Below 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 Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with multiple chronic conditions had a documented Full Code status and an advance directive care plan requiring CPR to honor the resident’s wishes. When the resident was found unresponsive, not breathing, and cold to the touch, a KMA and an RN assessed the resident but did not initiate CPR, and no documentation showed that life-saving measures were attempted. Staff interviews revealed that the RN was unaware of the resident’s code status, the KMA did not verify it or initiate emergency procedures, and both relied on the KMA’s outside role as a deputy coroner rather than following the care plan, resulting in the resident’s death without implementation of the ordered Full Code interventions.
A resident with COPD, dementia, chronic kidney disease, and bilateral below-knee amputations had documented physician orders and a care plan indicating Full Code status, requiring CPR if found without vital signs. On one morning, an aide reported the resident was not doing well, an LPN initially found vital signs within normal limits, and later a KMA found the resident cold, not breathing, and assessed her as dead. The aide asked about starting CPR, but the KMA, who also worked as a deputy coroner outside the facility, stated nothing could be done. The RN and LPN, who did not know the resident’s code status at that time, relied on the KMA’s assessment, did not immediately verify the code status, and no CPR was initiated despite the absence of pulse and respirations. The resident’s daughter reported being told by phone that the resident’s eyes were glazed and then that she was deceased, and stated that no CPR was given, while multiple leaders and the medical director later confirmed staff failed to follow CPR protocol for a Full Code resident.
PASARR screening was not accurately completed for nine residents with psychiatric diagnoses and/or cognitive impairment. Level I PASARR records listed conditions such as bipolar disorder, psychosis, schizoaffective disorder, schizophrenia, anxiety, depression, PTSD, dementia, delirium, and HIV dementia, but the KLOCS documentation did not show whether a Level II assessment was needed, whether referrals were made, or that a Level II PASARR occurred. Interviews with MR, the Administrator, and Life Skills staff showed the facility relied on KLOCS routing, had limited training on PASARR entry, and did not consistently verify that the Level I results were complete.
Incomplete resident records were identified when a resident’s ordered weights were not documented, the MARs lacked the month and year, and multiple residents’ PASARR Level I records did not show whether a Level II assessment was needed or whether referrals were made. The DON confirmed the MARs were incomplete and that undated weights could not be tied to when they were obtained, while MR staff stated the PASARR determination did not print with the resident packet and the facility could not show complete screening documentation.
The facility’s QAPI program did not identify major system issues involving PASARR and advance directives. The DON stated PASARR was not discussed in QAPI meetings and was unfamiliar with the process, while the Administrator believed Level I PASARRs should have been reviewed for accuracy and to determine whether a Level II PASARR was needed. Record review showed multiple residents lacked required PASARR review, and several residents had incomplete or inaccurate advance directive documentation that Medical Records did not identify during chart audits.
Food items were found improperly stored in the kitchen and dry storage areas. An opened package of bacon, shredded cheese, and grape jelly in the refrigerator were not labeled, dated, or sealed, an opened jar of apple cider vinegar was not dated, and a package of liver loaf had open and discard dates recorded. Six totes of dry cereal were also stored too close to the ceiling and sprinkler heads. The KM, DON, and Interim Administrator stated food items were expected to be sealed, labeled, and dated, and that dry storage totes should not be stored so close to the sprinklers.
The facility failed to ensure advance directives were completed and reviewed for four residents. One resident with ALS and cognitive communication deficit had conflicting code status documentation, with a DNR order and DNR notation in some parts of the record but CPR listed in the physician order section, and staff could not locate all required forms. Three other residents with diagnoses including dementia, bipolar disorder, epilepsy, and COPD had no advance directives on file and no evidence they were offered the opportunity to complete or decline one.
Damaged Flooring and Inconsistent Housekeeping in Resident Rooms: The facility failed to maintain a safe, clean, comfortable, and homelike environment when multiple resident rooms had missing or broken floor tiles and housekeeping concerns were raised. A resident with intact cognition reported inconsistent room cleaning and said the flooring near the bathroom had been damaged since admission. Staff confirmed the flooring problems were known, one area was covered with a rug, and repairs had been delayed while hallway flooring was prioritized over resident rooms.
Expired influenza vaccines were found stored in one of the facility’s medication refrigerators, including an Afluria MDV vaccine and a Fluzone high-dose vaccine. Staff interviews showed inconsistent understanding of medication storage responsibilities, with an LPN unsure of the requirements, a CMA describing a process for reporting expired meds, and the DON stating routine checks had previously been done by the pharmacy company. The Administrator stated medications were expected to be stored properly.
Failure to Post Required Daily Staffing Data: Surveyors observed that the required daily staffing information was not posted during two facility tours, and review of the facility policy showed it addressed only the census portion of the required posting. The DON stated she had never posted a staff information sheet and was unaware of the regulation, while the Scheduler/Staffing Coordinator said she did not know about the requirement until told by the Administrator. The Interim Administrator confirmed awareness of the posting requirement but did not know when the report was last posted or why it had not been done.
An LPN failed to perform hand hygiene between glove changes and did not use required PPE while providing wound care to a resident on contact precautions. The resident had multiple diagnoses, including osteomyelitis and pressure ulcers. The LPN was unaware of the contact isolation status and did not follow facility policies for infection control, as confirmed by interviews with the DON and Administrator.
Failure to Implement Full Code Advance Directive and Initiate CPR
Penalty
Summary
The deficiency involves the facility’s failure to implement a comprehensive care plan related to advance directives for one resident who had been admitted with diagnoses including COPD, unspecified dementia, chronic kidney disease, and bilateral below-knee amputations. The resident’s physician order and the Advanced Directives Comprehensive Care Plan identified the resident as Full Code, with goals to have the resident’s health care wishes honored and interventions that included communicating the resident’s choice and providing CPR. The facility’s policy required individualized comprehensive care plans with measurable objectives and timetables to meet residents’ needs, including honoring advance directives. On the day of the incident, a Kentucky Medication Technician (KMA) found the resident at approximately 10:25 AM not breathing and cold to the touch. The KMA called a Registered Nurse (RN) to the room, and the RN assessed the resident and found no heart rate, no breath sounds, and that the resident was cold to the touch. A progress note documented these findings but did not indicate that CPR was initiated, despite the resident’s Full Code status and the care plan intervention to provide CPR. A certified death certificate documented that the resident expired in the facility at 10:29 AM. Multiple staff interviews confirmed that CPR was not performed and that the resident’s care plan was not followed. The RN stated she did not know the resident’s code status, even though it was listed on the care plan, and acknowledged that staff failed to follow the care plan and perform CPR, relying instead on directions from the KMA, who also worked outside the facility as a deputy coroner. The KMA admitted she did not follow the care plan and did not verify the code status, call for help, obtain a crash cart, or begin CPR. Other staff, including an LPN, the MDS Coordinator, the Medical Director, the County Coroner, a Regional Nurse, the Interim DON, and the Administrator, all confirmed that staff did not implement the resident’s Full Code care plan by initiating CPR when the resident was found without pulse or respirations.
Failure to Initiate CPR for a Full Code Resident
Penalty
Summary
The deficiency involves the facility’s failure to initiate CPR for a resident who was documented as Full Code. Facility policy required staff to provide emergency basic life support, including CPR, to any resident needing such care, in accordance with physician orders and the resident’s advance directives. The resident was admitted with diagnoses including COPD, unspecified dementia, chronic kidney disease, and bilateral below-knee amputations, and had a physician’s order and care plan indicating Full Code status, with interventions to communicate the resident’s choice and provide CPR. On the morning of the incident, a nurse aide reported that the resident was not doing well, with an open mouth and no verbal response. An LPN assessed the resident around that time and documented normal vital signs, then returned to charting. Later, staff observed changes in the resident’s condition, including being cold and not breathing. A medication technician assessed the resident as cold and stiff and told staff the resident was dead. The aide asked whether CPR should be started, and the medication technician responded that nothing could be done. The LPN and RN did not know the resident’s code status at that moment and relied on the medication technician’s assessment instead of immediately verifying the code status and initiating CPR. The RN subsequently assessed the resident, found no heart rate or breath sounds, and confirmed that no one in the room performed CPR. Staff interviews revealed that the RN and LPN deferred to the medication technician, who also worked outside the facility as a deputy coroner, and that this influenced the decision not to initiate CPR despite the resident’s Full Code status. The resident’s daughter reported being informed by phone that her mother’s eyes were glazed and then shortly afterward that she was deceased, and stated that no CPR was given and that she overheard staff discussing not knowing the code status as the reason CPR was not performed. The medical director, regional nurse, interim DON, administrator, and county coroner all confirmed in interviews that staff did not follow the CPR protocol and that CPR should have been performed for a Full Code resident.
PASARR Screening Not Accurately Completed for Multiple Residents
Penalty
Summary
The facility failed to accurately complete the PASARR process for nine sampled residents with mental disorders and/or intellectual disabilities. Review of the facility policy showed PASARR was intended to determine whether an individual seeking admission had serious mental illness, intellectual disability, or related conditions and whether nursing facility placement and related services were appropriate. The record review found that for each of the nine residents, the Level I PASARR documentation listed psychiatric or cognitive diagnoses, but the KLOCS record did not show whether a Level II assessment was needed, whether a referral was made, or any documented evidence that a Level II PASARR occurred. The affected residents included individuals with diagnoses such as bipolar disorder, psychosis, schizoaffective disorder, schizophrenia, anxiety, depression, PTSD, dementia, delirium, and HIV dementia. Several residents had cognitive impairment documented on MDS assessments, including BIMS scores showing intact cognition, moderate impairment, or severe impairment. Despite these findings, the MDSs indicated the residents were not evaluated by Level II PASARR. In multiple cases, the Level I PASARRs noted diagnoses and, for some residents, a history of intensive psychiatric treatment, but the facility record still did not show the required Level II referral or determination. During interviews, the MR stated she entered resident information into KLOCS before admission and that the system would alert Life Skills if a Level II assessment was needed, but the Level I determination did not always print with the resident packet and she was unsure why. She also stated she had limited training, consisting mainly of instruction from the prior MR employee and Zoom training. The Administrator stated MR was responsible for entering accurate information and that she should have been reviewing PASARRs to ensure they were correct and did not require a Level II. The Director of Crisis for Life Skills stated the facility should review the Level I and, if a resident should have triggered but did not, redo the Level I and resubmit it into KLOCS so the resident could be evaluated.
Incomplete Resident Records and PASARR Documentation
Penalty
Summary
The facility failed to ensure medical records were complete, accurate, and maintained for 8 of 25 sampled residents, based on interview, record review, and review of facility policies requiring that all services, observations, medications, and changes in condition be documented in each resident’s record. The report identified missing or incomplete documentation for resident weights, Medication Administration Records (MARs), and PASARR screening records. Facility policy stated that appropriate medical/clinical records should be maintained for each resident and that all services provided, medications administered, and observations must be documented in the clinical record. For one resident admitted with diagnoses including a nondisplaced fracture of the left ulna, dementia, and visual loss, the admission orders required weekly weights for four weeks and then monthly weights, but the record contained no evidence that the ordered weights were obtained. The only weight found in the weight binder was handwritten with the resident’s last name and a weight of 193 pounds, but it had no date or month. The resident’s MARs since admission were also incomplete because they did not include the month or year for the medication records. The DON reviewed the MARs and confirmed they were incomplete, stating that the records should always include a month and year and that weights without dates could not be tied to when they were actually obtained. For seven residents with diagnoses including bipolar disorder, psychosis, schizoaffective disorder, schizophrenia, anxiety, depression, and dementia, the Level I PASARRs were documented in KLOCS but did not include information showing whether a Level II assessment was needed or whether appropriate referrals were made. The facility’s MR staff stated she entered the PASARR information into KLOCS and that the system would alert Life Skills if a Level II assessment was needed, but the determination did not print with the packet kept in the resident records. The Administrator confirmed that the facility could not provide further information showing that the residents’ records were complete and included the determinations made from the Level I screening.
QAPI Program Failed to Identify PASARR and Advance Directive Deficiencies
Penalty
Summary
The facility failed to develop, implement, and maintain an effective, comprehensive, data-driven QAPI program that focused on outcomes of care and quality of life. Review of the facility’s QAPI policy showed the program was intended to identify issues and concerns with facility systems and develop plans to correct or improve identified areas, but interviews revealed that PASARR was not discussed in QAPI meetings. The DON stated she did not know anything about PASARR and had not heard about it until the recertification survey, while the Administrator stated she believed Level I PASARRs should have been reviewed to ensure they were completed accurately and to determine whether a Level II PASARR was needed. Record review showed 20 of 25 sampled residents triggered in IQIES for not having a Level II PASARR completed, and nine residents reviewed for PASARR were not assessed for a Level II PASARR to determine the need for mental health care and services. In addition, four residents reviewed for advance directives did not have complete and accurate advance directive documentation and/or were not afforded the opportunity to formulate an advance directive. The DON stated Medical Records was responsible for chart audits to ensure required documents were present, and the Administrator stated Medical Records completed monthly chart reviews for accuracy; however, Medical Records staff confirmed she performed chart audits but did not identify the advance directive issues for these residents.
Food Storage Not Labeled, Dated, Sealed, or Properly Positioned
Penalty
Summary
Food was not stored in accordance with professional standards for food service safety. During observation of Refrigerator 3, an opened package of bacon was found on the top shelf without a label, date, or seal, along with an opened bag of shredded cheese that was not labeled, dated, or sealed and an opened jar of grape jelly that was not dated. The refrigerator also contained a package of liver loaf with an open date of 08/17/2025 and a discard date of 08/24/2025. In the dry storage room, an opened jar of apple cider vinegar was not dated. The dry storage area also contained six totes of dry cereal stored on a top shelf approximately 8 inches from the ceiling and sprinkler heads. The Kitchen Manager stated that all food items should be labeled, that the identified items should be discarded because they were not labeled, and that totes should be stored 18 inches from the ceiling and sprinklers. She also stated that meat should be stored on the bottom shelf of the refrigerator to prevent contamination to other foods, and that she had previously asked administration for more shelving in the dry storage area but had not received it. The DON and Interim Administrator/Regional President both stated that kitchen items were expected to be sealed, labeled, and dated, and the Interim Administrator confirmed the dry storage totes should not have been stored so close to the ceiling and sprinkler heads.
Advance directive documentation incomplete and conflicting
Penalty
Summary
The facility failed to ensure advance directives were completed and reviewed for four residents, and one resident had missing and conflicting code status information in the medical record. Review of the facility policy titled, Advance Directives Standard of Practice, showed that on admission the facility was to determine whether a resident had executed an advance directive and, if not, determine whether the resident wanted to formulate one. The policy also stated that advance directive decisions were to be documented in the medical record and communicated to the IDT. For one resident with diagnoses including ALS, major depressive disorder, anxiety disorder, depression, and cognitive communication deficit, the record contained a Kentucky EMS DNR order signed by the POA, a care plan identifying DNR status, and a DNR notation on the face sheet. However, the physician order section listed CPR instead of DNR, and there was no evidence that the resident or responsible party requested a code status change or that required documentation was completed to verify the current advance directive. Staff interviews showed uncertainty about where to find the correct code status documentation, and the DON could not locate the CPR Consent form referenced by the SSD. Three other residents, including residents with diagnoses such as dementia, altered mental status, severe bipolar disorder with psychotic features, generalized anxiety disorder, epilepsy, and COPD, did not have advance directives on file. Their records also contained no evidence that the facility afforded them the opportunity to formulate or decline an advance directive. The SSD stated she completed advance directives on admission and would ask residents what they wanted, but the records reviewed did not show that this occurred for these residents. The Medical Records staff confirmed chart audits were performed but did not identify the advance directive documentation issues.
Damaged Flooring and Inconsistent Housekeeping in Resident Rooms
Penalty
Summary
The facility failed to provide housekeeping and maintenance services necessary to maintain a safe, clean, comfortable, and homelike environment for five residents reviewed for the environment. Review of facility policies showed residents have the right to a safe, clean, comfortable, and homelike environment, and the facility’s homelike environment policy stated residents are to be provided with that environment. Observation and record review identified missing or broken floor tiles in multiple resident rooms, including near the bathroom door in one resident’s room, between the bed and the air conditioning unit in two other rooms, and near the door in another room. One resident with intact cognition, based on a BIMS score of 15/15, stated housekeeping was “kind of shabby” on weekends, that rooms had at times gone without daily cleaning, and that the floor tiles by the bathroom had been that way since admission. The resident also stated concerns about the building had been discussed at a resident council meeting. Staff interviews confirmed the flooring problems were known to the facility. A housekeeper stated the end of the facility had the most flooring problems because it was the oldest part of the building and that the facility was aware of the issue. She also stated the area with missing tiles in one resident’s room had been covered with a rug. The maintenance director stated replacement tiles were difficult to obtain and that the facility was in the process of getting new tiles, but the owners had chosen to replace hallway flooring before resident room flooring. The administrator stated she expected the facility to be clean and acknowledged that broken or missing tiles were supposed to be reported to maintenance for repair. Despite this, the report documented multiple resident rooms with damaged flooring and resident concerns about housekeeping and maintenance.
Expired Influenza Vaccines Found in Medication Refrigerator
Penalty
Summary
Expired influenza vaccines were found stored in one of the facility’s two medication refrigerators, showing that drugs and biologicals were not being kept in accordance with accepted storage and labeling principles. During observation on 09/10/2025 at 1:00 PM, surveyors found two expired vaccines in the refrigerator: Afluria 2024-2025 MDV Vaccine, lot #P100712359, expired 06/30/2025, and Fluzone 2024-2025 High-Dose, a box of 10 single-dose prefilled syringes, lot #UT8425CA, also expired 06/30/2025. Facility staff interviews showed inconsistent understanding of how expired medications were to be handled. An LPN stated she was not certain what the requirements were for medication storage and said the DON was responsible for the task, while a CMA stated expired medications should be reported to a nurse or ADON and then taken to the house supervisor for disposal. The DON stated that in the past the pharmacy company checked for expired medications, and that in the future she would like the DON and nursing staff to check routinely, but this depended on staffing. The Administrator stated she expected medications to be stored properly.
Failure to Post Required Daily Staffing Data
Penalty
Summary
The facility failed to consistently post the required daily staffing data. During the recertification survey, surveyors observed that the staffing information was not posted during a tour on 09/09/2025 at 10:00 AM and again on 09/10/2025 at 10:05 AM, meaning no data was posted for two of four survey days. Review of the facility policy titled "Census Report," revised 01/02/2013, showed that it addressed only the census component of the mandatory daily staffing data and stated that a daily census report was to be completed by the charge nurse on duty at midnight and submitted to the Social Service Director or an administrative designee. During interviews, the DON stated she had never posted a staff information sheet and said she was unaware this was a regulation, noting she had recently taken over as DON on 09/10/2025 after serving as ADON since January. The DON also stated she thought the task was not done because of staffing shortages. The Scheduler, who also served as the Staffing Coordinator, stated she was not aware of any regulation requiring daily posting of the staffing sheet until the Administrator told her to do it on 09/11/2025 after surveyor intervention. The Interim Administrator/Regional President confirmed awareness of the requirement and stated the Staffing Coordinator was supposed to have been posting the staffing sheet daily, but she did not know when it was last posted or why it had not been done.
Failure to Follow Infection Control Protocols During Wound Care
Penalty
Summary
A deficiency was identified when a Licensed Practical Nurse (LPN) failed to follow established infection prevention and control protocols while providing wound care to a resident on contact precautions. The LPN did not sanitize her hands between glove changes and did not wear the required personal protective equipment (PPE), including a gown, mask, and eye protection, during the procedure. Observations showed that after removing soiled dressings and gloves, the LPN donned new gloves without hand hygiene and continued wound care activities without proper PPE. The resident involved had a medical history including osteomyelitis, type 2 diabetes mellitus with a foot ulcer, a pressure ulcer on the right buttock, and obesity. The LPN stated she was unaware the resident was on contact isolation and acknowledged she should have followed the correct protocols for hand hygiene and PPE use. Both the Director of Nursing and the Administrator confirmed their expectations that staff adhere to contact isolation and handwashing policies during resident care.
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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) |
|---|---|---|---|---|
| Creekwood Nursing & Rehabilitation | 10.1 mi | ★★★★★ | 4 | 0 |
| Hopkins Nursing And Rehabilitation Center | 10.2 mi | ★★★★★ | 6 | 0 |
| Franklin-simpson Nursing And Rehabilitation Center | 12.8 mi | ★★★★★ | 0 | 0 |
| Colonial Nursing And Rehabilitation Center | 15.1 mi | ★★★★★ | 2 | 0 |
| Magnolia Village Nursing And Rehabilitation Center | 15.9 mi | ★★★★★ | 0 | 0 |
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