Auburn Oaks Care Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain an informed consent for a dental procedure from one of three sampled residents (Resident 1's) Responsible Party (RP) in a census of 96. This failure compromised the resident's right to make informed decision regarding their care and resulted in Resident 1 receiving a dental procedure they had not agreed to or fully understood.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow physician orders for two of 24 sampled residents (Resident 41 and Resident 31), when:1. Resident 41's administered oxygen amount did not match the physician's order, and 2. Resident 31 received tramadol (an opioid analgesic for pain) on 12/6/25, 12/7/25, 12/27/25, and 12/28/25 without having scheduled physical therapy (PT) sessions as per physician order. These failures decreased the facility's potential to follow the residents' physician orders as prescribed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for a census of 93 residents, when:1. Resident bowls and food containers were found stacked upright in the drying area;2. Unsealed bags of food were found in the refrigerator and freezer; and3. Unlabeled food items were found in the refrigerator. These failures decreased the facility's potential to prevent foodborne illness among vulnerable residents eating facility prepared food.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a safe environment for one of 24 sampled residents (Resident 112), when a transition strip (a narrow piece of material [often metal, wood, or vinyl] used to cover and protect the seam where two different types of flooring meet) between Resident 112's bedroom and bathroom was not securely affixed. This failure decreased the facility's potential to prevent Resident 112 from a fall, injury or harm due to tripping hazard.

Inspectors wroteBased on interview and record review, the facility failed to prevent an elopement (the act of leaving a facility unsupervised and without prior authorization) for one resident (Resident 5) of a census of 96, when Resident 5 was found by a family member walking down the street outside the facility and standing at a traffic light intersection. This failure decreased the facility's potential to maintain Resident 5's safety.

Inspectors wroteBased on interview and record review, the facility failed to protect the right to be free from abuse for one of three sampled residents (Resident 1) when Resident 2 pushed Resident 1's plate of food onto her chest and landed in her lap which affected Resident 1's emotional well-being. This failure resulted in Resident 1 not free from abuse by Resident 2.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide safe supervision and assistance to prevent accidents for one of three sampled residents (Resident 1) when Resident 1 fell on the ground while being transferred from bed to shower chair by 2 Certified Nursing Assistants (CNA 1 and CNA 2) who failed to follow the proper maneuvering and operation of a Hoyer lift (a mechanical device used to lift and/or transfer a person from one surface to another) during the transfer and when CNA 2 was behind the shower chair away from the Hoyer lift. This failure resulted in Resident 1 sustaining a right ankle sprain (a soft tissue injury that occurs when ligaments are stretched or torn), back pain, and developed fear of being moved out of bed using a lift.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure needed care or services were provided for one of three sampled residents (Resident 1) when Resident 1's use of postoperative boot (designed to protect and support the foot while healing from injuries) after a fall for right ankle sprain (a soft tissue injury that occurs when ligaments are stretched or torn) was not monitored and evaluated. This failure decreased the facility's ability to evaluate Resident 1's response to intervention and had the potential to result in Resident 1's increased risk for skin breakdown related to the use of the boot.

Inspectors wroteBased on interview and record review, the facility failed to follow their policy for pronouncing death for one resident (Resident 1) in a census of 96 when two licensed vocational nurses (LVNs) worked out of their scope of practice (services that a trained health professional is deemed competent to perform and permitted to undertake according to the terms of their professional nursing license) and pronouced the resident's death. This failure resulted in a violation of the facility's policy and had the potential to jeopardize resident health and safety.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect one of 5 sampled residents (Resident 2) from physical abuse when Resident 2 ' s hands were grabbed by Resident 1. This resulted in Resident 2 sustaining a scratch to her face and felt unsafe in the room.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure confidentiality was maintained for one of four sampled residents (Resident 2) when Resident 1 received Resident 2's labeled medication cards upon discharge by mistake. This failure resulted in Resident 2's confidential information being provided to an unauthorized recipient.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe discharge home for one of four sampled residents (Resident 1), when Resident 1 was discharged home with another resident's (Resident 2) medications. This failure had the potential for Resident 1 to take the wrong medications causing adverse effects.

Inspectors wroteBased on interview and record review, the facility failed to complete annual performance evaluations (PEs) for three of five sampled certified nursing assistants (CNAs; CNA 3, CNA 4, and CNA 5), for a census of 95. This failure increased the risk of residents receiving poor-quality care from the CNAs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure care and services in accordance with acceptable professional standards of quality were provided for four of 25 sampled residents (Resident 143, Resident 144, Resident 36, and Resident 85), when: 1. Medication and ointments were left at the nightstand of Resident 143; 2. Medication, hazardous liquids and ointments were left at the bedside of Resident 144; 3. A medication was not administered completely and left at the bedside, and oxygen tank was empty while in use for Resident 36; and 4. The oxygen (O2) saturation levels were not monitored for Resident 85. These failures had the potential risks to negatively affect the residents' health status.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure: 1. Controlled substance medications (medication with a high potential for abuse and addiction) were accurately accounted for on the medication administration record (MAR) and the Controlled Drug Record (CDR) for four of five randomly selected residents (Residents 3, 22, 75 and 78); and 2. An antibiotic emergency kit (e-kit; a kit/box containing medications and supplies for immediate use during a medical emergency) was replaced timely after being opened and medications were removed. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a process to ensure clinical rationale was documented when no changes were made to medications in response to identified irregularities and recommendations by the pharmacy consultant (PC) for one of 25 sampled residents (Resident 83). This failure had the potential to result in medication-related problems, errors, or irregularities identified and reported by the PC, and the potential for unnecessary medications (such as prolonged use, excessive dose, unmonitored use, duplication, etc.) for the resident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure expired medications were not available for resident use, medications with shorter expiration dates after use were labeled with an open date, single-use medications were discarded after use, medications were labeled with a pharmacy label, and medications in medication carts were stored in a clean, safe and orderly manner in accordance with the facility's policy and procedure (P&P). These failures had the potential for residents to receive medications with unsafe or reduced potency from being used past their expiration date or improper storage, and diversion or misuse of medications from not being safely stored.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, and distribute food in accordance with professional standards for food service safety for a total of 95 residents who received facility prepared foods, when: 1. Proper food labeling was not followed; 2. Expired foods were not discarded; 3. Undated box of loose bananas with dark brown to black discoloration and leaking fluids were stored in the walk-in refrigerator; and 4. Several wet steam table pans were found stacked at the clean and ready-to-use storage areas. These failures had the potential to cause food-borne illnesses.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program for four of 25 sampled residents (Resident 148, Resident 36, Resident 1 and Resident 3), when: 1. A hand held nebulizer (HHN, breathing treatment device) and a nasal cannula (tubing that delivers oxygen) were unlabeled and undated for Resident 148; 2. A nasal cannula and HHN with expired dates were found at the nightstand of Resident 36; 3. Resident 1's oxygen (O2) tubing and face mask was not labeled or dated; and 4. Resident 3 O2 tubing and face masks were not labeled or dated and the antimicrobial bag was labeled with an expired date. These failures increased the potential risk for respiratory infection.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Minimum Data Set (MDS, an assessment tool) accurately reflected the resident's current condition for one of 25 sampled residents (Resident 92), when the discharge MDS indicated the resident was discharged to an acute hospital. This failure resulted in Resident 92's MDS inaccurate assessment data submitted to CMS (Centers for Medicare-Medicaid Services).

Inspectors wroteBased on interview and record review, the facility failed to ensure comprehensive care plans were developed or implemented for three out of 25 sampled residents (Resident 36, Resident 148, and Resident 85), when: 1. Resident 148 had no care plan for a newly ordered respiratory treatment; 2. Resident 36's respiratory treatment and oxygen (O2) therapy care plan was not implemented; and 3. Resident 85's O2 therapy care plan was not implemented. These failures increased the potential risk to result in the residents not attaining their highest practicable physical, mental and psychosocial well-being.

Inspectors wrote2. Resident 29 was admitted to the facility in early 2024 with diagnoses which included spinal stenosis (narrowing of the spinal canal in the lower part of the back), dysphagia (difficulty swallowing foods or liquids), and unspecified dementia (loss of memory, language, problem-solving and other thinking abilities). During a review of Resident 29's MDS, dated [DATE], indicated Resident 29's cognition as moderately impaired. The MDS reflected that Resident 29 required supervision, verbal cues, and touching/steadying assistance when eating. During a review of Resident 29's care plan (CP), dated 8/5/24, the CP indicated Resident 29 was on, 1:1 assist and needs encouragement and sometimes feeding assist .Eats in dining room for most meals. During a dinning observation on 9/30/24 at 12:50 p.m. Resident 29 did not receive 1:1 assistance after the staff placed her meal in front of her. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure physician's orders were followed in accordance with professional standards for two of 25 sampled residents (Resident 85 and Resident 71), when: 1. Resident 85's oxygen (O2) was not administered as ordered and O2 saturation level was not monitored; and 2. Resident 71's insulin medication was administered outside of physician ordered parameters. These failures increased the potential risk for the decline in the residents' health status and well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the residents with a safe and comfortable environment free of accident hazards when four out of ten residents' bathroom faucets had water temperatures above 120 degrees Fahrenheit (F, scale for measuring temperature). This failure could potentially place residents at risk of accidental scalds or burns from hot water.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident food preferences were accommodated for four of 25 sampled residents (Resident 51, Resident 60, Resident 82, and Resident 20), when the residents' meal choices were not served. This failure increased the potential risk for the residents not attaining their highest practicable mental, physical and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the antibiotic stewardship guidelines were followed for one of 25 sampled residents (Resident 12), when Resident 12 received an antibiotic with no end date. This failure resulted in inappropriate or unnecessary use of antibiotic treatment for the resident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect one of four sampled residents (Resident 1) from verbal abuse when a Certified Nursing Assistant (CNA 1) used profanity while Resident 1 asked for assistance. This failure resulted in Resident 1 feeling intimidated and verbally abused at the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1's) rights were exercised safely when the resident self-administered medications without being evaluated or monitored by the health professionals. This failure resulted in Resident 1 taking multiple non-prescription supplements and vitamins, taking duplicate medications and increased the potential for adverse effects, medication errors, and ineffective medication therapy.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adequate monitoring and supervision for one of three sampled residents (Resident 3), when Resident 3 eloped (leaving unsupervised and undetected) from the facility. This failure had the potential to cause harm to Resident 3.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safety measures were in place for one out of five sampled residents (Resident 4), who was at risk for falling. This failure had the potential to cause physical injury.

Inspectors wroteBased on interview and record review the facility failed to medicate Resident 5 with her scheduled fentanyl (opioid pain medication) patch. This failure had the potential to increase pain during end-of-life care. A review of a facility document titled, admission RECORD, indicated Resident 5 was admitted on [DATE], with diagnoses that included Alzheimer's (problems with memory, thinking and behavior). Resident had a hospice (agency that assists with end-of-life care) provider. During a telephone interview on 10/3/23 at 9:38 a.m. with Resident 5's Responsible Party (RP), RP stated she went to visit Resident 5 around 9/22 and noticed the resident was grabbing her stomach and was moving around in bed. RP stated Resident 5 appeared in pain. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the resident call light system was accessible for two out of five residents (Resident 1 and Resident 3). This failure increased the risk of residents being unable to obtain assistance when needed.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure records of disposition and effective storage of destroyed controlled medications (regulated substances or drugs) were maintained when: 1. Random controlled medication audits did not reconcile for two out of five residents (Resident 3 and Resident 27); and 2. Multiple vials containing crushed and partially crushed medications, including narcotics, were found to be retrievable in four medications carts. These failures resulted in the facility not having accurate accountability of controlled substances and increased the potential for drug diversion and accidental exposure to destroyed medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed ensure the medication error rate of 5 percent or below was maintained for a census of 93, when two medication errors were observed during medication pass. This failure resulted in medication error rate of 5.41%.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of four sampled residents (Resident 66) was free of a significant medication error, when the resident received a blood pressure medication twenty-nine times, below the hold parameter as ordered. This failure had the potential risk for harm to Resident 66.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure drugs and biologicals were stored and labeled in accordance with current guidelines and principles in a census of 93, when: 1. Two bottles of expired medications were available for resident use; and 2. Ten opened inhalers were not labeled with an open and discard date. These failures had a potential for residents to receive unsafe medications.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a baseline care plan (BCP), for two of 25 sampled residents (Resident 185 and Resident 187), was completed and provided to the resident or the resident's responsible party (RP). This failure had the potential to leave the residents and the responsible parties without information summarizing the goals, medications, treatments, diet, and discharge plans.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement a plan of care for two of 25 sampled residents (Resident 56 and Resident 185), when: 1. Resident 56 had no care plan developed for respiratory failure and the use of oxygen (O2); and 2. Resident 185 had no care plan developed and implemented for the use of a neck collar. These failures had the potential to result in the residents not attaining their highest practicable well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that one of 25 sampled residents (Resident 28) received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan, when a fall mat was not in place as ordered by the physician. This failure increased the potential for injury.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure an appropriate intervention was implemented for one of 25 sampled residents (Resident 28), when Resident 28's plan of care, to turn and reposition every two hours and as needed to prevent wound progression, was not followed. This failure resulted in Resident 28's coccyx (tailbone) pressure wound progressing from Stage 2 (shallow open or break in the top two layers of the skin) to a Stage 4 (deep wound that may impact the muscle, tendons, ligaments and bone).

Inspectors wroteBased on interview and record review, the facility failed to ensure one of 25 sampled residents (Residents 27) was free from unnecessary psychotropic (drugs that affects brain activities associated with mental processes and behavior) medications when Resident 27 received as-needed lorazepam (a psychotropic medication for anxiety) without prescriber-documented rationale and specified duration for extended use beyond 14 days. This failure had the potential to result in unnecessary use of medication.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide safe food storage and preparation, as well as maintain kitchen equipment and utensils in accordance with professional standards for food safety for a census of 93, when: 1. Five bags of frozen chicken breasts covered with ice crystals were found in the freezer; 2. A cutting board and can opener were found with rough surfaces which interfere with sanitization; and 3. Clean forks were touched on the eating surface by ungloved hands after being cleaned, sanitized, and dried. These failures increased the potential for food-borne illnesses.