Above average — CMS composite of the measures below.
A standard survey is most likely before 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 Ravine Healthcare Center during CMS and state inspections, most recent first.
A resident with severe cognitive impairment was physically abused by her roommate, who had a known history of aggression toward both staff and other residents. The roommate grabbed the resident's wrist and covered her mouth, causing pain and distress. Staff and other residents reported ongoing issues with the roommate's aggressive behavior, which had not been adequately addressed, resulting in repeated disturbances and harm.
Two staff members failed to wear required PPE, specifically gowns, while performing wound care on a resident under enhanced barrier precautions for chronic wounds, despite clear facility policies and signage. Additionally, a contracted hairdresser who regularly interacted with residents had not received ongoing infection prevention and control training, contrary to facility agreements and expectations.
Food storage and preparation practices were deficient when multiple items in the kitchen were found past their use-by date, including apple sauce, prepared pudding, vanilla pudding mix, and fajita seasoning. Several other items, including coleslaw, sour cream, peaches, custard dessert, and pudding cups, were not labeled with a use-by date. The RD stated that food items should be dated and discarded once past their use-by date, and the facility policy required refrigerated foods to be covered, labeled, dated, and monitored.
Medication Labeling Deficiency: Four eye drops in the top drawer of the number two med cart were labeled only with a room number and did not include resident names. An LN confirmed the labels were incomplete and noted the meds could be mixed up if residents moved rooms, and the DON also confirmed the only identifier was a room number. Facility policy stated individual resident medications must include the resident's name.
Infection control practices were not followed for three residents. A resident with COPD had oxygen tubing and a humidifier container that were over 7 days old, another resident with acute respiratory failure had oxygen tubing and a humidifier container that were not dated, and a resident on EBP for an indwelling catheter was observed during catheter care with gloves but no gown. The IP and DON stated that oxygen equipment should be changed and labeled as required, and that gown and gloves are expected for high-contact care under EBP.
The facility failed to develop and implement comprehensive care plans for four residents. Two residents prescribed psychotropic medications lacked care plans for their use, while another resident with a Wander/Elopement Alarm (WEA) also had no care plan. Additionally, a resident with a WEA and a history of disorientation and dementia had no care plan addressing the device's use, despite facility policies requiring such plans for at-risk residents.
The facility failed to adhere to professional standards by prescribing psychotropic medications without proper indications or monitoring for two residents, not labeling or dating nasal cannulas and humidifiers for three residents, and not following physician orders for oxygen delivery. Additionally, two residents had incomplete monitoring orders for Wander/Elopement Alarms (WEA), and one resident had a WEA applied without a physician's order.
The facility failed to ensure the Dietary Supervisor met state educational requirements, leading to deficiencies in meal distribution, food texture preparation, and sanitation. The Registered Dietitian's involvement was limited, focusing mainly on clinical duties rather than food service oversight. Several sanitation issues were identified, including improper cooling of cooked chicken and unclean kitchen equipment.
The facility failed to follow professional standards for food safety, including improper cooling of cooked chicken, lack of temperature monitoring for ambient foods, and poor sanitation practices. Observations revealed wet and dirty serving pans, expired bread, and unclean ice machines. The Registered Dietitian acknowledged the need for staff training and adherence to proper procedures.
The facility failed to maintain a clean environment as the only garbage dumpster outside was not securely closed due to deformed lids, leaving a gap. This was confirmed by the Dietary Supervisor and acknowledged by the Director of Clinical Operations, who noted the lack of a policy on dumpster conditions. The deficiency posed a risk for pest infestation and disease spread, violating the FDA Food Code 2022.
A CNA in the facility was found to be working with an expired license, as confirmed by the DON and DSD. Despite being aware of the impending expiration, the CNA continued to work without a valid license, which is against the facility's policy and state law. This oversight had the potential to impact the care of all 55 residents.
The facility failed to maintain an effective infection control program, with staff not adhering to hand hygiene protocols and inadequate PPE use in the laundry department. Environmental Service staff and a CNA were observed skipping hand sanitation, while the Linen Room Technician processed soiled linens without proper PPE. Additionally, the facility did not monitor washing machine water temperatures, failing to meet the required standards for effective disinfection.
The facility failed to implement an effective IPCP, leading to inappropriate antibiotic prescriptions and inadequate infection control training. The IP could not provide a proper tracking tool for residents on antibiotics, resulting in unnecessary prescriptions for two residents. Additionally, the facility lacked sufficient hand hygiene training, increasing the risk of infection transmission.
The facility failed to ensure that both contracted and facility-employed CNAs received the required in-service training, including dementia management and abuse prevention. Interviews and record reviews revealed a lack of documentation proving that CNAs completed at least 12 hours of continuing education per year. The facility was responsible for ensuring training completion, but could not provide evidence of compliance.
The facility failed to develop and implement baseline care plans within 48 hours of admission for two residents, one with sepsis and urine retention and another with dementia and pneumonia. Both residents did not receive a copy of their care plans or information about their care goals, leading to confusion about their treatment. The DON and DCO confirmed the oversight, which violated the facility's policy requiring timely care plan development and communication.
A facility experienced a medication error rate of 22.58% due to late administration of medications to four residents. Errors included late administration of morphine, pramipexole, omeprazole, gemfibrozil, gabapentin, a lidocaine patch, cephalexin, and lisinopril. The DON confirmed the errors and emphasized the importance of following physician orders.
The facility failed to follow the prescribed menu for therapeutic diets, affecting residents' nutritional intake. Regular portion diets were under-served, pureed diets received incorrect bread items, and modified diets were given the wrong type of dinner rolls. Additionally, small portion diets lacked accurate measurements, leading to inconsistencies in serving sizes.
The facility failed to provide the correct food texture for residents on a puree diet, serving pureed ziti with cheese that contained chunks, contrary to IDDSI standards. This posed a risk for residents with swallowing difficulties, as confirmed by the Dietary Supervisor and Registered Dietician.
A resident was prescribed lorazepam PRN indefinitely, contrary to the facility's policy limiting PRN psychotropic medication orders to 14 days. The DON and DCO confirmed the order lacked a stop date, posing potential risks of medication interactions, confusion, and falls.
A resident with dysphagia and COPD was found with moldy food in their room, brought by family and not properly stored or labeled. A CNA confirmed the food was moldy, and the DON stated that personal food items should be labeled and stored correctly. The facility's policy requires perishable foods to be stored in resealable containers and discarded if spoiled.
A resident with multiple health issues, including dementia and mobility impairments, was unable to reach their call light, which was tied to the bed, while seated in a chair. Staff confirmed the call light should have been accessible, as per facility policy, to allow the resident to communicate their needs.
Failure to Protect Resident from Physical Abuse by Roommate
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and agitation was not protected from physical abuse by her roommate, who had a history of aggressive behavior. The incident involved the roommate placing her hand over the resident's mouth and grabbing and squeezing her wrist while the resident was being cared for by a CNA. The resident complained of pain during the incident, and the roommate's actions were witnessed by staff. Prior to this event, the roommate had a documented pattern of aggressive and disruptive behavior toward both staff and other residents, including taking belongings, becoming combative, and making roommates uncomfortable. Staff interviews confirmed that the roommate had been moved multiple times due to issues with previous roommates, including an incident where she was caught putting a pillow over another resident's head. Despite these ongoing concerns, the roommate continued to be placed with new roommates, resulting in repeated disturbances and discomfort for others. The facility's policies require protection of residents from abuse by anyone, including other residents, and mandate measures to address factors that may lead to abusive situations. However, the facility failed to prevent the abusive incident, as evidenced by the roommate's continued aggressive behavior and the harm experienced by the resident. Interviews with staff and other residents further corroborated the roommate's pattern of aggression and the negative impact on those sharing a room with her.
Failure to Follow Infection Control Protocols During Wound Care and Lack of Training for Contracted Staff
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program in two key areas. First, two staff members did not adhere to required personal protective equipment (PPE) protocols while performing wound care on a resident who was under enhanced barrier precautions (EBP) due to chronic wounds. Despite clear signage and care plan instructions indicating the need for both gown and gloves during high-risk care activities such as wound care, the staff were observed wearing only gloves. Both the treatment nurse and the wound doctor confirmed during interviews that they did not wear gowns during the procedure, acknowledging this was not in compliance with facility policy and increased the risk of wound contamination. The resident involved had a history of cellulitis and required assistance with personal care. Physician orders and the care plan specifically documented the need for EBP every shift, and the resident was listed as requiring these precautions due to chronic wounds. Facility policies outlined that EBP includes the use of both gown and gloves during high-contact care activities, such as wound care, to prevent the spread of infection. Interviews with the Infection Preventionist (IP) and Director of Nursing (DON) confirmed that staff are expected to follow these protocols to minimize infection risks. Additionally, the facility failed to provide ongoing infection prevention and control training to the facility hairdresser, a contracted employee who regularly interacted with residents. The hairdresser reported not receiving any ongoing infection control training or participating in facility in-service sessions, despite an agreement requiring adherence to infection control policies. The IP confirmed that the hairdresser had never attended infection control in-services, and the DON stated that all staff, including contracted personnel, should follow the infection prevention and control program to prevent the spread of infections among residents.
Food Items Left Unlabeled and Past Use-By Date
Penalty
Summary
The facility failed to store and prepare food in accordance with professional standards of food safety. During an initial kitchen tour, several food items were observed past their use-by date, including a container of apple sauce, four containers of prepared pudding, a bag of vanilla pudding mix, and a container of fajita seasoning. In addition, several items were found without a use-by date, including a container of coleslaw, two trays of sour cream, one tray of peaches, one tray of custard dessert, and three pudding cups. The Registered Dietitian stated that food items should be labeled with a date and discarded once past their use-by date. The facility policy titled Food Receiving and Storage stated that foods stored in the refrigerator or freezer are to be covered, labeled and dated, and that refrigerated foods are to be labeled, dated, monitored, frozen, or discarded by their use-by date.
Medication Labeling Deficiency
Penalty
Summary
The facility failed to properly label medications for a census of 54 when four eye drops in the top drawer of the number two medication cart were labeled only with a room number and did not include resident names. During a concurrent observation and interview, the LN confirmed the eye drops should have had the resident name on them and stated that if residents moved rooms, the medications could be given to the wrong person or mixed up, and someone may be allergic. The DON later reviewed a picture of the eye drops and confirmed that the only identifier was a room number, stating medications should be labeled with resident names because residents could move rooms. The facility policy titled, Labeling of Medication Containers, dated 4/19, stated that medications maintained in the facility are properly labeled in accordance with current state and federal guidelines and that labels for individual resident medications include the resident's name.
Infection Control Failures With Oxygen Equipment and Enhanced Barrier Precautions
Penalty
Summary
Proper infection prevention and control practices were not followed for three sampled residents. Resident 9, who was admitted with COPD, had an order dated 7/10/25 directing that the oxygen humidifier bottle and oxygen tubing be changed weekly. During a 9/7/25 observation with CNA 1, Resident 9's oxygen tubing and humidifier container were found to be over seven days old, and CNA 1 confirmed the tubing had a date of 8/30/25. Resident 11, who was admitted with acute respiratory failure with hypoxia, was observed on 9/7/25 with oxygen tubing and a humidifier container that were not labeled with a date, and CNA 1 confirmed the finding. Resident 43, who had an order for Enhanced Barrier Precautions related to an indwelling catheter every shift, was observed on 9/9/25 during care involving urinary catheter tubing. The Director of Rehabilitation was wearing gloves but no gown while handling the tubing. The IP stated that staff should wear a gown when providing high-contact care to residents on EBP, and the DON stated she expected staff to put on a gown and gloves when providing care to residents on EBP. The facility's respiratory therapy policy stated that oxygen bottles should be marked with the date and initials upon opening and that oxygen cannulas and tubing should be changed every seven days or as needed, and the EBP policy identified device care or use as a high-contact activity requiring gown and gloves.
Failure to Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement person-centered comprehensive care plans for four residents. Resident 2 and Resident 36 were prescribed psychotropic medications, sertraline and seroquel respectively, but their care plans did not include any documentation or strategies for the use of these medications. Resident 10, who had an order for a Wander/Elopement Alarm (WEA), also lacked a care plan addressing the use of this device. The Director of Nursing confirmed the absence of these care plans, acknowledging that comprehensive person-centered care plans should be completed within 21 days and include specific physician orders. Additionally, Resident 56, who had a history of disorientation, apraxia, and dementia, was observed with bruises around the right eye and face, and a WEA on the right ankle. Despite the presence of the WEA, there was no comprehensive care plan for its use. The facility's policy on wandering and elopements stated that care plans should include strategies and interventions for residents identified as at risk for wandering or elopement, but this was not implemented for Resident 56. The facility's policy on comprehensive person-centered care plans also emphasized the need for measurable objectives and timetables to meet residents' needs, which was not adhered to in these cases.
Deficiencies in Medication Management and Equipment Labeling
Penalty
Summary
The facility failed to provide care and services in accordance with acceptable professional standards of quality for several residents. Psychotropic medications were prescribed for two residents without appropriate indications, manifestations, or monitoring of behaviors. Specifically, one resident was prescribed sertraline for depression without an order for monitoring feelings of sadness or loneliness, and another resident was prescribed quetiapine for depression without indications or orders to monitor behaviors. The Director of Nursing acknowledged the need for specific indications and monitoring orders for psychotropic medications, as outlined in the facility's policy. Additionally, the facility did not properly label or date nasal cannulas and humidifiers for three residents, and oxygen was not provided per physician orders. One resident was observed receiving oxygen at a higher rate than prescribed, and the nasal cannula and humidifier were not labeled. Another resident's oxygen cannula was not dated, and the facility's practice of labeling and changing oxygen tubing weekly was not followed. The Director of Nursing and Director of Clinical Operations confirmed the expectation for labeling and changing oxygen tubing. Furthermore, the facility failed to have complete monitoring orders for Wander/Elopement Alarms (WEA) for two residents, and one resident had a WEA applied without a physician's order. The facility's policy required physician consultation and documentation of attempts to exit the building before applying a WEA. The Director of Nursing and Director of Clinical Operations confirmed the need for monitoring orders for WEAs, and the facility was unable to provide a policy for the use of WEAs. The lack of care plans and physician orders for WEAs was also noted for one resident who had a fall and was wearing a WEA without documentation or orders.
Deficiencies in Dietary Services Due to Unqualified Supervisor
Penalty
Summary
The facility failed to ensure that the Dietary Supervisor (DS) met the state's educational qualification requirements, as mandated by federal regulations, to effectively manage the food and nutrition services. The DS, who started the position in September 2023, was not certified as a Dietary Services Supervisor (DSS) or Certified Dietary Manager (CDM) and was still in the process of taking courses to become CDM certified. This lack of qualification led to lapses in the delivery of food and nutrition services, including issues with meal distribution accuracy, modified food texture accuracy, and safe food handling and sanitation. The Registered Dietitian (RD) was contracted to provide consultations and oversee food safety and sanitation, food preparation, meal service, and food storage. However, the RD's involvement was primarily focused on clinical work, with only a small portion of their time dedicated to food service operations. The RD was unaware that the DS was not qualified for the position and did not meet state standards. The RD's contract allowed for a maximum of 20 hours per week, with a significant portion of this time allocated to clinical duties rather than food service oversight. During the survey, several deficiencies were identified, including improper meal distribution, incorrect preparation of puree food textures, and numerous sanitation issues such as improper cooling of cooked chicken, expired bread not being discarded, and unclean kitchen equipment. The DS was responsible for staff in-services but had only conducted one since starting the position. The Regional Operations Director (ROD) was aware of the DS's lack of qualifications and acknowledged the requirements after reviewing state standards.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as evidenced by multiple deficiencies in food storage, preparation, and distribution. During an inspection, it was observed that the cool down process for cooked chicken breasts was not performed, and there was no temperature monitoring before storing them in the refrigerator. The Dietary Supervisor confirmed the absence of a cooling log entry for the chicken, and the cook admitted to not following the cool down procedure, acknowledging it as a mistake. This oversight was corroborated by the Registered Dietitian, who emphasized the importance of the cool down procedure for food safety. Further observations revealed that the facility lacked a system for cooling ambient foods, such as chicken salad, and staff were not practicing temperature monitoring or using cooling logs. The Dietary Supervisor initially stated there was no policy for ambient foods but later confirmed the existence of a process that was not being followed. Additionally, metal serving pans were found stacked wet with brown and white substances on them, and expired bread was not discarded, indicating a lapse in food safety practices. The Registered Dietitian acknowledged the need for staff training and adherence to proper labeling and storage guidelines. The facility also exhibited poor sanitation practices, as evidenced by a dirty microwave, cutting boards with gouges and a rancid odor, and personal beverage containers stored in the food preparation area. Ice machines in the kitchen and nourishment rooms were found with pink and black slimy substances, indicating inadequate cleaning. The Maintenance Supervisor and an outside vendor technician confirmed the presence of these substances, suggesting insufficient scrubbing during cleaning. The Registered Dietitian noted the importance of maintaining cleanliness in the ice machines, as outlined in the facility's policy and FDA Food Code.
Improper Garbage Disposal Due to Deformed Dumpster Lids
Penalty
Summary
The facility failed to maintain a clean environment for residents and visitors due to improper disposal of garbage and refuse. During an observation and interview, it was noted that the only garbage dumpster located outside the facility was not securely closed because the lids were deformed, leaving a two-inch gap. This condition was confirmed by the Dietary Supervisor, who acknowledged the need for either repair or replacement of the dumpster lids. The Director of Clinical Operations later confirmed that the facility lacked a policy regarding dumpster conditions and that the maintenance department had contacted a waste management company to purchase new lids. This deficiency was identified as a potential risk for pest infestation and disease spread, as per the FDA Food Code 2022, which requires outside receptacles to have tight-fitting lids.
Expired CNA License in Facility
Penalty
Summary
The facility failed to ensure that one of its Certified Nursing Assistants (CNA), referred to as CNA 2, had a valid CNA license. This deficiency was identified during a survey involving observation, interview, and record review. The Director of Nursing (DON) confirmed that CNA 2's license had expired, and the Director of Staff Development (DSD) acknowledged awareness of the impending expiration but allowed CNA 2 to continue working without a renewed license. CNA 2 also confirmed that her license had expired and she had not yet received a renewal. The facility's policy requires all nursing staff to meet competency requirements as defined by state law, which includes maintaining a valid license. The California Health and Safety Code mandates that certificate holders receive notice 90 days before their license expiration, but non-receipt of this notice does not exempt them from renewing their license on time. The failure to ensure CNA 2's license was current had the potential to affect the care of all 55 residents in the facility, as they could receive care from an unqualified individual.
Infection Control Deficiencies in Hand Hygiene and Laundry Practices
Penalty
Summary
The facility failed to maintain an effective infection control program, as evidenced by multiple observations of staff not adhering to proper hand hygiene protocols. Environmental Service staff were seen entering and exiting resident rooms without performing hand sanitation, despite being trained in these practices. One staff member admitted to rushing and skipping hand sanitation to save time, while another handled dirty towels without gloves and then touched a resident's clean blanket without sanitizing her hands. A Certified Nursing Assistant also failed to use available alcohol-based hand sanitizers when moving between resident rooms. In the laundry department, the facility did not ensure the use of adequate Personal Protective Equipment (PPE) when processing soiled linens. The Linen Room Technician only used disposable gloves and was not trained to wear a gown or face shield, which are necessary for handling potentially contaminated materials. The Infection Preventionist confirmed the lack of PPE and acknowledged that staff should be wearing gloves, gowns, and face shields when dealing with dirty linens. Additionally, the facility did not monitor the water temperatures of the washing machines, which is crucial for effective disinfection of linens. The Linen Room Technician and Maintenance Supervisor were unaware of the required temperature settings for washing and drying linens. The facility's policy indicated that laundry should be processed in hot water at 160 degrees Fahrenheit for 25 minutes, but the current setup did not meet these standards, as the water heater was set to 131 degrees Fahrenheit and the dryer temperatures were not monitored.
Deficiencies in Antibiotic Monitoring and Infection Control
Penalty
Summary
The facility failed to develop, implement, and monitor an effective Infection Prevention and Control Program (IPCP) concerning the use of antibiotics. The Infection Preventionist (IP) was unable to provide a proper tracking tool for monitoring residents on antibiotics and could not confirm the clinical indications for antibiotic use. During an interview, the IP admitted to using a facility map to track residents with Urinary Tract Infections (UTIs) but could not identify specific residents or confirm laboratory indicators such as urinalysis or culture and sensitivity tests. This lack of proper tracking led to the inappropriate prescription of antibiotics, as evidenced by Resident 35 being prescribed Ciprofloxacin without laboratory confirmation of a UTI, and Resident 29 being on Cephalexin for 48 days without any laboratory examinations to justify its use. The facility also lacked adequate tools for tracking antibiotic use, as confirmed by the Director of Clinical Operations (DCO). The DCO acknowledged that the Electronic Health Records (EHR) system, which was supposed to include tracking tools, was still in development and not yet active. This absence of a functional tracking system contributed to the inability to monitor infections and antibiotic use effectively, further exacerbating the issue of inappropriate antibiotic prescriptions. Additionally, the facility failed to provide adequate infection control in-services for staff, particularly concerning hand hygiene. The IP was unable to produce sufficient attendance records for handwashing in-services, with only six staff members attending the sessions documented. This lack of comprehensive training and monitoring of hand hygiene practices increased the risk of infectious disease transmission among residents and staff, further highlighting the deficiencies in the facility's infection control program.
Deficiency in CNA Training Documentation
Penalty
Summary
The facility failed to ensure that both contracted and facility-employed Certified Nursing Assistants (CNAs) received the required in-service training, including dementia management and abuse prevention, as mandated by regulations. This deficiency was identified through interviews, observations, and record reviews, which revealed that three out of four sampled Contracted Certified Nursing Assistants (CCNAs) and three out of five sampled facility-employed CNAs did not have documentation proving they completed at least 12 hours of continuing education per year. The Director of Clinical Operations and the Staffing Coordinator were unable to provide evidence of completed mandatory training for the CCNAs, and the Director of Staff Development did not have a specific training plan for them, relying instead on staffing agencies to provide the necessary training. Further investigation into the facility's contracts with staffing agencies showed that the facility was responsible for ensuring the completion of mandatory training for contracted staff. However, the facility could not produce documentation to support that the CCNAs and CNAs had completed the required training. The Regional Operations Director confirmed the lack of training records for both contracted and facility-employed CNAs. The facility's policy and procedure on the competency of nursing staff, as well as the Facility Assessment Tool, emphasized the necessity of in-service training to ensure the competence of nurse aides, particularly in dementia management and abuse prevention, but these requirements were not met.
Failure to Implement Baseline Care Plans Within 48 Hours
Penalty
Summary
The facility failed to ensure that baseline care plans were developed, implemented, and signed by the resident or responsible party within 48 hours of admission for two residents. Resident 260 was admitted with diagnoses including sepsis and urine retention and was observed with a urinary catheter. The resident reported not receiving a copy of the baseline care plan or being informed about their care goals upon admission. Similarly, Resident 261, admitted with dementia and pneumonia, was observed with an oxygen concentrator out of reach and was unsure about its use. This resident also confirmed not receiving a baseline care plan or being informed about their care plan. During a review with the DON and DCO, it was confirmed that the baseline care plans for both residents were not completed within the required 48-hour timeframe. The facility's policy mandates that a baseline care plan be developed within 48 hours of admission and that a written summary be provided to the resident or their representative, with documentation of the delivery method in the medical record. The failure to adhere to this policy resulted in residents and staff being unaware of the residents' care plans.
Medication Administration Errors Exceeding 5% Rate
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a 22.58% error rate during a medication administration observation. This deficiency involved four residents who received their medications at incorrect times. Resident 1 was given morphine ER and pramipexole over three hours late. Resident 18 received omeprazole and gemfibrozil after breakfast instead of 30 minutes prior, as prescribed. Resident 28 was administered gabapentin and a lidocaine patch significantly later than scheduled. Resident 29 received cephalexin and lisinopril nearly three hours after the prescribed time. The errors were confirmed during observations and interviews with the licensed nurses responsible for administering the medications. The Director of Nursing acknowledged that the nurses did not adhere to physician orders, emphasizing the importance of timely medication administration, particularly for antibiotics. The facility's policy on medication administration, which requires adherence to physician orders, was not followed, contributing to the high medication error rate.
Menu Non-Compliance in Therapeutic Diets
Penalty
Summary
The facility failed to adhere to the prescribed menu for therapeutic diets during a lunch meal, affecting the nutritional intake of residents. Specifically, 44 residents on regular portion size diets received only two scoops (8 oz.) of pasta instead of the prescribed three scoops (12 oz.). This discrepancy was acknowledged by the Dietary Supervisor (DS) during an interview, who confirmed that the residents should have received the full portion as indicated in the facility's Diet Extensions document. Additionally, five residents on pureed texture diets were served pureed garlic bread sticks instead of the prescribed soaked white dinner rolls. The DS acknowledged this error during an interview and confirmed that the Diet Extensions document specified soaked white rolls for these residents. Furthermore, 16 residents on various modified diets, including IDDSI Level 5 Minced and Moist, Heart Healthy/Cardiac, and Renal diets, received wheat dinner rolls instead of the specified white dinner rolls, as confirmed by the DS. The facility also failed to provide accurate portion sizes for residents on small portion diets. The DS admitted that the current menu system did not include specific measurements for small portions, leading to inconsistencies in serving sizes. This issue was further corroborated by the Registered Dietician, who emphasized the need for accurate portion sizes to prevent potential weight loss in residents. The facility's documents, including the Diet Extensions and job descriptions, did not provide clear guidance on portion sizes for small diets, contributing to the deficiency.
Inappropriate Food Texture for Residents on Puree Diet
Penalty
Summary
The facility failed to provide the appropriate food texture for five residents who were on a puree texture diet. These residents received pureed ziti with cheese that contained chunks of pasta and tomato, which is not suitable for individuals with swallowing and/or chewing difficulties. The Dietary Supervisor confirmed that the texture of the pureed pasta was lumpy and not smooth as required, posing a potential risk for choking or aspiration. During an interview, the Registered Dietician expressed disappointment with the puree's texture, noting that the kitchen staff and cook needed more training. The facility's procedure for pureed pasta indicated that the final product should be smooth and lump-free, in accordance with the IDDSI Framework for texture-modified foods. However, the observed puree did not meet these standards, leading to the deficiency.
Failure to Limit PRN Psychotropic Medication Orders
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary psychotropic medications. Resident 10, who was admitted with diagnoses including dementia without behavioral disturbance or anxiety and recurrent depressive disorders, was prescribed lorazepam on an as-needed (PRN) basis indefinitely. This prescription was not aligned with the facility's policy, which limits PRN orders for psychotropic medications to 14 days unless reviewed for continued use or discontinuation. During a review of Resident 10's Order Summary Report, it was confirmed by the Director of Nursing (DON) and the Director of Clinical Operations (DCO) that the lorazepam order was PRN and lacked a stop date. The facility's policy, dated July 2022, specifies that psychotropic medications should not be prescribed on a PRN basis unless necessary for a diagnosed condition documented in the clinical record, and PRN orders should be limited to 14 days. The failure to adhere to this policy had the potential to cause medication interactions, confusion, and falls for Resident 10.
Failure to Ensure Safe Food Handling and Storage
Penalty
Summary
The facility failed to ensure safe food handling and storage for a resident, identified as Resident 2, who was admitted with diagnoses including dysphagia and chronic obstructive pulmonary disease (COPD). During an observation, a transparent plastic container with a red lid was found on Resident 2's bedside table, containing indistinguishable food items with greenish-blue spots and fuzzy growth. Resident 2 was unsure of the contents, stating that their family had brought the food some time ago. A Certified Nursing Assistant (CNA 1) confirmed the presence of moldy food in the container and acknowledged the potential health risk if Resident 2 had consumed it. The Director of Nursing (DON) confirmed that personal food items brought by family should be labeled with the resident's name, date, and time, and stored properly. The facility's policy indicated that perishable foods should be stored in resealable containers in a refrigerator and discarded if they show signs of spoilage, such as mold growth.
Inaccessible Call Light for Resident
Penalty
Summary
The facility failed to ensure that a call light was accessible for a resident, identified as Resident 11, which had the potential to result in unmet needs and delayed staff response. Resident 11 was admitted to the facility in 2016 with multiple diagnoses, including spastic hemiplegia, contracture, polyarthritis, dementia, and a history of falling. The resident's Minimum Data Set indicated moderate memory problems and dependency on staff for mobility and care related to incontinence. During an observation, Resident 11 was found sitting in a padded chair, slumped to one side, with a strong odor of feces, and unable to reach the call light, which was tied to the bed. Interviews with staff, including a Certified Nurse Assistant and a Licensed Nurse, confirmed that the call light was out of reach and acknowledged that it should have been accessible to Resident 11. The Director of Staff Development and the Director of Nursing both stated that they expected call lights to be within reach of residents to ensure they can communicate their needs. The facility's policy on the call system, dated September 2022, indicated that residents should have a means to call staff for assistance from their bed, toileting, and bathing facilities.
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Illustrative
What surveyors actually found near you
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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
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Illustrative
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Nursing homes near Auburn
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Rock Creek Care Center | 1.6 mi | ★★★★★ | 9 | 0 |
| Auburn Oaks Care Center | 3 mi | ★★★★★ | 9 | 0 |
| Siena Skilled Nursing & Rehabilitation Center | 3.1 mi | ★★★★★ | 15 | 0 |
| Westview Healthcare Center | 3.2 mi | ★★★★★ | 12 | 0 |
| Lincoln Meadows Care Center | 13 mi | ★★★★★ | 18 | 0 |
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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.