Average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Auburn Oaks Care Center during CMS and state inspections, most recent first.
A resident with a history of subarachnoid hemorrhage, cognitive communication deficit, encephalopathy, and documented moderate memory impairment underwent extensive surgical dental extractions without informed consent from the identified Responsible Party (RP). The physician’s orders indicated the resident lacked capacity, and the face sheet listed a family member as RP, yet consent was reportedly obtained from the resident instead. The DON confirmed no RP consent could be located, and a dental hygienist stated they normally contact the RP but were unaware of the RP status and had never spoken with the family member.
Failure to Follow Physician Orders for Oxygen and Pre-Therapy Medication: A resident with COPD and respiratory failure was observed receiving oxygen at a higher flow rate than ordered, and staff confirmed the oxygen setting did not match the physician order. Another resident with a fracture and mobility impairment received tramadol for pain management prior to therapy on multiple occasions even though PT was not scheduled, and the EMAR and service log confirmed the medication was given or offered outside the ordered therapy schedule.
Food service safety standards were not followed when resident bowls and containers were stacked upright in the air-drying area, unsealed food was found in the refrigerator and freezer, and a bag of Danish pastries was found unlabeled in the refrigerator. The RD and DM confirmed the observations, and the DM stated the chopped onions, pot stickers, and pastries should have been properly sealed or labeled. Facility policy required food items in the storeroom, refrigerator, and freezer to be labeled, dated, and closed.
Loose Transition Strip in Resident Room: A resident with difficulty walking who used a walker and wheelchair had a transition strip between the bedroom and bathroom that was not securely affixed. The resident said the strip caught on the walker’s rubber tips and that she had reported the issue to staff, but it remained unaddressed. An LN, the MS, and the DON confirmed the strip was loose and could be a trip hazard, and the maintenance log had no record of the issue.
A resident with moderate dementia, PTSD, and a history of unsafe wandering was able to leave the facility unsupervised after the removal of a previously ordered wander guard and the resolution of elopement risk in the care plan. The resident was found outside by a family member, and staff were unaware of the absence until notified. The care plan did not reflect the resident's ongoing elopement risk at the time of the incident.
A resident with cognitive impairment and physical limitations was not protected from abuse when another cognitively impaired resident became physically aggressive during a meal, pushing the first resident's plate onto her chest and lap. The incident was witnessed by CNAs and resulted in emotional distress for the affected resident.
A resident sustained injuries during a transfer from bed to shower chair due to improper use of a Hoyer lift by two CNAs. The resident, who required assistance for transfers and was at high risk for falls, fell when the lift tipped over due to incorrect maneuvering and lack of stability. This resulted in a right ankle sprain and back pain, causing the resident to fear future transfers.
A resident with a right ankle sprain was not properly monitored for the use of a postoperative boot, as there were no physician orders or care plans in place. Despite the resident's high fall risk and moderate cognitive impairment, the facility failed to document or evaluate the boot's use, which was confirmed by the ADON and DOR.
Two LVNs at a facility pronounced a resident deceased, which violated the facility's policy and state law as only a physician or RN is authorized to do so. The resident, on hospice care for COPD, was found unresponsive with no signs of life. Interviews confirmed the LVNs acted outside their scope of practice, potentially jeopardizing resident safety.
A resident with cognitive impairments was physically abused by another resident, resulting in a scratch on her face and feelings of unsafety. The incident occurred after a verbal exchange when one resident accidentally bumped into the other's foot, leading to a physical altercation. The facility's policies on abuse prevention and resident-to-resident altercations were not effectively implemented, resulting in a failure to protect the resident from abuse.
A resident was mistakenly given another resident's medications upon discharge, breaching confidentiality. The error occurred because medications for both residents were stored in the same drawer, and staff failed to verify the medications properly. The facility's policy on confidentiality was not followed, and the breach was not reported to the state or the affected resident's family.
A resident was discharged with another resident's medications due to a mix-up by the nursing staff. The error occurred when medications were pulled from a shared drawer without proper verification. The facility's policy for reviewing discharge instructions and medications was not adequately followed, leading to the resident leaving with incorrect medications.
The facility did not complete annual performance evaluations for three CNAs, as required by policy, increasing the risk of poor-quality care. The DSD admitted to not conducting evaluations for 2023-2024, and the DON and ADM confirmed the oversight. These evaluations are crucial for identifying areas for improvement and assessing CNA competency.
The facility failed to properly manage medications and oxygen for several residents, leading to potential health risks. Medications were left unlabeled and undated at the bedside, and oxygen equipment was not maintained or monitored as required. These deficiencies were confirmed by nursing staff, highlighting a lack of adherence to professional standards.
The facility failed to document controlled substance medications accurately for four residents, with discrepancies between the MAR and CDR. Additionally, an opened antibiotic e-kit was not replaced within the required timeframe, risking medication availability. Interviews confirmed the expectation for accurate documentation and timely e-kit replacement, as per facility policy.
A facility failed to document clinical rationale when disagreeing with pharmacy consultant recommendations for a resident's medication regimen. The resident, with multiple diagnoses including Huntington's disease and depression, was on a complex medication regimen. The pharmacy consultant identified potential risks, but the provider disagreed with recommendations without documenting reasons. The facility lacked a policy for reviewing pharmacy consultant reports.
The facility failed to properly store and label medications, leading to expired and improperly stored medications being available for use. Inspections revealed expired medications, loose tablets, and improper storage of medications requiring different administration routes. The DON confirmed the need for separate storage and proper labeling, as per facility policies.
The facility failed to follow professional standards for food service safety, affecting 95 residents. Observations revealed improper food labeling, expired items not discarded, and poor storage conditions for produce and utensils. The RD confirmed these issues, which contradict the facility's policies and FDA guidelines.
The facility failed to maintain proper infection control by not labeling, dating, or changing respiratory equipment weekly for several residents, increasing the risk of respiratory infections. Staff confirmed lapses in following policies for managing oxygen therapy equipment, which were not consistently adhered to, posing potential infection risks.
A facility failed to accurately code the MDS for a resident, indicating discharge to a hospital instead of home, despite documentation showing the correct discharge destination. The MDS Coordinator confirmed the error, and the DON emphasized the need for accurate MDS coding. The resident had multiple diagnoses, including heart failure and difficulty walking.
The facility failed to develop or implement comprehensive care plans for three residents, leading to deficiencies in their care. A resident with pulmonary edema had no care plan for a respiratory treatment, while another with asthma had expired respiratory equipment and an empty oxygen tank. A third resident with lung cancer received oxygen therapy at a higher rate than prescribed, and their oxygen saturation levels were not monitored. These oversights resulted in care plans not being followed.
The facility failed to assist four residents with activities of daily living, leading to deficiencies in personal hygiene and nutrition. A resident with Huntington's Disease and another with cognitive impairment had long, unclean fingernails despite needing assistance. Another resident with dementia also had unclean nails. Additionally, a resident with spinal stenosis and dysphagia did not receive the required one-to-one assistance during meals, as confirmed by staff and care plans.
The facility failed to adhere to physician's orders for two residents, leading to deficiencies in care. A resident with lung cancer and COPD received oxygen at a higher rate than prescribed, and monitoring was inconsistent. Another resident with diabetes received insulin despite blood sugar levels being below the ordered threshold. Staff confirmed these discrepancies, highlighting a failure to follow medical orders.
The facility failed to ensure safe water temperatures in resident bathrooms, with four bathrooms having water temperatures exceeding 120 degrees Fahrenheit. Staff confirmed the excessive heat, and residents expressed fear of burns. The facility's policy requires water temperatures to be between 105 and 120 degrees Fahrenheit, but this was not adhered to, posing a risk of scalds or burns.
The facility failed to accommodate the food preferences of four residents, leading to dissatisfaction and potential nutritional risks. A resident with severe memory impairment was served a regular sandwich instead of a meal that met her dietary needs. Another resident expressed dissatisfaction with being served pasta despite disliking it, and a third resident repeatedly received meals with sauces despite expressing a dislike for them. A fourth resident was served a sandwich for lunch, which did not align with her expectations or preferences.
A resident with a history of UTIs was prescribed Cephalexin without a stop date, contrary to the facility's antibiotic stewardship policy. Staff interviews revealed a lack of clarity and monitoring for the antibiotic's necessity and duration, with no specific orders to monitor for UTIs.
A resident, who was cognitively intact and required assistance with toileting, experienced verbal abuse from a CNA who used profanity and refused to help. The incident was witnessed by another resident and staff, who confirmed the CNA's aggressive behavior. The facility's policies on resident rights and abuse prevention were not followed, leading to a deficiency in care standards.
A resident with chronic conditions self-administered multiple non-prescription supplements and vitamins without evaluation or monitoring by health professionals. The facility's policy required an IDT evaluation for safe self-administration, but no such evaluation was conducted. This oversight led to the resident taking duplicate medications and supplements without professional oversight, raising safety concerns.
Failure to Obtain Informed Consent from Responsible Party for Extensive Dental Extractions
Penalty
Summary
The deficiency involves the facility’s failure to obtain informed consent from a resident’s Responsible Party (RP) prior to extensive dental extractions. The resident had diagnoses including subarachnoid hemorrhage, cognitive communication deficit, encephalopathy, and long-term use of anticoagulants, and an MDS dated 2/5/26 documented moderate memory impairment. The physician’s orders indicated the resident was not capable, and the nurse practitioner note from 3/31/26 stated the resident was awake but had periods of confusion. The face sheet identified a family member as the RP. Despite this, the resident was scheduled on a dental visit list for surgical extraction with bone removal of multiple teeth, and post-operative documentation showed that oral surgery was completed on 4/7/26. During a telephone interview, the RP stated they were not asked for consent for the extractions and that the facility reported obtaining consent directly from the resident, even though the resident was confused at times. On observation, the resident demonstrated memory problems and was unable to answer all questions posed by the nurse surveyor. The DON confirmed that, based on the face sheet and physician’s order indicating no capacity, the RP should have been contacted for consent and that no consent from the RP for the extraction of 21 teeth could be found. A registered dental hygienist reported that they normally call the RP if there is one but stated they did not realize the RP had changed and had never spoken to the identified RP. When requested, the facility was unable to provide a policy and procedure related to this issue.
Failure to Follow Physician Orders for Oxygen and Pre-Therapy Medication
Penalty
Summary
The facility failed to follow physician orders for Resident 41 when the resident’s oxygen was observed running at 3.5 liters per minute, although the physician order and care plan specified oxygen at 2 liters per minute via nasal cannula for COPD and respiratory failure. During the observation and concurrent review, the LN confirmed the oxygen concentrator was set above the ordered amount and stated she had not checked the resident’s oxygen during morning rounds. The DON also confirmed the order was for 2 liters per minute and stated staff should have set the oxygen condenser according to the physician’s order. The facility also failed to follow physician orders for Resident 31, who was admitted with a thigh fracture and difficulty walking. The resident had an order for tramadol 50 mg by mouth once daily for pain management prior to therapy, with PT scheduled five times per week for four weeks. The service log showed multiple dates when PT was not scheduled, and the EMAR showed tramadol was administered on several dates when no PT session was scheduled, including times when the resident’s pain score was zero. The EMAR also showed tramadol was offered and refused on other dates when there was no scheduled PT. The LN and DON both confirmed the EMAR and service log findings and acknowledged that nurses were required to follow physician orders exactly.
Food Storage and Labeling Deficiencies
Penalty
Summary
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. During a concurrent observation and interview with the RD and DM, several resident bowls and containers were observed stacked upright in the air-drying area, and the RD confirmed the observation. The FDA Food Code 2022 was cited as requiring cleaned and sanitized equipment and utensils to be air-dried and stored in a self-draining position that allows air drying or covered or inverted. During additional observations with the DM and RD, a bag of chopped onions was found stored unsealed in the refrigerator, frozen pot stickers were found unsealed with freezer burn in the freezer, and a bag of Danish pastries was found unlabeled in the refrigerator. The DM stated the chopped onions and pot stickers should have been properly sealed, and the DM stated the Danish pastries should have been labeled. The facility policy titled, Labeling and Dating of Foods, dated 2023, indicated all food items in the storeroom, refrigerator, and freezer need to be labeled and dated and should be closed.
Loose Transition Strip in Resident Room
Penalty
Summary
The facility failed to maintain a safe environment for one resident when a transition strip between the resident’s bedroom and bathroom was not securely affixed. The resident was admitted in late 2025 with difficulty walking, had a BIMS score of 13 out of 15 indicating intact cognition, and used a walker and wheelchair for ambulation. During observation, the transition strip could be easily lifted off the floor, and the resident stated it was not properly secured and that it caught on the rubber tips of the walker when moving in and out of the bathroom. The resident stated she had reported the issue to staff in December 2025, but no corrective action was taken. The resident’s care plan identified her as at risk for falls due to a history of falls, unsteady gait, and visual impairment. Facility staff, including an LN, the MS, and the DON, confirmed the strip was not properly secured and acknowledged it could be a trip hazard. The facility’s Maintenance Repair Log for December 2025 contained no record of a loose transition strip in the resident’s room.
Failure to Prevent Elopement for Resident with Dementia and PTSD
Penalty
Summary
A resident with moderate dementia, PTSD, and difficulty walking was admitted to the facility and identified as being at risk for elopement, as documented in the resident's Elopement and Wandering Risk Assessment. The assessment indicated the need for a wander alarm device, and a physician's order for a wander guard was in place. However, the wander guard order was discontinued and the device was removed several months prior to the incident. The resident's care plan was also revised to indicate that the elopement risk and need for a wander guard were resolved, despite the resident's ongoing cognitive impairments and history of unsafe wandering. On the date of the incident, the resident left the facility unsupervised and was found by a family member walking down the street and standing at a traffic light intersection. Facility staff were unaware of the resident's absence until notified by the family member. Upon review, the care plan did not reflect the resident's elopement risk during the period leading up to the incident, and staff confirmed that the resident's elopement was a safety issue due to his dementia and PTSD. The facility's policy required that residents identified as at risk for wandering or elopement have care plans with appropriate interventions to maintain safety, which was not followed in this case.
Failure to Protect Resident from Abuse by Another Resident
Penalty
Summary
A deficiency occurred when a resident with moderately impaired cognition and a history of hemiplegia, dementia, and anxiety disorder was not protected from abuse by another resident. The incident took place in the dining room, where three CNAs were present. During the meal, another resident with severely impaired cognition due to metabolic encephalopathy and Alzheimer's disease became physically aggressive, pushing the first resident's plate onto her chest and lap. The affected resident reported feeling upset by the incident. Staff interviews confirmed that the altercation was witnessed, and the facility's policy states that residents must be protected from abuse by anyone, including other residents. Despite this, the event resulted in a failure to ensure the resident's right to be free from abuse, as required by federal regulations.
Plan Of Correction
Residents were separated immediately at the time of the incident and Resident 21 was removed from the dining room. All residents who have an altercation have the potential to be affected by the same deficient practice. Any residents who have an altercation will be separated immediately and reported accordingly. DSD in-serviced staff on 07/08/25 on Abuse Policy and ways to prevent altercations. DSD to observe the behavior of Resident 12 in the dining room weekly x 4 weeks, monthly x 1 month to ensure no altercations occur and residents feel safe. Any findings out of compliance will be brought to the attention of the Administrator and addressed immediately. All findings will be reported to the QA Committee. Corrective action will be achieved and sustained by 07/24/2025.
Improper Use of Hoyer Lift Leads to Resident Injury
Penalty
Summary
The facility failed to provide safe supervision and assistance during a transfer for a resident, resulting in an accident. The incident occurred when two CNAs were transferring a resident from bed to a shower chair using a Hoyer lift. The CNAs did not follow the proper maneuvering and operation procedures for the lift, leading to the lift tipping over and the resident falling to the ground. This resulted in the resident sustaining a right ankle sprain, back pain, and developing a fear of being moved out of bed using a lift. The resident involved in the incident had been admitted to the facility with diagnoses including morbid obesity, muscle weakness, fibromyalgia, and difficulty walking. The resident's Minimum Data Set indicated moderate cognitive impairment and a dependency on staff for toileting hygiene, transfers, and showering, requiring the assistance of two or more staff members. The resident was also assessed as being at high risk for falls, with a care plan in place to minimize fall risks, including a recommendation for a room change to accommodate a bariatric bed and ease the maneuvering of the Hoyer lift. During the transfer, CNA 1 improperly maneuvered the lift by moving it sideways instead of pivoting it, and CNA 2 was positioned away from the lift, failing to provide adequate support. The lift's legs were not opened or extended, compromising its stability, and the brakes were not used correctly. As a result, the lift tipped over, causing the resident to fall and the lift to land on the resident's right ankle. The incident was compounded by the CNAs not adhering to the facility's policy and procedure for using mechanical lifts, which emphasized the importance of stability and proper handling to prevent accidents.
Failure to Monitor Postoperative Boot Use
Penalty
Summary
The facility failed to provide necessary care and services for a resident who was using a postoperative boot following a fall that resulted in a right ankle sprain. The resident, who was admitted with conditions including morbid obesity, muscle weakness, fibromyalgia, and difficulty walking, was at high risk for falls and had moderate cognitive impairment. After a fall, the resident was diagnosed with a possible avulsion fracture and was discharged from the hospital with a postoperative boot and pain medication. However, the facility did not monitor or evaluate the use of the boot, as there were no physician orders, treatment notes, or care plans in place for its use. During observations and interviews, it was confirmed that the resident was wearing the boot, but there was no documentation or monitoring for skin integrity and circulation, which are essential when using such devices. The Assistant Director of Nursing (ADON) and the Director of Rehabilitation (DOR) acknowledged the lack of orders and care plans for the boot. The facility's policy on safety and supervision of residents emphasizes the need for implementing, documenting, and evaluating interventions, which was not adhered to in this case.
Improper Pronouncement of Death by LVNs
Penalty
Summary
The facility failed to adhere to its policy regarding the pronouncement of death, resulting in a violation of professional standards of quality. Two Licensed Vocational Nurses (LVNs) pronounced a resident deceased, which is outside their scope of practice according to the facility's policy and state law. The resident, who was on hospice care for Chronic Obstructive Pulmonary Disease (COPD), was found unresponsive in bed with no signs of life. The LVNs documented the absence of a pulse and respiratory effort, and subsequently declared the time of death. Interviews with the Registered Nurse (RN), Hospice Clinical Consultant (HCC), and Director of Nursing (DON) confirmed that only a physician or RN is authorized to pronounce death, especially for residents on hospice care. The facility's policy titled "Death of a Resident" explicitly states that a resident may only be declared dead by a licensed physician or RN with physician authorization. The DON verified that the LVNs acted outside their scope of practice, which could potentially jeopardize resident health and safety.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse when another resident grabbed her hands, resulting in a scratch on her face and feelings of unsafety. The incident involved two residents with cognitive impairments. Resident 1, who has a history of cerebral infarction and schizophrenia, was sitting in her wheelchair when Resident 2, diagnosed with postconcussional syndrome and mild cognitive impairment, accidentally bumped into her foot. This led to Resident 1 grabbing Resident 2's wrists and scratching her face. The incident was witnessed by a CNA and a Licensed Nurse (LN 1), who were at the nursing station when they heard yelling from the residents' room. The CNA reached the room first and observed Resident 1 grabbing Resident 2's hands after a verbal exchange. LN 1 intervened by pulling Resident 2's wheelchair back. Both residents had a history of memory problems, and Resident 1 was known for behaviors such as yelling and repetitiveness. The facility's policy on abuse prevention and resident-to-resident altercations emphasizes the need to protect residents from abuse, including physical abuse by other residents. The policy outlines that all altercations should be investigated and reported to the nursing supervisor, director of nursing services, and the administrator. However, the incident highlights a failure in preventing resident-to-resident abuse, as Resident 2 sustained a physical injury and felt unsafe in her room.
Confidentiality Breach Due to Medication Mix-Up
Penalty
Summary
The facility failed to maintain confidentiality for one of its residents when medications belonging to another resident were mistakenly given to an unauthorized recipient. Resident 1, who was admitted with orthopedic aftercare and spinal stenosis, was discharged with medications that included those belonging to Resident 2, who had been admitted with hemiplegia and hemiparesis following a stroke. This error occurred because the medications for both residents were stored in the same drawer, and during the discharge process, Resident 2's medications were inadvertently included with Resident 1's. The error was discovered when Resident 1's family member noticed the mistake after leaving the facility. Interviews with the Director of Nursing (DON) and several Licensed Nurses (LNs) revealed that the medication cart nurse and desk nurse did not adequately verify the medications before discharge. The medication cart nurse mistakenly pulled medications from the wrong drawer, and the desk nurse failed to thoroughly check the contents of the medication bag, leading to the breach of confidentiality. The DON acknowledged the mistake and noted that the confidentiality breach was not reported to the state, and the family of Resident 2 was not informed of the incident. The facility's policy on confidentiality and resident rights emphasizes the protection of personal and medical records, but the policy was not followed in this instance. The facility's failure to adhere to its own procedures resulted in the unauthorized release of Resident 2's confidential information.
Resident Discharged with Wrong Medications
Penalty
Summary
The facility failed to ensure a safe discharge for a resident, who was discharged with another resident's medications. This incident involved two residents, one of whom was discharged with medications belonging to their roommate. The discharged resident had been admitted with orthopedic aftercare needs and was cognitively intact, while the roommate had been admitted with conditions related to a stroke. The error occurred when the medication cart nurse mistakenly pulled the roommate's medications instead of the discharged resident's. The desk nurse briefly reviewed the medications but failed to notice the error, resulting in the wrong medications being sent home with the resident. The facility's Director of Nursing acknowledged the mistake and noted that the medications were not properly verified before discharge. Interviews with staff revealed that the medications for both residents were stored in the same drawer without proper separation, leading to the mix-up. The staff involved admitted to not thoroughly checking the medications before discharge, and the error was only discovered after the resident had left the facility. The facility's policy required that discharge instructions and medications be reviewed with the resident or responsible party, which was not adequately followed in this case.
Failure to Conduct Annual Performance Evaluations for CNAs
Penalty
Summary
The facility failed to complete annual performance evaluations for three of five sampled certified nursing assistants (CNAs) in a facility with a census of 95. During interviews and record reviews, it was found that CNAs hired on various dates had no documented evidence of annual performance evaluations being conducted. The Director of Staffing Development (DSD) admitted to not completing any performance evaluations for the year 2023 to 2024. The Director of Nursing (DON) and the Administrator (ADM) confirmed the absence of these evaluations, which are intended to identify areas for improvement in resident care and assess the competency of CNAs. The facility's policy requires that job performance be reviewed and evaluated at least annually, but this was not adhered to, increasing the risk of residents receiving poor-quality care.
Medication and Oxygen Management Deficiencies
Penalty
Summary
The facility failed to ensure that medications and ointments were properly managed and stored for several residents, leading to potential health risks. For Resident 143, medications and ointments were left on the nightstand, unlabeled and undated, which the resident did not recognize. This was confirmed by both a Certified Nursing Assistant (CNA) and a Licensed Nurse (LN), who acknowledged that the medications should not have been left there and were not properly labeled. Resident 144 experienced a similar issue, with medications and hazardous liquids left at the bedside. A medication labeled for another resident was found in Resident 144's room, along with an unlabeled container of mentholatum ointment and a large plastic container of mouthwash. The CNA and LN confirmed that these items should not have been at the bedside and that medications from home should be checked in with a nurse and stored properly. For Resident 36, a medication was not administered completely and was left at the bedside, and an oxygen tank was found empty while in use. The nasal cannula and other equipment were not dated or changed as required, leading to potential infection risks. Additionally, Resident 85's oxygen saturation levels were not monitored as ordered, and the oxygen was administered at an incorrect rate. These failures were confirmed by the nursing staff, who acknowledged the importance of following physician orders and the potential for respiratory distress if not adhered to.
Deficiencies in Controlled Medication Documentation and E-Kit Replacement
Penalty
Summary
The facility failed to ensure accurate documentation and accountability of controlled substance medications for four residents. For Resident 3, a hydrocodone/acetaminophen tablet was removed but not documented on the medication administration record (MAR). Resident 22 received tramadol, but its removal was not recorded on the Controlled Drug Record (CDR). Resident 75 had lorazepam removed, but the administration was not documented on the MAR. For Resident 78, multiple administrations of hydrocodone/acetaminophen were recorded on the MAR, but their removal was not documented on the CDR. Interviews with Licensed Nurse 2 and the Director of Nursing confirmed the expectation that both the CDR and MAR should reflect the administration and removal of controlled medications, as per the facility's policy. Additionally, the facility did not replace an opened antibiotic emergency kit (e-kit) in a timely manner. The e-kit, identified with a red plastic tie indicating it had been opened, contained logs showing medications were removed on several dates. The Assistant Director of Nursing confirmed that nursing staff were expected to request a replacement e-kit immediately after it was opened to ensure availability of medications. The facility's policy stated that opened kits should be replaced within 72 hours, which was not adhered to in this instance.
Failure to Document Clinical Rationale for Medication Decisions
Penalty
Summary
The facility failed to implement a process to ensure that clinical rationale was documented when no changes were made to medications in response to identified irregularities and recommendations by the pharmacy consultant (PC) for a resident. The resident, who was admitted with multiple diagnoses including Huntington's disease, anxiety, insomnia, dementia, high blood pressure, depression, and repeated falls, was on a complex medication regimen. The PC's monthly drug regimen reviews (MRR) identified potential medication-related problems, such as increased risk of central nervous system depression, serotonin syndrome, neuroleptic malignant syndrome, and extrapyramidal symptoms due to the combination of medications prescribed. Despite these identified risks, the provider disagreed with the PC's recommendations to evaluate and possibly adjust the medication regimen, including the dosing of lamotrigine ER and the use of two antidepressants, without documenting the clinical rationale for these decisions. The Director of Nursing (DON) confirmed that the provider marked disagreement with the PC's recommendations on the MRRs but did not provide the necessary clinical rationale. Additionally, the facility was unable to provide a policy and procedure (P&P) addressing the process for reviewing and acting upon the PC's MRRs when requested.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure that medications were stored and labeled according to professional standards and the facility's policies and procedures. During an inspection, expired medications, including Skintegrity Hydrogel and EvenCare G3 blood glucose test strips, were found in the Central Supply. Additionally, an open vial of Assure Platinum blood glucose test strips was identified without an open date label, and loose tablets were found in medication carts. Partially used bottles of sterile normal saline and acetic acid irrigation, which are intended for single use, were not discarded after opening, contrary to the manufacturer's instructions. Further inspections revealed that medications requiring different routes of administration were improperly stored together, such as injectable medications and topical patches being stored with oral medications. The Director of Nursing confirmed that medications should have been stored separately based on their administration routes and that all medications provided by the pharmacy should have been labeled with the resident's name. The facility's policies emphasized the importance of maintaining medication storage areas in a clean, safe, and orderly manner, which was not adhered to, leading to the potential for unsafe medication administration and misuse.
Food Safety and Storage Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, affecting 95 residents who received facility-prepared foods. During an initial kitchen tour, it was observed that proper food labeling was not followed. Items such as coconut flakes, diced onions, and cut celery sticks were found without proper labels indicating the opened or used-by dates. The Registered Dietitian (RD) confirmed these observations and acknowledged that the staff is expected to label food items correctly as per the facility's policy and procedure. Additionally, expired food items were not discarded as required. Expired items such as oat milk, salad dressing packets, chocolate baking chips, pie crust, and soy milk were found in various storage areas. The RD confirmed these findings and stated that expired items should have been discarded immediately. The facility's policy mandates that no food should be kept beyond its expiration date, aligning with the U.S. Food and Drug Administration (FDA) guidelines. The facility also failed to maintain proper storage conditions for produce and utensils. A box of undated bananas with discoloration and leaking fluids was found in the walk-in refrigerator, which the RD and Dietary Manager confirmed should not be served to residents. Furthermore, several wet steam table pans were found stacked in the clean storage area, contrary to the facility's policy and FDA guidelines that require items to be air-dried before storage to prevent microorganism growth.
Inadequate Infection Control in Respiratory Equipment Management
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the improper management of respiratory equipment for four residents. Resident 148 had a hand-held nebulizer and a nasal cannula that were unlabeled and undated, with a nebulizer bag that was dated more than a week prior. Resident 36 had an unlabeled and undated nasal cannula and nebulizer machine, with a disconnected nebulizer chamber and an undated oxygen mask, some of which were touching the floor. These items were not changed weekly as required, increasing the risk of respiratory infections. Resident 1's oxygen tubing and face mask were not labeled or dated, contrary to the facility's policy of weekly changes to prevent infections. The care plan for Resident 1 highlighted the risk of infection due to the use of muscle relaxants and a history of COVID-19, yet the necessary precautions were not followed. Similarly, Resident 3's oxygen tubing and face mask were not labeled or dated, and the antimicrobial bag was expired. The physician orders for Resident 3 specified weekly changes of oxygen equipment, which were not adhered to, posing a risk of infection. Interviews with staff, including CNAs and the Director of Nursing, confirmed the lapses in following the facility's policies for infection control. The facility's policies required that oxygen therapy equipment be labeled, dated, and changed weekly, with storage in antimicrobial bags changed monthly. These procedures were not consistently followed, leading to potential risks of respiratory infections among the residents.
Inaccurate MDS Discharge Coding for a Resident
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) accurately reflected the current condition of a resident, identified as Resident 92. The deficiency occurred when the discharge MDS inaccurately indicated that the resident was discharged to a short-term general hospital, despite documentation in the resident's Physician Orders, Nurse's Note, and Nurse Practitioner Note indicating that the resident was discharged to home. This discrepancy was confirmed during a record review and interview with the MDS Coordinator, who acknowledged the error and stated that the MDS should have been coded correctly. Resident 92 was admitted to the facility with multiple diagnoses, including heart failure and difficulty in walking. The facility's policy and procedure on resident assessments, which are federally mandated, require that discharge assessments be accurate and conducted by the interdisciplinary team. The Director of Nursing emphasized the expectation for MDS coding to be accurate. The inaccurate MDS submission to CMS resulted from a failure to adhere to these policies, as evidenced by the incorrect discharge status recorded in the MDS.
Failure to Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop or implement comprehensive care plans for three residents, leading to deficiencies in their care. Resident 148, who was admitted with pulmonary edema, muscle weakness, and swallowing difficulty, had a physician's order for a respiratory treatment using Ipratropium-Albuterol Solution. However, there was no care plan developed for this treatment, and the resident was unaware of the purpose of the nebulizer treatment, indicating a lack of communication and documentation. Resident 36, admitted with asthma exacerbation and respiratory failure with hypoxia, had care plans that were not implemented. Observations revealed expired and undated respiratory equipment, such as nasal cannulas and nebulizer masks, which were not replaced as required. Additionally, the resident's oxygen tank was found empty, and staff failed to monitor and replace it, leading to the resident experiencing shortness of breath. These oversights in equipment management and monitoring contributed to the failure in implementing the care plan. Resident 85, diagnosed with lung cancer, pulmonary fibrosis, and COPD, received oxygen therapy at a higher rate than prescribed. The care plan indicated oxygen should be administered at 3L/min, but observations showed it was consistently given at 4L/min. Furthermore, the resident's oxygen saturation levels were not monitored as ordered, and the staff did not adhere to the care plan interventions. These actions and inactions resulted in the care plan not being followed, potentially affecting the resident's health outcomes.
Deficiencies in ADL Assistance and Personal Hygiene
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADL) for four residents, leading to deficiencies in personal hygiene and nutrition. Resident 83, who has Huntington's Disease, was observed with long fingernails and a thick dark substance underneath them, despite requiring partial/moderate assistance for personal hygiene. Similarly, Resident 44, with cognitive impairment and muscle weakness, had long fingernails with chipped nail polish and a dark substance underneath, even though they needed substantial/maximum assistance with personal hygiene. Resident 20, diagnosed with dementia and lack of coordination, also had long fingernails with a dark substance underneath, despite requiring partial/moderate assistance for personal hygiene. Staff interviews confirmed the lack of nail care and the importance of maintaining clean nails to prevent cross-contamination and bacterial growth. Additionally, the facility failed to provide one-to-one assistance during meals for Resident 29, who has spinal stenosis, dysphagia, and dementia. Despite the care plan indicating the need for one-to-one assistance and encouragement during meals, Resident 29 did not receive the required assistance during a dining observation. The Registered Dietitian and Director of Nursing confirmed the need for one-to-one assistance, as outlined in the resident's care plan and meal ticket. The facility's policies on ADL and nail care emphasize the necessity of providing services to maintain good nutrition, grooming, and personal hygiene, which were not adhered to in these cases.
Failure to Follow Physician's Orders for Oxygen and Insulin Administration
Penalty
Summary
The facility failed to follow physician's orders for two residents, leading to deficiencies in care. Resident 85, who was diagnosed with lung cancer, pulmonary fibrosis, and COPD, was prescribed oxygen therapy at 3 liters per minute to maintain oxygen saturation levels above 90%, with monitoring every shift. However, observations revealed that the resident was receiving oxygen at 4 liters per minute, and the oxygen saturation levels were not consistently monitored as ordered, with some days having only one or two checks instead of every shift. Licensed nurses confirmed the discrepancies in oxygen administration and monitoring. Resident 71, who was readmitted with a diagnosis of diabetes, had a physician's order for Insulin Glargine to be administered with specific parameters: 25 units to be injected unless blood sugar was below 151. Despite this, the medication was administered on two occasions when the resident's blood sugar levels were below the specified threshold, at 110 and 136, respectively. The Director of Nursing confirmed that the insulin was given outside the ordered parameters, and a licensed nurse acknowledged the importance of adhering to insulin orders to prevent rapid drops in blood sugar levels.
Excessive Water Temperatures in Resident Bathrooms
Penalty
Summary
The facility failed to maintain a safe environment free from accident hazards, as evidenced by the water temperatures in four out of ten residents' bathrooms exceeding 120 degrees Fahrenheit. During observations and interviews conducted on September 30, 2024, it was confirmed that the water temperatures in these bathrooms ranged from 120.2 F to 122.2 F. Certified Nurse Assistants and a Housekeeper verified these temperatures, expressing concerns about the potential for burns or scalds due to the excessively hot water. Residents also expressed fear and caution when using the water, indicating awareness of the hazard. The facility's policy and procedure on water temperatures, dated May 2024, stipulates that water heaters in bathrooms should be set between 105 degrees Fahrenheit and 120 degrees Fahrenheit. However, the observed temperatures exceeded this range, indicating a failure to adhere to the established guidelines. This oversight could potentially place residents at risk of accidental scalds or burns, particularly given the fragility of the residents' skin as noted by the staff.
Failure to Accommodate Resident Food Preferences
Penalty
Summary
The facility failed to accommodate the food preferences of four residents, leading to dissatisfaction and potential nutritional risks. Resident 51, who has severe memory impairment and requires a mechanically altered diet, was served a regular sandwich instead of a meal that met her dietary needs. Despite her confusion and the meal ticket indicating a regular diet order, the Infection Preventionist confirmed the meal was not aligned with her preferences. Resident 60, with mild memory impairment and dietary restrictions, expressed dissatisfaction with the meals provided, specifically being served pasta despite disliking it. The meal ticket confirmed her dislikes, yet the meal did not reflect her preferences. The Licensed Nurse acknowledged the oversight but noted that the resident did not communicate her hunger or need for a replacement meal. Resident 82, who is at risk for malnutrition, repeatedly received meals with sauces despite expressing a dislike for them. The Assistant Director of Nursing verified the presence of sauce on the meal and offered a replacement. Similarly, Resident 20, with moderate memory impairment, was served a sandwich for lunch, which did not align with her expectations or the meal ticket indicating her preferences. The Infection Preventionist was unable to explain why both Resident 20 and Resident 51 received the same meal, highlighting a systemic issue in meal preparation and delivery.
Antibiotic Stewardship Guidelines Not Followed
Penalty
Summary
The facility failed to adhere to antibiotic stewardship guidelines for a resident who was prescribed an antibiotic without a specified end date. The resident, who was admitted in 2012 with conditions including diabetes, kidney disease, and a history of urinary tract infections (UTIs), was prescribed Cephalexin 250 mg daily for a UTI. However, the physician's order did not include a stop date for the antibiotic, and there was no documented evidence of monitoring for signs and symptoms of a UTI. Interviews with facility staff, including the Facility Pharmacist and the Director of Nursing, revealed that there was confusion and lack of clarity regarding the necessity and duration of the antibiotic treatment. The Facility Pharmacist expressed concerns about the indefinite use of the antibiotic and the potential for adverse effects such as Clostridium difficile infection. The Director of Nursing confirmed that there were no specific orders to monitor for UTIs and that the antibiotic order had not been reviewed or updated in 2024. The facility's policy on antibiotic stewardship required prescribers to provide a start and stop date or specify the number of days of therapy, which was not followed in this case.
Verbal Abuse by CNA
Penalty
Summary
The facility failed to protect a resident from verbal abuse by a Certified Nursing Assistant (CNA). The incident involved a resident who was cognitively intact and required substantial assistance with toileting hygiene. The resident had multiple medical conditions, including depression, a history of stroke, and an amputation above the knee. During an interaction, the resident requested assistance from CNA 1, who responded with profanity and refused to help, leaving the resident feeling intimidated and verbally abused. The incident was corroborated by another resident and staff members who witnessed the exchange. A second resident observed CNA 1's inappropriate behavior and noted that CNA 1 returned to the room laughing after the confrontation. Licensed nurses and the Director of Staff Development also confirmed CNA 1's use of foul language and aggressive demeanor, describing him as having a short temper and being easily flustered. The Director of Nursing and the Administrator acknowledged the unprofessional conduct of CNA 1, who was suspended and subsequently terminated for misconduct. The facility's policies on resident rights and abuse prevention emphasize treating residents with respect and protecting them from abuse, including verbal abuse. However, these policies were not adhered to in this instance, resulting in a deficiency in the facility's care standards.
Failure to Monitor Resident's Self-Administration of Medications
Penalty
Summary
The facility failed to ensure the safe self-administration of medications for a resident who was taking multiple non-prescription supplements and vitamins without evaluation or monitoring by health professionals. The resident, who had a history of chronic inflammation disorder affecting nerves, diabetes, pain, and hallucinations, was observed with numerous bottles of vitamins and supplements on their bedside table. These included nerve pain supplements, immune boosters, and dietary supplements, none of which were prescribed by a doctor or listed in the physician orders. Additionally, the resident had two medication cups with loose pills, which they reported taking three to four hours after their prescribed medications. The facility's policy required an evaluation by the interdisciplinary team (IDT) to determine if self-administration was clinically appropriate and safe, with documentation in the medical record and care plan. However, there was no such evaluation or documentation for this resident. The Licensed Nurse and Director of Nursing confirmed the lack of evaluation and monitoring, acknowledging the potential safety concerns and medication errors due to the resident's unsupervised self-administration of medications. The facility's failure to adhere to its policy resulted in the resident taking duplicate medications and multiple supplements without professional oversight.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 363 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Auburn
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Siena Skilled Nursing & Rehabilitation Center | 0.1 mi | ★★★★★ | 15 | 0 |
| Westview Healthcare Center | 0.9 mi | ★★★★★ | 12 | 0 |
| Auburn Ravine Healthcare Center | 3 mi | ★★★★★ | 19 | 0 |
| Rock Creek Care Center | 3.9 mi | ★★★★★ | 9 | 0 |
| Lincoln Meadows Care Center | 11.4 mi | ★★★★★ | 18 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.