Auburn Manor

Inspectors wroteBased on interview and document review, the facility failed to ensure resident mail was delivered to residents on Saturdays for 4 of 4 residents (R33, R34, R14, R24) who voiced concerns with mail delivery during Resident Council. This had the potential to affect all residents residing in the facility. On 4/30/26 at 9:33 a.m., a Resident Council meeting was held with four residents from varied areas of the facility. R24 stated mail was not delivered to residents on Saturdays. This was confirmed by R33, R34 and R14. R24 indicated mail delivered by the post office on Saturdays would be left on the receptionist's desk near the front entrance. On Monday morning the receptionist would sort and deliver the mail to residents. During interview on 4/30/26 at 1:09 p.m., Secretary (S)-A stated it was her job Monday through Friday to sort and deliver the mail. [...]

Inspectors wroteBased on observation, interview, and document review, the facility failed to store and label food properly, dispose of undated and expired food items to reduce the risk of foodborne illness. This had the potential to affect all the residents who were provided meals from the kitchen.

Inspectors wroteBased on interview and document review, the facility failed to provide ongoing communication to residents about their rights (e.g., through resident groups) for 4 of 4 residents (R33, R34, R14, R24) who attended the council meetings.

Inspectors wroteBased on interview and record review, the facility failed to ensure 2 of 2 (R33, R34) residents reviewed for dignity, received services in a dignified manner to promote quality of life when staff failed to respond timely to call light and provide toileting assistance resulting in episodes of incontinence.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure residents were aware how to file grievances anonymously, for 4 of 4 residents (R33, R34, R24, and R14) reviewed for grievances. Further, the facility failed to maintain a grievance log for a minimum of 3 years. This had the potential to affect all residents residing in the facility.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure mediations were administered in accordance with physician orders for 1 of 1 residents (R 24) reviewed for medications administration.

Inspectors wroteBased on record review and interview the facility failed to ensure COVID-19 vaccinations were offered to 1 of 5 residents (R6) reviewed for COVID-19 vaccination status.

Inspectors wroteBased on interview and document review, the facility failed to ensure 1 of 3 residents (R1) physician orders were followed for parameters set by the physician. This resulted in actual harm for R1 who became unresponsive and required emergency transport and hospitalization after receiving insulin that should have been held.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure sufficient nursing staff and leadership to meet assessed resident needs and facility processes for 2 of 2 residents (R5, R37) reviewed for pressure ulcer prevention, for R7, R42 reviewed for activities of daily living who were dependent on staff for their care, for R1 who was left exposed and nude on the toilet, and R18 who utilized an indwelling catheter reviewed for dignity. In addition, the facility failed to reassess and implement proactive interventions to reduce the risk of falls and injuries for R26 and R44 who sustained falls at the facility. Additionally, the facility failed to address ongoing staffing and long call light concerns identified during resident council meeting minutes. [...]

Inspectors wroteBased on observation and interview and policy review, the facility failed to ensure medications were securely stored safely and under direct observation of authorized staff in areas where residents, staff and guests could access medications in 3 of 5 medication carts affecting 3 of 4 units of the facility.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure toileting and personal care were provided in a dignified manner for R1 who was left exposed and nude on the toilet while facing a window to facility courtyard. The window was not closed for privacy. In addition, the facility failed to ensure dignity was maintained for 1 of 1 resident (R18) who utilized an indwelling catheter.

Inspectors wroteBased on interview and document review, the facility failed to provide the Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) to 1 of 3 residents (R30) reviewed whose Medicare Part A coverage ended and they remained in the facility.

Inspectors wroteDuring observation and interview, the facility failed to ensure 3 of 3 (R14, R19, R149) resident records that contained private, medical, and personal information were not accessible to unauthorized personnel.

Inspectors wroteBased on interview and document review, the facility failed to ensure an individualized comprehensive care plan was developed and maintained to ensure appropriate care was provided for 1 of 2 residents (R42) who required staff assistance with activities of daily living (ADLs) including prevention of pressure ulcers and care needs.

Inspectors wroteBased on interview and document review, the facility failed to ensure routine bathing was completed in accordance with identified wishes for 1 of 4 residents (R7) reviewed for activities of daily living (ADLs) and who was dependent on staff for their bathing care.

Inspectors wroteBased on interview and document review, the facility failed to assess potential signs of constipation to determine what, if any, proactive interventions were needed to promote comfort and reduce the risk of complication (i.e., impaction) for 1 of 1 residents (R41) who reported being constipated.

Inspectors wroteBased on observation, interview and document review, facility failed to provide 2 of 2 residents (R5, R37) with care consistent with professional standards of practice to prevent pressure ulcers (localized damage to the skin and underlying soft tissue) who were identified as risk for pressure ulcers/pressure injuries.

Inspectors wroteBased on observation, interview, and document review, the facility failed to comprehensively reassess and, if needed, develop proactive interventions to reduce the risk of further falls and injury for 2 of 2 residents (R44, R26) reviewed who had sustained falls at the care center.

Inspectors wroteBased on observation, interview, and document review, the facility failed to comprehensively assess for entrapment risk and attempt alternatives before installation of grab bars for 1 of 3 residents (R15) reviewed who were observed to have grab bars affixed to their beds.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure use of an as-needed (i.e., PRN) psychotropic medication was limited to a 14-day period and/or re-evaluated by the provider to ensure ongoing need and efficacy of the medication for 1 of 5 residents (R44) reviewed for unnecessary medication use.

Inspectors wroteBased on interview and document review, the facility failed to ensure recommended pneumococcal vaccinations, as outlined by the Centers for Disease Control (CDC), were offered and/or provided in a timely manner to reduce the risk of severe disease for 1 of 5 residents (R37) reviewed for immunizations.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure the completed Minimum Data Set (MDS) was accurately coded to reflect actual restraint use for 4 of 4 residents (R2, R15, R26, R41) reviewed for MDS accuracy. In addition, the facility failed to accurately complete a Brief Interview for Mental Status (BIMS) assessment for 1 of 4 residents (R17) reviewed for MDS accuracy.

Inspectors wroteBased on interview and document review, the facility failed to implement a Quality Assurance and Performance Improvement (QAPI) plan assuring care and services were identified to maintain acceptable levels of performance and continual improvement, and failed to conduct ongoing quality assessment and assurance activities, develop, and implement appropriate plans of action to correct repeated quality deficiencies identified during the survey the facility was aware of or should have been aware of which had the potential to adversely affect all 50 residents which resided in the facility.

Inspectors wroteBased on observation, interview and document review the facility failed to adhere to evidence based practices and assure resident catheter bags & ports were maintained in an appropriately placement for 2 of 2 resident (R7 & R146) whos catheter bags were on the the ground. The facility failed to ensure proper personal protective equipment (PPE) & hand hygiene was used for 2 of 2 residents (R146, R198) when providing care for residents on enhanced barrier precautions (EBP) & contact precautions. Furthermore the facility failed to identify and track potential infections for 1 of 1 resident (R198) reviewed for antibiotics use. [...]

Inspectors wroteBased on interview and document review, the facility failed to develop and implement a facility wide system to monitor the use of antibiotics and reduce unnecessary or inappropriate antibiotic use, which reduces risk of adverse effects, for 1 of 1 resident (R198) reviewed for antibiotic use. This had the potential to affect all 50 residents residing in the facility.

Inspectors wroteBased on observation and interview, the facility failed to ensure privacy was maintained for 1 of 2 residents (R146) reviewed for dignity.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure residents were free from accident hazards for 1 of 1 residents (R13) who used a remote-controlled recliner. In addition the faility failed to comprehensively assess resident falls to ensure appropriate interventions were implemented to reduce the risk of falls for 2 of 4 residents (R13, R99) reviewed for falls.

Inspectors wroteBased on observation, interview, and document review, the facility failed to comprehensively assess, discuss risks and benefits, obtain informed consent, and attempt alternatives prior to installation of grab bars for 2 of 2 residents (R96, R146) reviewed who were observed to have grab bars affixed to their beds.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure dishware was maintained in a safe and sanitary manner by failing to remove chipped and cracked dishware from use within the facility.