Activities of Daily Living, last revised 4/11/2024, documented Resident #109 required assistance with Activities of Daily Living task performance as follows: Effective 1/08/2024, Resident #109 was a supervision at mealtime; partial moderate one (1) staff member assist for bed mobility; partial moderate one (1) staff member assist for grooming, bathing and dressing. [...]

Inspectors wroteBased on record review and interviews during the recertification survey, the facility did not ensure that each resident was screened for a mental disorder or intellectual disability prior to admission for three (3) (Resident # ' s 9, 31, and 91) of 23 residents reviewed. Specifically, there was no documentation that a Preadmission Screening and Resident Review (PASARR, New York State Department of Health Form 695) was completed for these three (3) residents by a qualified screener prior to admission to the facility. This is evidenced by: [...]

Inspectors wroteBased on record reviews and interviews conducted during the recertification survey, the facility did not ensure the development of comprehensive person-centered care plans, that included measurable objectives and time frames to meet the resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for one (1) (Resident #72) of 23 residents reviewed for comprehensive care plans. Specifically, for Resident #72, comprehensive care plan was not developed to address the resident's medical issues requiring medications. This is evidenced by: The facility policy titled, Comprehensive Care Plans, last reviewed date 5/2024, documented the purpose to meet each resident's preference and goals, and address each resident's medical, physical, mental, and psychosocial needs. Under Procedures, documented routine data was collected, e.g. [...]

Inspectors wroteBased on observation, record review, and interviews conducted during the recertification survey, the facility did not ensure ongoing provision of programs to support each resident and their choices of activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident for one (1) (Resident #35) of 3 residents reviewed. Specifically, Residents #35, was not provided with any meaningful, accommodating activities to maintain their highest quality of life. This is evidenced by: The facility's Policy and Procedure Titled Activities Department Policy, revised 12/2024, documented it's policy is: To help residents maintain their optimal level of physical, mental, psychosocial, spiritual, and emotional functioning and independence. [...]

Inspectors wroteBased on observation, record review, and interviews conducted during a recertification survey, the facility did not ensure that its medication error rate did not exceed five (5) percent for two (2) (Resident #s 4 and 78) of four (4) residents observed during a medication pass for a total of 25 observations. This resulted in a medication error rate of eight (8) percent. This is evidenced by: The facility ' s policy and procedure titled, Medication Administration, revised 5/01/2024, documented, medications may be administered by Registered Nurses and Licensed Practical Nurses after satisfactory completion of the medication orientation requirements. Oral Medications: Read Electronic Medical Record, remove medication from drawer and compare label with Electronic Medical Record. Open medication into medicine cup, read label, and leave package. [...]

Inspectors wroteBased on observations and interviews conducted during the recertification survey, the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety in the main kitchen. Specifically, the automatic dishwashing machine was not sanitizing, floors were not clean, and concentration of the chemical sanitizing rinse in the 3-compartment sink was low. This is evidenced by: During observations on 4/14/2025 at 10:32 AM through 11:08 AM: The automatic dishwashing machine thermometer read 140 degrees Fahrenheit during the final rinse cycle. The walk-in freezer floor and floor under cooking equipment was soiled with food particles and/or a black build-up. [...]

Inspectors wroteBased on observation, record review, and interview during a recertification and abbreviated survey (Case # NY00343395), the facility did not ensure that all allegations of abuse were thoroughly investigated for one (1) (Resident #3) of seven (7) residents reviewed for abuse. Specifically, Certified Nurse Aide #8 reported an allegation of verbal abuse and rough treatment of Resident #3 during care on the evening shift on 5/24/2024, to the evening supervisor. The facility initiated the investigation on 5/24/2024 at 11:00 PM, when informed of the allegation. There was no documented evidence that all staff involved were interviewed before the determination was made that the allegation was inconclusive. This is evidenced by: The facility's policy titled Resident Abuse Reporting revised on 11/29/2021 and last reviewed on 10/24/2024 documented: 1. [...]

Inspectors wroteBased on observation, record review and interviews during an abbreviated survey (Case #NY00297324 and NY00311039), the facility did not ensure residents were free from neglect for 2 (Resident #1 and #2) of 2 residents reviewed for neglect. Specifically, Resident #1, who required two staff to transfer via mechanical lift, was injured when Certified Nursing Aide # 3 transferred Resident #1 by themselves. Additionally Resident #2, who was care planned for having a chair alarm, sustained injury when they attempted to transfer themselves and no chair alarm was present. This is evidenced by: The facility Abuse Prohibition policy and procedure revised 12/31/2021 documented all nursing home residents had the right to be free from verbal, physical, sexual, and mental abuse. All claims of abuse, neglect or mistreatment must be investigated. [...]

Inspectors wroteBased on record review and interviews during an abbreviated survey (Case # NY00304461), the facility did not ensure residents were free from any significant medication errors for 2 (Resident #'s 5 and 6) of 3 residents reviewed for significant medication errors. Specifically, Resident #'s 5 did not receive their Synthroid on 3/27/2022, and Resident #6 did not receive Aspercreme patch applied on 10/27/2022 as ordered. This is evidenced by: The Policy and Procedure titled, Medication Administration Documentation, revised on 5/2023, documented omission of medications was unacceptable except in the case of resident refusal, or when warranted by resident condition. Resident #5 Resident #5 was admitted to the facility with diagnosis of mild cognitive impairment; [...]

Inspectors wroteBased on observation, record review, and interviews during a recertification survey and an abbreviated survey (Case #NY00283532) dated 5/22/2022 through 5/26/2022, the facility did not ensure comprehensive care plans (CCP) were developed and implemented for each resident consistent with the resident rights and that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs for 6 (Resident #'s 25, 35, 50, 54, 69, 81) of 20 residents reviewed. Specifically, the facility did not ensure that a care plan was developed for Resident #25 to address the stage 2 pressure ulcer [NAME] was identified on their left heel on 5/11/2022; for Resident #35, the facility did not ensure the resident's toileting schedule was followed in accordance with the care plan for urinary incontinence; [...]

Inspectors wroteBased on observation, record review, and staff interview during the recertification survey, the facility did not store, prepare, distribute or serve food in accordance with professional standards for food service safety. Food preparation and serving areas are to be kept clean, kitchen equipment is to be kept in good repair, and a test kit is to be available to measure the parts per million (ppm) concentration of the solution used to sanitize equipment. Specifically, doors in the main kitchen were not clean, plumbing for sinks in the main kitchen was not in good repair, and a compatible test kit to measure concentration of chemical sanitizer used to manually sanitize food contract equipment (test kit) was not provided. This is evidenced as follows: During observations of the main kitchen on 05/22/22 at 11:15 AM, the door to the linen closet and the back door were soiled with black grime; [...]

Inspectors wroteBased on observation, record review and interviews during the recertification survey from 05/22/2022 through 05/26/2022, the facility did not ensure residents who use psychotropic drugs receive gradual dose reductions (GDR), and behavioral interventions, unless clinically contraindicated, to discontinue these drugs for 1 (Resident #s 69) of 5 residents reviewed for psychotropic drug use. Specifically, the medical record for Resident #69 did not include documentation to address a GDR for Mirtazapine (antidepressant) between 11/09/2020 and 05/25/2022. This was evidenced by: The Policy & Procedure titled Psychotropic Medication Tapering dated 9/18/2021 documented; Psychotropic medication will be prescribed only as necessary to treat a specific diagnosed condition and subsequent to a comprehensive assessment. [...]

Inspectors wroteBased on observation and staff interview during the recertification survey, the facility did not provide effective housekeeping services. Specifically, the facility did not ensure that floors were clean on 2 of 3 resident units. This is evidenced as follows: During observations on 05/22/22 during the initial tour at 11:08 AM and 11:22 AM, floors were sticky in resident rooms numbered 218 and 232. During observations on 05/25/22 at 10:30 AM, floors were soiled with old wax, black build up, scuff marks or dirt in corners in resident rooms numbered 218, 216, and 207, 307, 311, 315, and 330. During an interview on 05/22/22 at 2:58 PM, a resident representative reported that their resident had dropped a soda a couple weeks ago and it was many days before it was mopped up. [...]

Inspectors wroteBased on record review and interview during the recertification survey, the facility did not ensure a policy was developed, maintained, and implemented for the monthly medication regimen review (MRR) process that included time frames for the different steps in the process and the steps the pharmacist must take when an irregularity that requires urgent action to protect the resident was identified. Specifically, the MRR policy did not document time frames for the steps in the process. Additionally, the MRR policy did not document the steps the pharmacist must take when an identified irregularity requires immediate action to protect the resident and prevent the occurrence of an adverse drug event. This is evidenced by: [...]

Inspectors wroteBased on observation, record review and interview during the recertification, the facility did not ensure comprehensive care plans (CCP) were developed and implemented for each resident consistent with the resident rights and that included measurable objectives and timeframes to meet a resident's medical, nursing and mental and psychosocial needs for 9 (Resident #'s 2, 19, 21, 59, 66, 67, 71, 79, and #81) of 24 residents reviewed for CCP's. Specifically, for Resident #2, the facility did not ensure a CCP was developed for diabetes management; for Resident #19, a CCP was developed for pain management; for Resident #21, a CCP was developed for an actual pressure ulcer; for Resident #59, a CCP was developed for aphasia; for Resident #66, a CCP was developed for a right elbow wound; for Resident # 67, a CCP was developed for a urinary tract infection; [...]

Inspectors wroteBased on observation and staff interview during the recertification survey the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. Food packages shall be in good condition so that the food is not exposed to potential contaminants; food under refrigeration is to be kept at 41 degrees Fahrenheit (F) or less, food contact surfaces shall be cleaned after use; a chemical test kit (test papers) is to be provided for checking chemical sanitizer levels; and floors are to be kept clean. Specifically, cans of food were dented, refrigerated food was above the maximum temperature, test papers were not provided, and food contact surfaces, non-food contact surfaces, and floors were not clean. This is evidenced as follows. The main kitchen was inspected on 10/28/2019 at 9:32 AM. [...]

Inspectors wroteBased on observations, interviews, and record review during a recertification survey the facility did not ensure a resident with limited range of motion (ROM) received appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion for one (Resident #88) of one resident reviewed for ROM. Specifically, for Resident #88, the facility did not ensure bilateral (both) hand pillows were applied at all times for hand contractures. This is evidenced by: The Policy and Procedure titled Positioning last revised 11/6/18, documented all residents would be positioned in correct body ailment to prevent formation of or deterioration of contractures and positioning equipment included rolled washed cloths/hand pillows. The policy documented staff would follow the care plan and Certified Nursing Assistant (CNA) instructions. Resident #88: [...]

Inspectors wroteBased on observation, record review and interviews during the recertification survey, the facility did not ensure the resident's environment remained as free of accident hazards as was possible for 1 (Resident #75) of 1 resident reviewed for accidents. Specifically, for Resident #75, the facility did not ensure that the resident's refusal of care and behavior toward staff were adequately evaluated to assist in the prevention of falls and did not ensure causal factors leading to the resident's fall were identified to develop and implement relevant, consistent, and individualized interventions to prevent future falls. This is evidenced by: Resident #75: Resident #75 was admitted to the facility on [DATE], with diagnosis of diabetes, non-pressure chronic ulcer of lower leg, and chronic kidney disease. [...]

Inspectors wroteBased on observation, record review and interviews during the recertification survey, the facility did not ensure a resident maintained acceptable parameters of nutritional status for 1 (Resident #112) of 4 residents reviewed for nutrition. Specifically, for Resident #112, who was initially assessed as a high nutritional risk secondary to diabetes, the facility did not ensure the resident's weight and significant weight loss was evaluated to determine whether it was unavoidable and addressed in accordance with the comprehensive nutrition careplan (2000 calories, 95-114 grams of protein, and 2000 ml of fluid daily), provide diet per physician order (consistent carbohydrate, vegetarian diet) and cater to the resident's food preferences. This is evidenced by: Resident #112: [...]

Inspectors wroteBased on observation, record review, and interviews during the recertification survey, the facility did not ensure residents received dialysis services consistent with professional standards of practice and the comprehensive person-centered care plan for 1 (Resident #363) of 1 resident reviewed for dialysis. Specifically, the facility did not ensure dialysis specific policies and procedures were developed based on current standards of practice, the resident's medical record included orders for the provision of dialysis treatment, and the resident's care plan included resident specific parameters for monitoring of blood pressures before and after dialysis treatments. This is evidenced by: Resident #363: Resident #363 was admitted to the facility on [DATE], with diagnoses of end stage renal diasease on dialysis, diabetes, and chronic obstructive pulmonary disease. [...]

Inspectors wroteBased on record review and interviews during the recertification survey, the facility did not ensure the menus were planned in advance, followed, and met the nutritional needs of residents in accordance with established national guidelines. Specifically, the facility did not ensure menus were developed and prepared to meet nutritional needs of residents on a vegetarian diet. This is evidenced by: The facility specific diet manual did not include documentation of a vegetarian diet. The Corporate Diet Manual dated 10/30/19, documented vegetarian diets were healthful and nutritionally adequate when appropriately planned, and included a variety of foods - fruits, vegetables, whole grains, legumes, nuts, seeds, tofu or other soy products, and if desired, dairy products and eggs. [...]

Inspectors wroteBased on record review and interview during the recertification survey, the facility did not provide a policy regarding foods brought to residents by family and other visitors that included information on the safe and sanitary storage, handling and consumption of food. Specifically, the facility does not provide information for family and other visitors on safe food handling practices or safe reheating of food that is brought in to residents. This is evidenced is as follows. Record review of the facility policy for foods brought in by visitors was reviewed on 10/28/2019. This policy does not include a process to ensure family and other visitors are provided information on safe food handling practices. [...]