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 Life Care Center Of Auburn during CMS and state inspections, most recent first.
A resident with dysphagia, a history of aspiration pneumonia, and NPO orders with all medications to be given via PEG tube received a levothyroxine tablet orally from an RN, who elevated the bed, placed the pill in the resident’s mouth, and gave a sip of water, causing the resident to cough. Later, another nurse found blue medication residue around the resident’s mouth and a cup of water at the bedside, despite documentation and assignment sheets clearly indicating NPO and PEG-only administration. Review of orders and the MAR confirmed that the RN had administered the blue levothyroxine tablet orally in error, constituting a significant medication error.
A resident who was initially admitted with depression and a negative PASRR screen later developed delusional disorders and hallucinations, leading to the initiation of antipsychotic medication. Despite these significant changes in mental health status, the facility did not refer the resident to the PASRR Office for a required Resident Review.
A resident with chronic heart failure and other serious conditions developed new bilateral lower extremity edema that was not identified or assessed in a timely manner. Despite visible swelling and the resident's report of new symptoms, staff did not notify nursing, and the assigned nurse failed to assess or document the change. The delay in assessment and lack of communication led to the resident's edema remaining unaddressed for several days.
Two residents requiring Enhanced Barrier Precautions for indwelling urinary catheters did not receive care in accordance with infection control protocols. In both cases, staff performed hands-on catheter assessments wearing only gloves, omitting the required gown, and in one instance, failed to perform hand hygiene before donning PPE. These actions were contrary to facility policy and CDC guidelines, as confirmed by staff interviews and posted signage.
The facility did not accurately complete MDS assessments for two residents. One resident receiving hospice care was not coded as such on the MDS, despite having a physician's order and being admitted to hospice. Another resident transferred to the hospital for an acute health change was incorrectly coded as 'discharge return not anticipated,' even though staff expected the resident to return. These inaccuracies were confirmed by the MDS nurse.
The facility failed to follow its Abuse Prohibition Policy when two residents reported allegations of inappropriate conduct by a housekeeper. One resident, with intact cognitive patterns, reported being kissed on the cheek, while another, with moderately impaired cognition, reported inappropriate contact. Staff did not immediately report these allegations to supervisors, violating facility policy.
The facility failed to report allegations of abuse involving two residents to the DPH. In one case, a CNA found a housekeeper alone with a cognitively impaired resident in a bathroom, but the incident was not reported. In another case, a resident expressed feeling stalked by the housekeeper, but the DON concluded the resident felt safe and did not report it. These actions violated mandatory reporting requirements.
The facility failed to thoroughly investigate allegations of potential sexual abuse involving two residents. In one case, a resident with cognitive impairment was found alone in a bathroom with a housekeeper, but no physical assessment or interviews were documented. In another case, a resident expressed feeling stalked by the same housekeeper, yet the investigation lacked necessary documentation and interviews. The facility did not adhere to its policies on abuse investigation and response.
The facility failed to provide care consistent with professional standards to prevent and treat a pressure ulcer for a resident with a high risk of developing pressure ulcers due to a history of diabetes and peripheral vascular disease. The resident was provided an orthopedic surgical shoe, but the facility staff failed to assess its fit and use, leading to the development of ulcers. The staff did not implement timely treatments or skin assessments, resulting in further skin breakdown.
A resident with peripheral vascular disease and a chronic ulcer experienced severe pain during a dressing change because the nurse did not offer pain medication beforehand. Despite the resident's known sensitivity and history of severe pain, the nurse proceeded with the procedure, causing significant distress. Interviews confirmed that the resident should have been assessed and medicated for pain prior to the dressing change.
The facility failed to notify the NPP of a resident's significant weight loss, delaying medical evaluation. Despite monitoring and confirming severe weight loss, the NPP was not informed until weeks later, contrary to the care plan and NPP's request.
A resident with a history of weight loss experienced severe weight loss due to the facility's failure to obtain weekly weights, monitor weights as recommended, coordinate care among the interdisciplinary team, and evaluate causative factors. Despite the resident's good appetite and requests for additional food, the staff did not consistently perform weight monitoring or alert the physician to the severe weight loss.
The facility failed to ensure staff adhered to infection control standards for four residents on two units. Staff did not wear appropriate PPE during nephrostomy and wound care for a resident on Enhanced Barrier Precautions and did not perform proper hand hygiene for two residents, one of whom was on Contact Precautions for C. difficile.
The facility failed to provide the correct topical wound medication as ordered by the Physician for a resident, resulting in the removal and re-application of the dressing, causing additional discomfort. The resident had specific orders for Silver Sulfadiazine for the left foot wound and Santyl for the left heel wound, but Nurse #1 incorrectly applied both medications to both wounds.
The facility failed to schedule a necessary Urology consultation for a resident with an indwelling urinary catheter, despite a physician's order. The resident developed a ventral erosion of the genitalia, and the appointment was not scheduled until prompted by a surveyor, leading to a delay until August 2024.
The facility failed to ensure that a nurse had the necessary competencies for pain management and wound care, resulting in severe pain and improper treatment for a resident with peripheral vascular disease and a chronic ulcer. The nurse did not offer pain medication before a dressing change and did not follow the physician's orders, leading to significant discomfort for the resident. The facility lacked proper training and competency assessments for the nurse.
The facility failed to adhere to food service safety standards, with dietary staff not wearing proper hair restraints and a CNA improperly reheating a resident's meal without checking the temperature. The Food Service Director acknowledged the lapses in following the facility's policies.
The facility failed to accurately complete, encode, and transmit MDS Assessments for three residents. One resident's Discharge MDS Assessment was not transmitted within the required timeframe, another resident's Death in Facility Tracking Record was not completed, and a third resident's Discharge MDS Assessment was completed six days past the due date. The MDS Nurse confirmed these deficiencies.
Oral Administration of Medication to NPO PEG-Tube Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from a significant medication error when a nurse administered an oral medication contrary to NPO and PEG tube orders. The facility’s medication administration policy required medications to be administered safely and appropriately per physician orders. For the resident in question, physician orders specified NPO status with all nutrition, fluids, and medications to be given via PEG tube, including a levothyroxine 137 mcg tablet ordered via PEG tube once daily. The resident had been admitted with diagnoses including dysphagia, pneumonitis due to inhalation of food and vomit, hypothyroidism, a history of aspiration pneumonia, was non-verbal, and developmentally delayed. On the morning in question, the nurse assigned to the 11:00 P.M. – 7:00 A.M. shift reported that she entered the resident’s room, informed the resident she had thyroid medication, elevated the head of the bed, and placed the levothyroxine pill directly into the resident’s open mouth, followed by a sip of water. The resident began to cough, and the nurse further elevated the head of the bed until the coughing stopped, after which she left the room believing the resident appeared comfortable. Later that morning, the nurse on the 7:00 A.M. – 3:00 P.M. shift observed a blue crushed substance in and around the resident’s mouth and a cup of water on the bedside table. This nurse stated he was concerned because the resident’s record and assignment sheet clearly indicated NPO status and that the resident could not have anything by mouth. Subsequent review by the unit manager and DON confirmed that the resident’s orders specified NPO with all medications via PEG tube, that the levothyroxine tablet was blue in color, and that the administering nurse had signed off on giving the medication. The administering nurse later acknowledged that, despite having been told at shift start that the resident was NPO, she had given the medication orally in error, constituting a significant medication error.
Failure to Notify PASRR Office After Significant Change in Mental Condition
Penalty
Summary
The facility failed to promptly notify the state mental health authority (PASRR Office) of the need for a Resident Review when a resident experienced a significant change in mental condition from their initial Level I PASRR. The resident was originally admitted with a diagnosis of depression and had a negative screen for serious mental illness, with no Level II PASRR evaluation indicated at admission. During the stay, the resident developed new diagnoses of Delusional Disorders and Hallucinations, and was started on antipsychotic medication (Seroquel) following behavioral health evaluations and physician orders. Despite these significant changes, including the addition of new mental health diagnoses and the initiation of antipsychotic treatment, the clinical record did not show any evidence that a referral to the PASRR Office for Resident Review was made. This was confirmed during an interview with the facility's Social Worker, who acknowledged that the resident should have been referred for a Resident Review at the time of the new diagnoses and medication changes.
Failure to Timely Identify and Assess New Onset Edema in Resident with Heart Failure
Penalty
Summary
A deficiency occurred when staff failed to identify and assess the new onset of bilateral lower extremity edema in a resident with chronic heart failure, chronic kidney disease, hypertension, atrial fibrillation, and a malignant neoplasm of the pancreas. The resident was admitted for palliative care and had no edema upon admission, as documented in the initial nursing assessment and confirmed by a nurse practitioner. The facility's policy required regular inspection and monitoring for edema in residents with heart failure, but this was not followed. The resident began experiencing swelling in both lower extremities, which was observed by the surveyor and reported by the resident as a new development. Despite visible signs of swelling and the resident's own report of the issue, the certified nurse aide who assisted with bathing did not notify nursing staff, believing the swelling was not new. The assigned nurse was unaware of the edema and did not assess or document the change in condition. There was no evidence in the clinical record that an assessment of the edema was performed in a timely manner after the onset of symptoms. Multiple interviews revealed that neither the physician nor the physician assistant assessed the resident promptly after being notified of the swelling. The nurse responsible for the resident did not complete a required nursing note or health status note regarding the change in condition. The delay in assessment and lack of timely communication and documentation resulted in the resident's edema going unaddressed for several days, contrary to facility policy and standard care expectations for residents with heart failure.
Failure to Follow Enhanced Barrier Precautions During Catheter Care
Penalty
Summary
The facility failed to adhere to infection control standards of practice for two residents who required Enhanced Barrier Precautions (EBP) due to the presence of indwelling urinary catheters. For one resident with Alzheimer's Disease and neuromuscular dysfunction of the bladder, a nurse did not perform hand hygiene before donning gloves and entering the resident's room, and only wore gloves—omitting the required gown—while performing a hands-on assessment of the urinary catheter. The nurse later acknowledged not following the EBP signage, and the unit manager confirmed that a gown was required for any hands-on catheter care. For another resident with incomplete paraplegia and neuromuscular dysfunction of the bladder, a unit manager performed hand hygiene, donned gloves only, and entered the resident's room to assess the indwelling urinary catheter. The unit manager did not wear a gown as required by the EBP signage for catheter care. Upon review, the unit manager acknowledged that a gown should have been worn during the procedure to prevent potential contamination. Both incidents were observed by surveyors and confirmed through interviews and review of facility policy and CDC guidelines. The facility's own policy and posted signage indicated that both gloves and gowns were required for high-contact care activities involving indwelling medical devices, such as urinary catheters, under EBP. The failure to follow these protocols was directly observed and acknowledged by the staff involved.
Inaccurate MDS Assessments for Hospice and Discharge Status
Penalty
Summary
The facility failed to complete accurate Comprehensive Minimum Data Set (MDS) assessments for two residents out of a sample of 30, as identified through record reviews and staff interviews. For one resident with multiple sclerosis and dementia, who was severely cognitively impaired and had an invoked health care proxy, the facility did not accurately code for hospice services on the MDS, despite the resident having a physician's order for hospice and being admitted to hospice services during the assessment period. The MDS nurse confirmed that hospice services should have been coded but were not, resulting in an inaccurate assessment that did not reflect the resident's status. For another resident with hypertension and atrial fibrillation, the facility failed to accurately code the discharge status on the MDS. The resident experienced an acute change in health status, was unresponsive with abnormal vital signs, and was transferred to the hospital for evaluation. Although the facility expected the resident to return at the time of transfer, the MDS was coded as 'discharge return not anticipated.' The MDS nurse acknowledged that the coding was inaccurate, as the correct code should have been 'discharge return anticipated' based on the circumstances at the time of transfer.
Failure to Report Allegations of Abuse
Penalty
Summary
The facility failed to adhere to its Abuse Prohibition Policy when allegations of abuse involving two residents were not immediately reported to the appropriate supervisory staff. Resident #2, who had intact cognitive patterns, reported an incident where Housekeeper #1 kissed him/her on the cheek to Housekeeper #2. However, Housekeeper #2 did not report this allegation to her immediate supervisor or the Administrator until after being prompted by a surveyor. This delay in reporting violated the facility's policy, which mandates immediate reporting of suspected abuse. In another incident, Resident #3, who had moderately impaired cognitive patterns, allegedly experienced inappropriate contact from Housekeeper #1, as reported by a family member to Nurse #2. Despite this report, Nurse #2 failed to clearly communicate the allegation to the appropriate supervisory staff, as neither Unit Manager #2, Unit Manager #3, nor the Assistant Director of Nursing received the report. This lack of communication and failure to follow the facility's policy resulted in a deficiency in handling and reporting allegations of abuse, neglect, and theft.
Failure to Report Allegations of Abuse
Penalty
Summary
The facility failed to report allegations of abuse involving two residents to the Department of Public Health (DPH) as required by their policy. In the first case, a certified nurse aide (CNA) found a housekeeper alone in the bathroom with a resident who had severely impaired cognitive patterns. The CNA reported this to the nursing staff, including the Director of Nursing and the Administrator. Despite initiating an internal investigation, the Director of Nursing and the Administrator did not report the incident to the DPH, as they did not perceive it as an allegation of abuse. In the second case, a resident with intact cognitive patterns expressed concerns to a CNA and an Occupational Therapy Assistant about feeling stalked and uncomfortable due to the housekeeper's behavior. These concerns were reported to the Director of Nursing, who conducted an investigation and concluded that the resident felt safe and comfortable, thus deciding not to report the incident to the DPH. The facility's failure to report these allegations to the appropriate authorities constitutes a deficiency in adhering to mandatory reporting requirements.
Failure to Investigate Allegations of Abuse
Penalty
Summary
The facility failed to conduct a thorough investigation following allegations of potential sexual abuse involving two residents. For the first resident, who was cognitively impaired, a Certified Nurse Aide (CNA) discovered the resident alone in a bathroom with a housekeeper. The CNA reported the incident to the nursing staff, including the Director of Nursing (DON) and the Assistant Director of Nursing. However, the investigation lacked a documented physical assessment of the resident by a nurse and did not include interviews with the housekeeper or other staff present at the time of the incident. The internal investigation report also failed to document any interviews with the resident's representative. In the case of the second resident, who had intact cognitive patterns, the resident expressed concerns about the same housekeeper's behavior, feeling stalked and uncomfortable. These concerns were reported by a CNA and an Occupational Therapy Assistant to the DON. Despite the resident's expressed fear and anxiety, the facility's investigation did not include a documented physical assessment by a nurse or interviews with the housekeeper, other staff, or the resident's representative. The internal investigation report only included a written statement from the DON, indicating that the resident later stated feeling safe and comfortable. The facility's policies on abuse investigation and response were not adhered to, as evidenced by the lack of comprehensive documentation and assessments. The policies required prompt and thorough investigations, including physical examinations or psychosocial assessments of alleged victims and interviews with all involved parties. The facility's failure to document these critical steps in both cases highlights a significant deficiency in their handling of abuse allegations.
Failure to Prevent and Treat Pressure Ulcers
Penalty
Summary
The facility failed to provide care consistent with professional standards to prevent and treat a pressure ulcer for a resident with a high risk of developing pressure ulcers due to a history of diabetes and peripheral vascular disease. The resident was admitted with diagnoses including diabetes with neuropathy and peripheral vascular disease. The resident was dependent on staff for putting on and taking off footwear and required assistance with various activities of daily living. Despite being at risk for pressure ulcers, the resident did not have any pressure ulcers upon admission but had two venous and arterial ulcers. The facility's policy required regular skin observations and timely treatment for any skin breakdown, but these were not adequately followed for this resident. The resident was provided an orthopedic surgical shoe on the right foot after experiencing significant pain and a loud crack while ambulating. Despite the x-ray being negative, the resident continued to experience pain and was given the surgical shoe for support. However, the facility staff failed to assess the fit and use of the orthopedic surgical shoe, which led to the development of ulcers on the right plantar foot, back of the right ankle, and right heel. The resident continued to wear the surgical shoe until after an orthopedic appointment, during which the ulcers were identified. The facility staff did not implement any physician orders for treatments immediately after the ulcers were identified, and the resident's skin was not assessed until several days later during the facility's weekly skin rounds. Interviews with the Director of Nurses, a nurse, and a Physician Assistant revealed that the facility staff did not follow proper procedures for assessing and treating the resident's skin breakdown. The orthopedic surgical shoe was not removed at night, and the resident remained in the shoe throughout the night, causing further pain and skin breakdown. The Physician Assistant noted that the facility staff should have done an assessment to ensure the shoe was not too tight and that the resident should only wear the shoe when out of bed. The lack of timely skin assessments and appropriate treatment led to the development and worsening of the resident's pressure ulcers.
Failure to Provide Appropriate Pain Management During Dressing Change
Penalty
Summary
The facility failed to provide appropriate pain management for a resident during a painful dressing change procedure. The resident, who was admitted with peripheral vascular disease and a non-pressure chronic ulcer, experienced severe pain during the dressing change. Despite the resident's known sensitivity and history of severe pain, the nurse did not offer pain medication prior to the procedure, resulting in the resident experiencing significant distress and pain rated as nine out of ten during the dressing change. The facility's policy on pain management requires that pain relief be anticipated and provided in accordance with professional standards of practice. However, during the observed dressing change, the nurse did not inform the resident about the procedure in advance or offer pain medication beforehand. The resident expressed that the pain medication would take too long to work and endured the procedure in significant pain, crying and wincing throughout. Interviews with the nurse and the Director of Nurses confirmed that the resident should have been assessed and medicated for pain prior to the dressing change. The resident's pain was not adequately managed, as evidenced by the resident's high pain levels during and after the procedure. The nurse practitioner also noted the resident's sensitivity and the expectation that pain management should have been provided before the dressing change.
Failure to Notify NPP of Significant Weight Loss
Penalty
Summary
The facility failed to notify the Physician/Non Physician Practitioner (NPP) of a significant change in physical status for a resident, resulting in a lack of medical evaluation of the resident's status relative to weight loss. Specifically, the facility staff did not inform the NPP of the resident's severe weight loss, which was greater than five percent in one month and greater than seven point five percent in three months. This failure occurred despite the NPP's request to be notified if the severe weight loss was verified. The resident's weight was monitored and recorded multiple times, showing a significant decrease, but the NPP was not informed until much later, delaying potential medical intervention. The resident, who was admitted to the facility with diagnoses including diverticulitis and dysphagia, had a history of weight loss and was at increased nutritional risk. The resident's care plan included goals to maintain a stable weight and instructions for staff to report significant weight loss to the physician. Despite these instructions, the resident's severe weight loss was not communicated to the NPP in a timely manner. The resident's weight records showed a drop from 189.9 lbs to 173.8 lbs over a few months, indicating severe weight loss, but the NPP was not notified until weeks later. Interviews with the Registered Dietician (RD) and the NPP revealed that the RD had been monitoring the resident's weight loss since February and had recommended weekly weight monitoring. The NPP had ordered weekly weights and requested to be notified if the severe weight loss was confirmed. However, despite re-weighs confirming the severe weight loss, the NPP was not informed until April, which delayed the medical evaluation and potential treatment for the resident's condition.
Failure to Monitor and Address Severe Weight Loss
Penalty
Summary
The facility failed to provide adequate nutrition care and services for a resident with a history of weight loss. Specifically, the staff did not obtain weekly weights as ordered by the physician, monitor weights weekly as recommended by the registered dietician (RD), coordinate care among the interdisciplinary team (IDT), or evaluate causative factors for the resident's severe weight loss. The resident experienced significant weight loss over several months, which was not properly addressed by the facility staff. The resident, who was admitted with diagnoses including diverticulitis and dysphagia, had a care plan indicating increased nutrition risk and a history of weight loss. Despite this, the resident's weight was not consistently monitored, and significant weight loss was not reported to the physician. The resident's weight dropped from 191 pounds to 173.8 pounds over several months, indicating severe weight loss. The RD requested re-weighs and weekly monitoring, but these were not consistently performed, and the physician was not alerted to the severe weight loss. Observations and interviews revealed that the resident continued to have a good appetite and often requested additional food. However, the facility staff failed to follow through with the necessary weight monitoring and communication with the physician. The resident's weight was not obtained for three consecutive weeks, and the NPP was not alerted to the severe weight loss until prompted by the surveyor. This lack of coordination and communication among the facility staff led to the resident's severe weight loss not being properly evaluated or addressed.
Failure to Adhere to Infection Control Standards
Penalty
Summary
The facility failed to ensure that staff adhered to infection control standards for four residents on two out of three units observed. Specifically, staff did not wear appropriate Personal Protective Equipment (PPE) while performing nephrostomy and wound care for a resident on Enhanced Barrier Precautions (EBP) on the Primrose Unit. The nurse only wore gloves and did not wear a gown as required by the facility's policy. The nurse acknowledged the mistake during an interview. Another resident on the Magnolia Unit, who was also on EBP, did not receive proper care as the nurse failed to wear a gown while measuring the resident's foot wounds. The nurse admitted to the oversight during an interview. The facility's policy clearly indicated that both gloves and gowns were necessary for high-contact resident care activities, which were not followed in these instances. Additionally, the facility did not perform appropriate hand hygiene for two residents housed in the same room, one of whom was on Contact Precautions due to C. difficile. The housekeeper used alcohol-based hand rubs (ABHR) instead of soap and water, which is ineffective against C. difficile spores. The housekeeper and the Unit Manager were unaware of the correct hand hygiene protocol, and the signage outside the room incorrectly indicated the use of ABHR.
Incorrect Wound Medication Application
Penalty
Summary
The facility failed to provide the correct topical wound medication as ordered by the Physician for one resident, resulting in the removal and re-application of the dressing, causing additional discomfort to the resident. The resident, who was admitted with peripheral vascular disease and a non-pressure chronic ulcer, had specific orders for wound care that were not followed. The Physician's orders required Silver Sulfadiazine for the left foot wound and Santyl for the left heel wound. However, during a dressing change, Nurse #1 incorrectly applied both Santyl and Silver Sulfadiazine to both wounds, contrary to the Physician's orders. The error was observed by a surveyor and confirmed through interviews with Nurse #1 and the Unit Manager. Nurse #1 acknowledged the mistake and informed the Unit Manager. The Physician confirmed that using both medications on the same wound is counterproductive to healing. The facility's policy and procedures for wound care were not adhered to, leading to the deficiency in providing appropriate treatment and care according to the resident's needs and Physician's orders.
Failure to Schedule Urology Consultation for Resident with Urinary Catheter
Penalty
Summary
The facility failed to provide necessary services and assistance for a resident with an indwelling urinary catheter to obtain a specialist consultation with a Urologist. The resident, who was admitted with diagnoses including neuromuscular dysfunction of the bladder and urine retention, developed a ventral erosion of the genitalia. Despite a physician's order on 2/2/24 for the resident to be seen by a Urologist, the facility did not schedule the appointment until 4/9/24, after the surveyor's inquiry. The resident had not been seen by a Urologist at any time since the order was given, and the appointment was delayed until August 2024. Observations by the surveyor noted the resident's catheter tube exiting the pant leg and draining into a urine collection bag. The resident reported occasional aching pain in the genitalia but had not seen a specialist for the urinary catheter. Medical records staff and the Director of Nurses confirmed that the appointment should have been scheduled when the order was obtained, but it was not done until prompted by the surveyor. The facility's failure to schedule the necessary specialist consultation in a timely manner led to the deficiency noted in the report.
Inadequate Pain Management and Wound Care Competency
Penalty
Summary
The facility failed to ensure that Nurse #1 had the specific competencies and skills necessary to provide appropriate pain management and perform wound care for Resident #18. This resulted in poor pain control and improper wound treatment, potentially compromising the resident's healing process. The resident, who was admitted with peripheral vascular disease and a non-pressure chronic ulcer, experienced severe pain during a dressing change procedure due to the nurse's lack of competency in pain management and wound care techniques. During the dressing change, Nurse #1 did not offer pain medication to the resident beforehand, despite the resident's history of severe pain. The resident expressed significant discomfort and pain during the procedure, which was not adequately managed by the nurse. Additionally, Nurse #1 did not follow the physician's orders for wound treatment, applying incorrect medications and failing to perform the procedure as prescribed. The facility's records indicated that Nurse #1 had not received proper training or competency assessments in pain management or wound care. The Staff Development Coordinator confirmed that there was no documented evidence of such training, and the facility had not implemented a skills checklist for newly hired nurses. The Director of Nurses and the Administrator were also unaware of the specific training and competency requirements for Nurse #1, highlighting a systemic issue in the facility's staff training and competency evaluation processes.
Failure to Adhere to Food Service Safety Standards
Penalty
Summary
The facility failed to adhere to professional standards of practice for food service safety in the main kitchen and for one resident. Specifically, three dietary staff members did not wear hair restraints while working in the food preparation and service areas, increasing the risk of food contamination. Dietary Staff #3 and #4 were observed without hair restraints while handling food, and Dietary Staff #2 wore an improperly placed hair restraint, leaving large amounts of hair exposed. The Food Service Director and Assistant Food Service Director acknowledged that hair restraints were required and that the staff should have been wearing them as per the facility's policy. Additionally, the facility failed to reheat a resident's meal in a safe and appropriate manner. Resident #86, who has Alzheimer's disease, had their breakfast meal reheated by a CNA in a microwave without checking the temperature to ensure it reached the required 165 degrees Fahrenheit. The CNA admitted to not knowing the proper reheating procedure and used a hand-over method to check if the food was warm. The Food Service Director stated that nursing staff typically call the main kitchen for a new tray if food needs to be reheated and was unaware that staff were using the microwave to reheat resident meals.
Failure to Accurately Complete and Transmit MDS Assessments
Penalty
Summary
The facility failed to accurately complete, encode, and transmit Minimum Data Set (MDS) Assessments as required for three residents out of a total sample of 25 residents. Specifically, the facility did not electronically transmit a Discharge MDS Assessment for one resident within 14 days of completing the assessment. Another resident's Death in Facility Tracking Record was not completed when the resident expired at the facility. Additionally, a Discharge MDS Assessment for a third resident was not completed within 14 days of the resident's discharge from the facility when the return was not anticipated. Resident #101, diagnosed with Congestive Heart Failure, was discharged from the facility, but the MDS Discharge Assessment was not transmitted to CMS within the required timeframe. Resident #164, diagnosed with Hypertension, expired at the facility, but no Death in Facility Tracking Record was completed. Resident #131, diagnosed with Spinal Stenosis, was discharged, but the MDS Discharge Assessment was completed six days past the due date. The MDS Nurse confirmed these deficiencies and acknowledged the importance of timely completion and processing of MDS data.
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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) |
|---|---|---|---|---|
| Meadows Of Central Massachusetts (the) | 2 mi | ★★★★★ | 4 | 0 |
| Parsons Hill Rehabilitation & Health Care Center | 4.2 mi | ★★★★★ | 1 | 0 |
| Hermitage Healthcare (the) | 5.6 mi | ★★★★★ | 18 | 0 |
| St Mary Health Care Center | 5.9 mi | ★★★★★ | 10 | 0 |
| Worcester Rehabilitation & Health Care Center | 6 mi | ★★★★★ | 1 | 0 |
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