Auburn Rehabilitation & Nursing Center

Inspectors wroteBased on observations, record review, and interviews during the recertification and abbreviated surveys (NY00364436) conducted 1/2/2025 -1/7/2025, the facility did not ensure residents received adequate supervision to prevent accidents for 1 of 4 residents (Resident #276) reviewed. Specifically, Resident #276 did not have their hydrocollator pack (a device that heats cloth pads filled with a soft clay to provide moist heat therapy) monitored during therapy, causing a blister to their shoulder. This resulted in harm to Resident #276 that was not Immediate Jeopardy.

Inspectors wroteBased on observations, record review, and interviews during the recertification and abbreviated surveys (NY00356805) conducted 1/2/2025-1/7/2025, the facility did not ensure residents had the right to a safe, clean, comfortable, and homelike environment for 4 of 4 resident halls (North, West, East, and South). Specifically, there was a strong urine smell on North, West, East, and South halls; there was food and debris on the floor in the Northwest common area; Resident room [ROOM NUMBER] was unclean with food debris and spots on the floor and floor mats; and Resident #16 wanted a chair in their room and did not have one.

Inspectors wroteBased on observations, record review, and interviews during the recertification and abbreviated (NY000325307, NY00035605, and NY000359258) surveys conducted 1/2/2025-1/7/2025, the facility did not ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 4 of 5 residents (Residents #4, #24, #27, and #178) reviewed. Specifically, Resident #4 was not provided oral care; Resident #24 was not shaved as planned; Resident #27 was not provided toenail care as planned; and Resident #178 was not showered, shaved, or groomed as planned.

Inspectors wroteBased on observations and interviews during the recertification survey conducted 1/2/2025-1/7/2025, the facility did not ensure drugs and biologicals were labeled and stored in accordance with currently accepted professional principles and includes the expiration date when applicable for 1 of 2 medication carts and 1 of 1 treatment cart on the East Hall. Specifically, the East Hall medication cart was left unsecured; contained an expired insulin pen and an insulin pen without an opened or expired/discard date for Resident #27; and an insulin pen without any resident identifiers or opened/discharge date . Additionally, the East Hall treatment cart was left unsecured and contained medications and scissors.

Inspectors wroteBased on observations and interviews during the recertification survey conducted 1/2/2025-1/7/2025, the facility did not ensure each resident received and the facility provided food and drink that was palatable, flavorful, and at an appetizing temperature for 2 of 2 meals reviewed (1/3/2025 and 1/6/2025 lunch meals on the East Hall). Specifically, food was not flavorful and was not served at palatable and appetizing temperatures during the lunch meals on 1/3/2025 and 1/6/2025. Additionally, two residents (Resident #24 and #53) interviewed stated the food did not taste good and was cold.

Inspectors wroteBased on observations, record review, and interviews during the recertification survey conducted 1/2/2025-1/7/2025, the facility did not ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety for 1 of 1 main kitchen, and 1 of 2 (Northwest Unit) kitchenette nourishment areas. Specifically, the main kitchen had soiled and poorly maintained equipment, improper food and food product storage, and the lack of access to proper hand washing facilities; and the nourishment area on the Northwest Unit had unclean equipment.

Inspectors wroteBased on observations and interviews during the recertification survey conducted 1/2/2025-1/7/2025, the facility did not ensure that garbage and refuse was disposed of properly. Specifically, garbage was not properly contained outside on facility grounds.

Inspectors wroteBased on observations, record review, and interviews during the recertification and abbreviated (NY00356805 and NY00362194) surveys conducted 1/2/2025-1/7/2025, the facility did not ensure residents had the right to a dignified existence in a manner and an environment that promoted the maintenance or enhancement of quality of life for 2 of 2 residents (Resident #29 and Resident #282) reviewed. Specifically, Resident #29 was visible from the hallway in bed with their incontinence brief exposed; and Resident #282, who was continent of urine, urinated in bed when their call light was not answered timely.

Inspectors wroteBased on observations, record review, and interviews during the recertification survey conducted 1/2/2025-1/7/2025, the facility did not ensure residents received adequate supervision to prevent accidents for 2 of 4 residents (Residents #50 and #57) reviewed. Specifically, Residents #50 and #57 had medications at their bedsides and did not have orders for self- medication administration.

Inspectors wroteBased on observations, record review, and interviews conducted during the recertification survey conducted 1/2/2025-1/8/2025, the facility did not ensure residents were provided the appropriate treatment and services to maintain or improve their ability to carry out the activities of daily living including functional communication systems for 1 of 1 resident (Resident #13) reviewed. Specifically, Resident #13 was deaf and was not consistently provided a communication board as planned.

Inspectors wroteBased on record review and interviews during the recertification and abbreviated (NY00359258) surveys conducted 1/2/2025-1/7/2025, the facility did not ensure a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice to promote healing, prevent infection and prevent new ulcers from developing for 1 of 2 residents (Resident #15) reviewed. Specifically, Resident #15 had a new skin impairment that was not assessed and treated timely by a qualified individual.

Inspectors wroteBased on observations, record review, and interviews during the recertification and abbreviated (NY00356805) surveys conducted 1/2/2025-1/7/2025, the facility did not ensure there was an effective pest control program for 1 of 4 hallways (East Hall) and 1 of 2 kitchenettes (South kitchenette). Specifically, fruit flies and an unknown insect were observed in the East Hall and South kitchenette.

Inspectors wroteBased on observation, record review and interview during the recertification survey conducted 2/8/23 - 2/14/23 the facility failed to determine a resident's ability to safely self-administer medication when clinically appropriate for 1 of 1 residents (Resident #62) reviewed. Specifically, Resident #62 had a prescribed inhaler (hand-held, portable device that delivers medication to the lungs), and five pills in a medication cup at the bedside during multiple observations and there was no physician order for self-administration of medication or a resident assessment to determine the ability to safely self-administer medications. The facility policy, Administration of Medication-General, effective 8/2018, documented during medication administration nursing would observe the resident to ensure medication consumption. [...]

Inspectors wroteBased on interview and record review during the recertification survey conducted 2/8/23-2/14/23, the facility did not incorporate the recommendations from the DOH-695 Pre-admission Screening and Resident Review (PASRR) program level II determination (referral process for individuals who were known or suspected of having serious mental illness) into a resident's assessment, care planning, and transition of care for 1 of 1 resident (Resident #78) reviewed. Specifically, there was no documentation Resident #78 was provided a level II screening as required.

Inspectors wroteBased on observation, record review, and interview during the recertification and abbreviated (NY00308466, NY00300100, NY00294008, NY00293414) surveys conducted 2/8/23-2/14/23, the facility failed to ensure residents who were unable to carry out activities of daily living (ADLs) received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 1 of 9 residents (Resident #59) reviewed. Specifically, Resident #59, was not toileted and did not receive perineal (private areas) care as care planned.

Inspectors wroteBased on observation, interview, and record review during the recertification survey conducted 2/8/23-2/14/23, the facility failed to ensure that residents maintained acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrated that this was not possible for 2 of 5 residents (Residents #57 and 59) reviewed. Specifically, - Resident #57 was not weighed for 2 months, had a significant weight loss and there was no documented evidence the medical provider was made aware of the weight loss. - Resident #59's weights were not obtained as ordered.

Inspectors wroteBased on observation, interview, and record review during the recertification survey conducted 2/8/23-2/14/23, the facility failed to ensure drugs and biologicals were labeled in accordance with currently accepted professional principles and included the expiration date when applicable for 1 of 2 medication carts (Unit 2 North-West) and 1 of 2 medication storage rooms (North-West Unit) observed. Specifically, Unit 2 North [NAME] had expired stock medications in the medication cart and in the medication room. The facility policy Administration of Medication-General dated 8/2018 documented each nurse was to check expiration dates on packaged containers. The facility policy Storage and Maintenance of Medications dated 10/2018 documented medication had to be checked regularly for expiration dates and deterioration. Expired medications were to be removed from use and returned to the pharmacy. [...]

Inspectors wroteBased on observation, interview and record review during the recertification survey conducted 2/8/23-2/14/23, the facility failed to ensure food was stored, prepared, and served in accordance with professional standards for food service safety for two isolated areas (the basement storeroom and the main kitchen) reviewed. Specifically, in the basement storeroom there was a pallet containing more than 150 gallons of the facility's onsite emergency water stored directly under the sewage/drain lines. Additionally, the floors and exhaust hood within the main kitchen were unclean.

Inspectors wroteBased on record review and interview during the recertification survey, the facility did not ensure 2 of 3 residents (Residents #66 and #69) and/or their designated representative were fully informed of potential financial liability for rehabilitative services during a non-covered stay. Specifically, Residents #66 and #69 who remained in the facility and had benefit days remaining were not provided a Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF ABN), form CMS 10055, when services were no longer covered under Medicare Part A benefits.

Inspectors wroteBased on observation, record review and interview during the recertification survey the facility did not ensure 3 of 3 residents (Residents #41, 49 and 55) had the right to a homelike environment. Specifically, the bedrooms of Residents #41, 49 and 55 were stark and impersonal.

Inspectors wroteBased on record review, observation, and interview during the recertification survey, the facility did not ensure a resident with limited range of motion (ROM) received the appropriate treatment and services to improve and/or to prevent a decrease in ROM for 2 of 2 residents (Residents #10 and 63) reviewed for positioning/mobility. Specifically, Residents #10 and 63 did not have contracture devices implemented as care planned.

Inspectors wroteBased on observation, record review and interview during the recertification survey, the facility did not ensure the resident environment remained as free of accident hazards as possible for 1of 2 residents (Resident #16) reviewed for accidents. Specifically, there was no evacuation plan for Resident #16 in the event of an emergency. In addition, 4 staff did not have education related to evacuation procedures.

Inspectors wroteBased on observation, record review and interview during the recertification survey, the facility did not provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being in accordance with the comprehensive assessment and plan of care for 1 of 4 residents (Resident #59) reviewed for behavioral-emotional care. Specifically, Resident #59 displayed new depressive symptoms that were not addressed by staff.

Inspectors wroteBased on observation and interview during the recertification survey the facility did not provide food and drink that was palatable, attractive, and at a safe and appetizing temperature for 1 of 3 meal trays (lunch tray for Resident #169) tested. Specifically, food was not served at palatable and safe temperatures.