Average — CMS composite of the measures below.
A standard survey is most likely before around September 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 Village during CMS and state inspections, most recent first.
Failure to Notify Family of Resident Death: The facility failed to promptly notify a resident's family of his death. The resident had cancer, diseased arteries, hospice services, and DNR orders. Staff found him without pulse or respirations, verified death, and contacted hospice, but only attempted to reach the POA and did not call the second listed family contact before releasing the body to the funeral home. The family said they were not notified until 2 days later and were not given the chance to say goodbye.
A resident with anxiety, depression, and respiratory failure experienced respiratory distress and urgently requested ADL assistance. A CNA reported the resident's breathing difficulty to an RN, who responded dismissively and refused to check on the resident. The CNA relayed this response to the resident, who became further distressed. Facility policy required staff to treat residents with dignity and respect, but this was not followed during the incident.
Surveyors observed multiple lapses in kitchen cleanliness, including unclean equipment, improper food labeling, and staff not restraining hair, with 70 residents consuming food prepared in these conditions. Staff and the Dietary Manager acknowledged the issues, which were not in line with facility policies for cleaning and food labeling.
A resident who was cognitively intact and required assistance with eating requested to dine in the main dining room for increased socialization, but was repeatedly seated in the assisted dining room despite expressing his preference. Staff cited dignity and safety concerns, though the resident was comfortable with assistance in public and had no documented safety or swallowing issues. The care plan and facility actions did not reflect the resident's choice, contrary to facility policy requiring respect for resident wishes.
A resident with chronic pain and frequent pain episodes interfering with sleep was not offered or documented to have received non-medication pain interventions as ordered by the physician prior to administration of PRN pain medications. Despite clear orders and facility policy, nursing staff did not document or provide these interventions, and the care plan lacked specific non-pharmacological strategies.
A resident with muscular dystrophy and pain requested massage therapy for discomfort, but despite repeated requests and documentation of need, the service was not provided in a timely manner. Staff were unclear about responsibility for arranging massage therapy, and the resident's care plan did not address this intervention, resulting in the resident not receiving the specialized rehabilitative service.
A resident with severe cognitive impairment and multiple mobility-limiting diagnoses was observed with wrist contractures and reported limited hand use. Although the care plan required daily ROM exercises, there was no documentation in the MAR, TAR, or aide task sheets that these were provided. The DON confirmed ROM was not documented or tracked due to the lack of a restorative program and policy.
The facility failed to follow public health recommendations during a Legionella outbreak investigation, affecting a resident who tested positive for Legionnaires' disease. Despite IDOH's advice to remove showers from service and use bottled water, the facility continued using showers due to resident preferences and did not install recommended filters. Staff lacked training on Legionella, and residents were not informed of the risks.
A facility failed to identify and address the underlying causes of distress in a resident with a history of childhood sexual trauma. The resident exhibited behaviors such as nonsensical speech, aggression, and inappropriate comments, but the care plans lacked specific strategies for managing these issues. Interviews with staff revealed that while the resident denied specific triggers, the facility did not adequately use observations to identify potential stressors, leading to insufficient individualized care.
Failure to Notify Family of Resident Death
Penalty
Summary
The facility failed to ensure timely family notification of a resident's death for Resident C. Resident C had diagnoses including cancer and diseased arteries, was admitted with hospice services due to expected decline, and had orders not to resuscitate if found without a pulse or respirations. The resident's face sheet listed a POA as the first contact for notifications of changes in condition and a family member as the second contact. A nurse note documented that Resident C was found lying in bed without a pulse or respirations, a second nurse verified death, and hospice was contacted. The note also indicated the POA was aware of the resident's death. An on-call NP was told that Resident C had passed away and hospice had been notified, and the NP ordered the body released when hospice and family were ready. However, the family member later stated the family was not notified until 2 days after the death, and the POA had been hospitalized and did not have their phone. Although the record listed a second emergency contact, that person was not notified. The DON stated staff had tried to contact the POA 3 times before notifying the funeral home but had not tried to contact the second family member listed, and staff should have called all listed contact numbers and spoken with someone before releasing the body to the funeral home.
Failure to Provide Dignified and Respectful Care During Resident Distress
Penalty
Summary
A deficiency occurred when staff failed to ensure respectful and dignified communication and care for a resident with anxiety, depression, and respiratory failure, who was cognitively intact and dependent on a tracheostomy and ventilator. The resident's care plan included interventions for anxiety and guidance for staff to use calm, consistent communication with firm boundaries. On the day in question, the resident experienced respiratory distress and expressed urgent needs for assistance with activities of daily living (ADLs). A CNA observed the resident appearing to have difficulty breathing and reported this to an RN, who responded that they did not care and refused to check on the resident. The CNA relayed this dismissive comment to the resident, further impacting the resident's emotional state. Progress notes indicated the resident was demanding immediate care, refused assistance from an available aide, and became upset when their needs were not met promptly. The RN, along with another nurse and a respiratory therapist, remained at the nurses' station and did not immediately respond to the CNA's concerns. The respiratory therapist eventually went to the resident after a delay. The resident reported feeling anxious, crying, and experiencing rapid breathing during the incident. Facility policy required staff to treat residents with dignity, respect, and sensitivity, especially during intimate care tasks, but this standard was not upheld in this instance.
Failure to Maintain Kitchen Cleanliness and Food Safety Standards
Penalty
Summary
The facility failed to maintain kitchen cleanliness and adhere to food safety protocols, as evidenced by multiple observations. Moisture was found in two out of three pans on the drying rack, and the stand mixer in the cooking and clean storage area had yellow particles and discoloration on its bowl, paddle, and main unit. An unlabeled fruit cup with a red liquid puddle was found in the mini fridge, and an employee was observed with unrestrained hair while working in the kitchen. Additionally, a food processor lid was placed right side up on a toaster with visible crumbs and dry brown particles, resulting in food and liquid transfer from the processor to the toaster. Brown stains and a dry, round, white food-like substance were also observed in the dining room near the coffee maker. Interviews with the Dietary Manager and staff confirmed awareness of these issues, including the need for hair restraints and proper cleaning and storage of kitchen appliances. The Dietary Manager indicated that 70 of 81 residents consumed food prepared in the facility's kitchen. Facility policies require proper cleaning of small appliances and labeling of food items, but these procedures were not consistently followed, contributing to the deficiency.
Failure to Honor Resident Dining Location Choice
Penalty
Summary
The facility failed to honor a resident's right to choose their dining location, despite the resident's clear and repeated requests. Observations showed the resident consistently seated in the assisted dining room with staff providing eating assistance. The resident, who is cognitively intact with a BIMS score of 15 and requires assistance with eating due to muscular dystrophy, expressed during a resident council meeting and in interviews that he wished to dine in the main dining room to increase socialization. Staff interviews confirmed that the resident's preference was communicated, but the Activities Director informed him he could not eat in the main dining room due to a perceived dignity issue, as directed by the Administrator and corporate staff. The resident stated he was comfortable receiving assistance in front of others. The Director of Nursing later cited safety concerns as the reason for the resident's placement in the assisted dining room, but did not specify any safety issues that could not be managed in the main dining room. The resident's care plan was updated to require all meals in the assisted dining room, but did not address his choice of dining location. Medical records indicated no swallowing or chewing problems, and the resident was on a regular diet. Facility policy requires resident wishes to be respected, but this was not followed in this case.
Failure to Implement Non-Medication Pain Interventions as Ordered
Penalty
Summary
The facility failed to implement non-medication pain interventions as ordered by the physician for a resident with chronic pain syndrome, low back pain, right leg pain, and polyneuropathy. The resident, who was cognitively intact, experienced frequent pain that interfered with sleep and was prescribed both pharmacological and non-pharmacological pain management strategies. Physician orders specifically required that non-medication pain interventions be offered prior to administering PRN pain medications. However, review of the resident's Medication Administration Record (MAR) and nursing notes showed that non-pharmacologic interventions were not documented or offered prior to the administration of PRN pain medications, despite the resident receiving Norco for moderate to severe pain on multiple occasions. Interviews with nursing staff and the DON confirmed that non-medication pain interventions were expected to be documented in the MAR when PRN pain medications were given, but this was not done for the resident in question. The DON also acknowledged that the resident's care plan did not specify non-medication pain interventions, even though such interventions were included in the physician's orders. The facility's pain management policy indicated that both pharmacological and non-pharmacological interventions may be implemented, but the required non-medication interventions were not provided or documented for this resident.
Failure to Provide Requested Massage Therapy for Resident with Muscular Dystrophy
Penalty
Summary
The facility failed to ensure that specialized rehabilitative services, specifically massage therapy, were provided as required for a resident diagnosed with muscular dystrophy and major depressive disorder. The resident, who was cognitively intact and had limitations in range of motion in both upper extremities, repeatedly expressed his desire for massage therapy to address discomfort and pain. He communicated this need to staff and during a Resident Council meeting, and it was noted in progress notes that he had previously benefited from massage therapy. Despite a progress note indicating a referral to Physical Therapy for ultrasound and massage therapy, there was no corresponding physician order for physical therapy, and the resident was not evaluated for massage therapy until several weeks after his initial request. The care plan for the resident addressed pain management but did not include interventions related to massage therapy or range of motion relief. Staff interviews revealed confusion regarding responsibility for providing massage therapy, with the DON indicating Occupational Therapy was handling it, while the Director of Therapy confirmed the resident had not been evaluated for massage therapy until prompted by the survey. Additionally, the resident's request for transportation to receive massage therapy at the VA hospital was not facilitated, and his inquiries were not consistently communicated among staff. The lack of timely assessment and provision of the requested rehabilitative service resulted in the resident not receiving massage therapy as required.
Failure to Provide and Document Range of Motion Care for Resident with Contractures
Penalty
Summary
A resident with diagnoses of rheumatoid arthritis, Parkinson's Syndrome, and Alzheimer's was observed to have contractures in both wrists and reported limited use of their hands, which prevented participation in activities. The resident's care plan identified limited mobility and contractures, with a goal to prevent further immobility complications and an intervention for daily gentle range of motion (ROM) exercises as tolerated. Despite these documented needs and interventions, there was no evidence in the Medication Administration Record, Treatment Administration Record, or nurse aide task sheets that ROM exercises were provided or documented for the resident. The Director of Nursing confirmed that ROM was not documented due to the absence of an official restorative program and stated that nurse aides were expected to perform ROM exercises during routine care without recording them. Additionally, the facility did not have an official policy for contracture care.
Failure to Follow Legionella Outbreak Recommendations
Penalty
Summary
The facility failed to ensure education about and follow public health authority recommendations during the investigation of a communicable disease outbreak involving Legionella bacteria. An anonymous complaint to the Indiana Department of Health (IDOH) indicated that Legionella bacteria had been found in water samples collected at the facility, and recommendations made to prevent disease were not being followed. This deficiency affected one resident, Resident M, who tested positive for Legionnaires' disease after being hospitalized, and had the potential to affect 68 residents residing in the facility. The facility was notified by IDOH of a Legionella outbreak investigation based on Resident M's positive urine test for Legionella and diagnosis of Legionnaires' disease. The resident had spent 12 days of the 14-day incubation period at the facility, prompting an outbreak investigation. IDOH provided recommendations for immediate water precautions, including removing ice machines from service, using bottled water for drinking, and removing showers from service until point-of-use filters could be installed. However, the facility did not fully implement these recommendations, as they continued to use showers per residents' preferences and did not install the recommended filters on showerheads. Interviews with facility staff revealed a lack of training on Legionella or other waterborne illnesses. Staff were not instructed to monitor for symptoms of pneumonia in high-risk residents or themselves, and there was no documentation indicating that residents had been notified of the presence of Legionella in the water. The facility's water management program identified showers in resident rooms as high-risk locations for Legionella bacteria, yet the facility elected not to follow the full extent of IDOH's recommendations, citing cost and resident preferences.
Failure to Address Trauma-Related Distress in Resident
Penalty
Summary
The facility failed to adequately identify, assess, and address the underlying causes of distress in a resident who is a survivor of childhood sexual trauma. The resident, who has a complex medical history including anxiety, major depressive disorder, paranoid schizophrenia, and insomnia, displayed various behaviors indicative of distress. These behaviors included speaking in nonsensical terms, swearing, making sexually inappropriate comments, and exhibiting physical aggression. Despite these behaviors, the facility did not effectively determine specific triggers or stressors that could be contributing to the resident's distress. The resident's care plans were found to be lacking in several areas. While the care plans addressed some behaviors and provided general interventions, they did not include specific strategies for managing the resident's obsessive-compulsive disorder or depression. Additionally, the care plans did not consider pain or male caregivers as potential stressors for the resident's aggression or refusal of care. The facility's approach to the resident's care was not sufficiently individualized to address the resident's unique needs and history of trauma. Interviews with facility staff, including the Social Service Director and the Director of Nursing, revealed that while the resident denied having specific trauma-related triggers, the staff acknowledged that triggers could be identified through observation rather than self-report. However, the facility's care plan approach did not include specific traumatic topics to be avoided or specific stressors for aggression or resistance to care. This lack of detailed and individualized care planning contributed to the facility's failure to provide appropriate treatment and services to the resident.
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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.
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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) |
|---|---|---|---|---|
| Betz Nursing Home | 1.6 mi | ★★★★★ | 1 | 0 |
| Miller's Merry Manor | 6 mi | ★★★★★ | 11 | 0 |
| Pines Of Dekalb | 8.9 mi | ★★★★★ | 2 | 0 |
| Cedars The | 10.7 mi | ★★★★★ | 5 | 0 |
| Ascension Living Sacred Heart Village | 10.8 mi | ★★★★★ | 8 | 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.