Auburn Nursing and Rehabilitation Center

Inspectors wroteBased on interview, record review, and review of the facility's policy, the facility failed to implement the care plan related to advance directives for one (Resident (R) 1) of 19 sampled residents reviewed for care plans. R1's care plan identified the resident as a Full Code (indicating that Cardiopulmonary Resuscitation (CPR) should be performed if the resident was found without vital signs.); however, staff failed to implement the care plan, and no lifesaving measures were attempted. On [DATE], at 3:10 PM the Administrator was provided a copy of the CMS Immediate Jeopardy (IJ) Template and was notified that the failure to implement the resident's care plan by performing CPR in accordance was likely to cause serious injury, impairment, or death. This failure constituted IJ at 42 CFR 483.21 (b) F656. [...]

Inspectors wroteBased on interview, record review and review of the facility's policy, the facility failed to ensure Cardiopulmonary Resuscitation (CPR) was initiated for one (Resident (R) 1) of 19 sampled residents reviewed for Advance Directives. Staff found R1 unresponsive on 11/09/2025 without pulse or respiration. R1 was a Full Code status (indicating that CPR should be performed if the resident was found without vital signs); however, no lifesaving measures were attempted. On 03/04/2026 at 3:10 PM, the Administrator was provided a copy of the CMS Immediate Jeopardy (IJ) Template and was notified the failure to ensure residents were provided CPR was likely to cause serious injury, impairment, or death. This failure constituted IJ at 42 CFR 483.24 F678, as well as Substandard Quality of Care (SQC) at 42 CFR 483.24, Quality of Care. [...]

Inspectors wroteBased on interview, record review, and facility policy review it was determined the facility failed to accurately complete the Preadmission Screening process for individuals with a mental disorder and/or individuals with intellectual disabilities for nine (Resident (R)3, R8, R9, R12, R15, R17, R25, R33, and R42) of nine sampled residents reviewed for Preadmission Screening and Resident Review (PASARR). The systemic failure to ensure the PASARR process is completed as required has the potential to affect all residents who must be screened using this process upon admission.

Inspectors wroteBased on interview, record review, and review of the facility's policy's, it was determined the facility failed to ensure medical records were complete, accurate, and maintained for 8 of 25 sampled residents (R3, R4, R9, R12, R15, R17, R25, R58).

Inspectors wroteBased on interview, record review, and facility policy review, it was determined the facility failed to develop, implement, and maintain an effective, comprehensive, data-driven Quality Assurance and Performance Improvement (QAPI) program that focused on indicators of the outcomes of care and quality of life. The QAPI program failed to identify concerns regarding the Preadmission Screening and Resident Review (PASARR) process, affecting nine (Resident (R)3, R8, R9, R12, R15, R17, R25, R33, and R42) of nine sampled residents reviewed for this mandatory screening. In addition, the QAPI program failed to identify issues for four (R6, R8, R22, R33) of four sampled residents reviewed for advance directives, who were not given the opportunity to formulate advance directives, or for whom the process was not accurately completed, with all required documentation. [...]

Inspectors wroteBased on observation, interview, and review of the facility's policy, the facility failed to store food in accordance with professional standards for food service safety. Food items were not dated or labeled at the time of storage. Opened food was not covered and/or sealed to prevent contamination. Food in the dry storage area was not free from the potential for contamination, as it was stored in bins on a top shelf approximately 8 inches from the ceiling/sprinkler heads. The failure to ensure food was stored, sealed, and/or dated after opening had the potential to affect 56 of the 56 facility's residents who consumed food from the kitchen.

Inspectors wroteBased on interview, record review, and review of facility policy, the facility failed to ensure advance directives were completed and reviewed for four (Resident (R)6, R8, R22 and R33) of four sampled residents reviewed for advanced directives. R22 had missing and conflicting information regarding code status. R6, R8, and R33 did not have advance directives or evidence that they were given the opportunity to formulate or decline one.

Inspectors wroteBased on observation, interview, record review, and review of facility policy, the facility failed to provide housekeeping and maintenance services necessary to maintain a safe, clean, and comfortable homelike environment for five (Resident (R) 10, R22, R35, R53, and R57) of five residents reviewed for the environment. The residents, who all resided on one of the three halls in the facility, had missing or broken floor tiles in their rooms and/or expressed concern with housekeeping and maintenance.

Inspectors wroteBased on observation, interview, and review of the facility's policy, the facility failed to ensure expired drugs/biologicals were not available for resident use. Two different expired influenza vaccines were stored in one of the facility's two medication refrigeratorsThe

Inspectors wroteBased on observation, interview, and review of the facility's policies, the facility failed to consistently post required staffing data. No data was posted for two of four days during the recertification survey. The failure to post required staffing data has the potential to affect any resident who wishes to know the staffing for that day.

Inspectors wroteBased on observation, interview, record review, and review of facility policy, it was determined the facility failed to establish and maintain 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 one of seven sampled residents (R 7). During an observation on 04/09/2025 at 10:20 AM, Licensed Practical Nurse (LPN) 1 failed to sanitize her hands between glove changes. Further, LPN 1, failed to wear gown, mask, and eye protection while providing care to a resident on contact precautions.

Inspectors wroteBased on observation, interview, record review, and facility policy review it was determined the facility failed to ensure residents received treatment to prevent a urinary tract infection for one (1) of fifteen (15) sampled residents (Resident #41). Observation revealed facility staff failed to change gloves, wash their hands, and obtain clean water between dirty and clean tasks while providing indwelling urinary catheter care for Resident #41.

Inspectors wroteBased on observation, interview, and facility policy review, it was determined the facility failed to ensure one (1) of fifteen (15) sampled residents, Resident #34, received food that accommodated the resident's food preferences in his/her meals served by the facility. Interview and observation revealed the facility failed to honor Resident #34's preferences/dislikes of mashed potatoes and beans by serving those food items to the resident.

Inspectors wroteBased on observation, interview and facility policy review it was determined the facility failed to provide a safe, clean, comfortable, and homelike environment outside the facility related to debris on the grounds/walkways, ceiling tiles with stains, chipping paint noted on the closet doors, and exposed dry wall.

Inspectors wroteBased on observation, interview and facility policy review, it was determined the facility failed to accommodate privacy for one (1) of seventeen (17) sampled residents related to staff not ensuring resident was provided privacy during care.

Inspectors wroteBased on interview, record review and review of the facility's policies, it was determined the facility failed to ensure services provided or arranged by the facility, as outlined by the comprehensive care plan, met professional standards of quality for one (1) unsampled resident not in the selected sampled of seventeen (17) residents (Resident 900). Resident #900 was identified to be experiencing nausea and vomiting on 01/07/2020. Staff failed to obtain vital signs when Resident #900 was identified to have the change in condition and failed to assess the effectiveness of as needed (PRN) medication after administered; per facility policy.

Inspectors wroteBased on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure therapeutic diets prescribed by the attending physician were followed, and meet preference accommodation for one (1) of seventeen (17) sampled Residents (Resident #30). Meal observation on 01/15/2020 at 12:45 PM revealed a magic cup not being served as ordered during a meal service, and a chocolate shake served but listed on the tray card as dislikes The findings Include: Review of the facility policy titled, Resident Nutrition Services, dated 01/05/15, revealed each resident shall receive the correct diet, with preferences accommodated as feasible, and shall receive prompt meal service and appropriate feeding assistance by interpretation and implementation of .1. Nursing personnel will assure that residents are served the correct food tray. 2. [...]

Inspectors wroteBased on interview, record review and facility policy review, it was determined the facility failed to ensure medical records, were complete and accurately documented for one (1) unsampled resident not in the selected sampled of (17) (Resident #900). On 01/07/2020, Resident 900 was identified to be vomiting and having diarrhea; however, licensed staff failed to document the resident's change in condition, vital signs, and assessment of the resident's condition before and after administering medication for the vomiting and diarrhea.

Inspectors wroteBased on interview, record review and review of facility policy, it was determined the facility failed to ensure a written notice of transfer/discharge, which included the reason for the resident's transfer, was sent to a representative of the Office of the State Long-Term Care Ombudsman for three (3) of seventeen (17) sampled residents (Residents #51, #34, and #40). Record review for Residents #51, #34, and #40, revealed no documented evidence a representative of the Office of the State Long-Term Care Ombudsman was notified of the resident transfers.