Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Rehabilitation & Nursing Center during CMS and state inspections, most recent first.
A resident with arthritis and chronic venous insufficiency received hydrocollator therapy for shoulder pain, but the therapy assistant failed to check the resident's skin after five minutes and left the pack on for 25 minutes, resulting in a blister. The resident, who had intact cognition, fell asleep during the session and did not remove the pack as instructed. The facility's policy required checking for redness after five minutes and removing the pack after 20 minutes, which was not followed.
The facility failed to provide necessary personal hygiene and grooming services to residents unable to perform activities of daily living. A resident with impaired cognition was not regularly showered or shaved, leading to poor hygiene. Another resident with severely impaired cognition did not receive adequate oral care, resulting in brown teeth and foul odor. Additionally, a resident with limited mobility did not receive proper toenail care, leading to unclean toenails. Staff interviews confirmed these deficiencies, highlighting the neglect in providing essential care.
The facility failed to properly dispose of garbage, with open dumpsters and debris observed around the premises. Staff acknowledged that dumpsters should have been closed and garbage properly contained to prevent hazards.
The facility was cited for deficiencies in food storage, preparation, and cleanliness. Observations revealed improper storage of food items on an unprotected loading dock, inadequate handwashing facilities, and unclean kitchen and kitchenette areas. Additionally, a freezer with ripped door seals failed to maintain proper temperatures. The Food Service Director acknowledged the issues, indicating a lack of adherence to professional standards for food service safety.
A facility failed to secure medication and treatment carts and properly label medications, leading to expired insulin being administered to a resident and unsecured access to medications and scissors. Staff acknowledged the carts should have been locked and medications labeled, as per facility policy.
The facility failed to provide food and drink that were palatable and served at appropriate temperatures during lunch meals, as observed during a recertification survey. Two residents reported that the food was cold and lacked flavor. Staff interviews confirmed these issues, with food items being served outside recommended temperature ranges, potentially leading to foodborne illnesses.
The facility did not ensure a clean and homelike environment, with a strong urine smell and food debris noted in multiple areas. A resident's room was found unclean, and they lacked a chair and tray table. Staff interviews revealed confusion over cleaning responsibilities, with housekeeping only available during limited hours, leaving nursing staff to manage cleanliness after hours.
A resident with severe cognitive and hearing impairments was not consistently provided with communication aids, such as a whiteboard and laminated picture sheets, as outlined in their care plan. Despite staff awareness of the resident's needs, they failed to use these tools, leading to the resident's inability to communicate effectively. Observations showed staff walking past the resident without attempting to understand their needs, resulting in a deficiency in maintaining the resident's ability to carry out daily activities.
The facility failed to maintain an effective pest control program, with fruit flies and other insects observed in the East Hall and South kitchenette. Despite monthly pest control services, staff and residents reported frequent sightings of various insects, attributing the issue to food left on the floor. The Maintenance Director and other staff acknowledged the problem, but the pest presence persisted.
Two residents experienced dignity issues due to facility failures. One resident was exposed in a brief visible from the hallway, while another urinated in bed due to delayed call bell response. Staff interviews confirmed these incidents, highlighting the need for timely care and privacy adherence.
Two residents in the facility were found with medications at their bedsides despite not being approved for self-medication administration. One resident with severely impaired cognition had a cup with seven medications, while another had a Breo inhaler. Staff confirmed that no residents were on a self-medication protocol, and medications should not be left at the bedside due to safety concerns, especially with wandering residents.
A resident with moderate cognitive impairment and high risk for pressure ulcers developed a new skin impairment that was not assessed or treated in a timely manner by qualified staff. Despite facility policy requiring comprehensive skin assessments and documentation, the sheared areas on the resident's buttocks were not properly addressed until days after they were first noted. Interviews with staff revealed a lack of communication and clarity regarding the resident's condition and necessary care.
Inadequate Supervision During Hydrocollator Therapy
Penalty
Summary
The facility failed to ensure adequate supervision during therapy for Resident #276, resulting in a blister on the resident's shoulder. The resident, who had diagnoses including arthritis, chronic venous insufficiency, and morbid obesity, was receiving hydrocollator therapy for shoulder pain. The facility's policy required the hydrocollator to be checked for redness after five minutes and removed after 20 minutes. However, the Certified Occupational Therapy Assistant (COTA) did not check the resident's skin after five minutes and left the hydrocollator on for 25 minutes, leading to a deroofed blister. Resident #276 had intact cognition and was able to report pain, but fell asleep during the therapy session. The COTA applied the hydrocollator at approximately 11:00 AM and instructed the resident to remove it after 20 minutes. However, the resident did not remove the pack and was asleep when the COTA returned 25 minutes later. The resident later reported pain and observed a blister on their shoulder, which was assessed by the Director of Nursing and documented as a 3.0 by 5.0 deroofed blister. The incident report indicated that the COTA was counseled for not following the policy of checking the skin after five minutes and leaving the hydrocollator on too long. The hydrocollator machine was inspected and found to be in proper working order. The Director of Rehabilitation stated that hydrocollator therapy should only be used with residents who have intact cognition and can report pain, and that residents should be visibly checked for skin redness after five minutes. The Director of Nursing expected the therapy staff to follow these procedures to prevent burns.
Deficiency in Personal Hygiene and Grooming Care
Penalty
Summary
The facility failed to ensure that residents who were unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. Specifically, Resident #178, who had severely impaired cognition and required assistance with personal hygiene, was not provided with regular showers, shaving, or grooming as planned. Observations revealed that the resident had a full beard, was drooling, and had white flakes in their hair, indicating a lack of personal hygiene care. Interviews with staff confirmed that the resident's care was not consistently provided, and the resident's family expressed concerns about the lack of grooming and hygiene. Resident #4, who also had severely impaired cognition and required assistance with oral care, was not provided with adequate oral hygiene. Observations noted that the resident's teeth were brown and emitted a foul odor, suggesting a lack of oral care. Staff interviews revealed that oral care was often neglected due to being busy, and the importance of oral hygiene for preventing tooth decay and maintaining the resident's ability to eat was acknowledged by the staff. Resident #27, who required assistance with personal hygiene due to limited physical mobility, did not receive proper toenail care. Observations showed that the resident's toenails were brown with a black substance around the nail beds, indicating a lack of cleaning. Staff interviews confirmed that toenail care was not provided as planned, and the resident expressed dissatisfaction with the infrequency of showers and toenail cleaning. The Director of Nursing emphasized the importance of providing comprehensive personal hygiene care to prevent infections and maintain residents' dignity.
Improper Garbage Disposal and Storage
Penalty
Summary
The facility failed to ensure proper disposal of garbage and refuse, as observed during a recertification survey. The facility's policy required that garbage be stored in a manner inaccessible to pests and that storage areas remain clean and free of nuisance. However, surveyors observed two dumpsters outside the facility left open with plastic bags exposed to the wind. Additionally, wet cardboard boxes, broken equipment, and debris were piled outside the Southwest exit, and mattresses were stacked between the dumpsters. Wooden pallets with debris were found behind a shed, and more equipment and debris were collected outside a garage at the parking lot's end. Garbage, plastic bags, and debris, including used gloves and masks, were visible on the lawn and around the building. Interviews with facility staff, including the Director of Environmental Services and the Administrator, confirmed that the dumpsters should have been closed and that garbage should not have been left piled or strewn about outside. The Director of Environmental Services acknowledged that the dumpsters were emptied weekly, but the furniture piled by the garage was received from another facility and was not usable, awaiting disposal. The Food Service Director also noted that garbage should not have been left on the loading dock, where packaging debris, plastic bags, and cigarette butts were observed. The staff recognized the importance of properly containing garbage to prevent it from becoming a hazard.
Deficiencies in Food Storage and Hygiene Practices
Penalty
Summary
The facility was found to have several deficiencies related to food storage, preparation, and cleanliness during a recertification survey. Observations revealed that the main kitchen had soiled and poorly maintained equipment, improper food storage, and a lack of access to proper handwashing facilities. Specifically, bread and other food service items were stored outside on a loading dock that was not enclosed or protected from the elements and pests. The area was littered with debris, and the bread remained outside for extended periods. The Food Service Director acknowledged that deliveries should be put away immediately and that the current storage practices were not compliant with safe food handling standards. Additionally, the facility failed to provide adequate handwashing facilities in the kitchen. The only handwashing sink was blocked, and staff were observed not performing hand hygiene when required, such as after changing gloves or returning to the kitchen. The Food Service Director confirmed that staff were expected to wash their hands at specific times, but the blocked sink hindered compliance with this policy. Furthermore, the kitchen and kitchenette areas were found to be unclean, with soiled coolers, floors, and equipment. The cleaning tasks were not completed as required, and the Food Service Director admitted that the cleaning assignments were not fulfilled during their absence. The facility also had issues with equipment maintenance, as observed with a two-door upright freezer that had ripped door seals and did not maintain proper temperatures. Some contents inside the freezer were not adequately frozen, indicating a failure to maintain equipment in good working order. The Food Service Director was unaware of the freezer's condition and stated that no work orders had been submitted for maintenance. These deficiencies highlight a lack of adherence to professional standards for food service safety, as required by federal and local health codes.
Medication and Treatment Cart Security and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure that drugs and biologicals were labeled and stored according to professional principles, leading to several deficiencies. During the recertification survey, it was observed that the East Hall medication cart was left unsecured, containing an expired insulin pen and another insulin pen without an opened or expired date for a resident. Additionally, there was an insulin pen without any resident identifiers or opened/discharge date. The treatment cart on the East Hall was also found unsecured, containing medications and scissors. Licensed Practical Nurse #8 admitted to administering expired insulin to a resident and acknowledged the lack of proper labeling and dating of insulin pens, which could lead to contamination and ineffective medication administration. The facility's policy required that medication carts be locked at all times when not in use, and medications with shortened expiration dates be dated when opened. However, observations revealed that the medication cart was left unlocked with resident information visible, and the treatment cart was also left unsecured. Interviews with staff, including Licensed Practical Nurse #9 and the Director of Nursing, confirmed that the carts should have been locked for safety reasons and that there were spare keys available. The failure to secure the carts and properly label medications posed a risk to resident safety and privacy.
Deficiency in Food Service: Inadequate Temperature and Palatability
Penalty
Summary
The facility failed to ensure that residents received food and drink that were palatable, flavorful, and served at appetizing temperatures during the recertification survey conducted from January 2, 2025, to January 7, 2025. Specifically, during lunch meals on January 3 and January 6, 2025, on the East Hall, food was observed to be not flavorful and not served at appropriate temperatures. Two residents, identified as Resident #24 and Resident #53, reported that the food was cold and lacked taste. Observations confirmed that food items such as applesauce, orange juice, milk, hamburger stew, beans, and coffee were served at temperatures outside the recommended ranges, which could potentially lead to foodborne illnesses. Interviews with staff, including a Certified Nurse Aide, a Licensed Practical Nurse Unit Manager, a Dietary Cook, and the Food Service Director, corroborated the residents' complaints about the food being bland and cold. The facility's policy, dated October 2023, required that food be served at safe and appetizing temperatures, yet the observed temperatures did not meet these standards. The Food Service Director acknowledged that the food served did not look appetizing and was outside the recommended temperature range, which could result in residents not eating and potentially losing weight or getting sick. The Director of Nursing noted that while there had been improvements with new staff, issues with food temperatures and palatability persisted.
Facility Fails to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to ensure a safe, clean, comfortable, and homelike environment for residents across all four halls, as evidenced by a strong urine smell and unclean conditions. Observations revealed a persistent urine odor in the North, West, East, and South halls, as well as food debris on the floor in the Northwest common area. Specific issues were noted in a resident's room, where crumbs, white circular spots on fall mats, and various items such as a cup and medicine cup were found on the floor. Additionally, a resident expressed a desire for a chair in their room, which was not provided, forcing them to eat off their wheelchair due to the absence of a tray table. Interviews with staff highlighted a lack of clarity regarding cleaning responsibilities, with some staff believing it was the housekeepers' job to maintain cleanliness, while others indicated it was a shared responsibility. Housekeeping staff were only available during specific hours, leaving nursing staff to manage cleanliness after hours. The Maintenance Director acknowledged reports of urine smells and attempted to identify the source, while the Director of Nursing and other staff recognized the unhomelike conditions and potential for infection control issues due to food on the floor. Despite these acknowledgments, the facility's policies on maintaining a clean and pleasant environment were not effectively implemented.
Failure to Provide Communication Support for Deaf Resident
Penalty
Summary
The facility failed to provide appropriate communication support for a resident who was deaf, leading to a deficiency in maintaining the resident's ability to carry out activities of daily living. The resident, who had severely impaired cognition and highly impaired hearing, was supposed to use a whiteboard and laminated picture sheets for communication. However, during multiple observations, the resident was seen attempting to communicate needs through gestures and moaning, without staff utilizing the prescribed communication aids. On several occasions, staff members, including a Certified Nurse Aide and a Registered Nurse Unit Manager, walked past the resident without attempting to communicate or understand the resident's needs. The resident was observed trying to communicate pain and discomfort by pointing to their shoulder and stomach, but staff did not use the available communication tools to assist. The resident's care plan included specific instructions for communication, such as using a whiteboard and asking yes or no questions, but these were not consistently followed. Interviews with staff revealed that while they were aware of the resident's communication needs, they did not consistently apply the necessary interventions. Staff acknowledged the importance of stopping to understand the resident's needs but failed to do so in practice. The deficiency highlights a lack of adherence to the resident's care plan and communication protocols, resulting in the resident's inability to effectively communicate their needs.
Pest Control Deficiency in Facility
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by the presence of fruit flies and other insects in the East Hall and South kitchenette. Observations made during the survey period revealed multiple instances of flying insects in various locations, including the South kitchenette, resident rooms, and the conference room. The facility's pest control policy, revised in October 2023, mandates immediate reporting of any signs of infestation to a supervisor. However, despite the pest control vendor's service reports from June to November 2024 indicating no signs of pest activity, the surveyors observed insects during their visit. Interviews with staff and residents further highlighted the issue. A resident reported seeing ants and fruit flies in their room, attributing the presence of bugs to food left on the floor, which staff did not clean promptly. A Certified Nurse Aide mentioned frequent sightings of various insects and noted that residents often complained about them. The Maintenance Director acknowledged being informed about the pest issues and stated that a pest control vendor was used monthly, but the problem persisted. The Director of Nursing and the Administrator both expressed that they did not expect to see pests or food on the floor for extended periods, acknowledging that such conditions could lead to pest infestations.
Deficiencies in Resident Dignity and Timely Care
Penalty
Summary
The facility failed to ensure a dignified existence for two residents, leading to deficiencies in maintaining their quality of life. Resident #29, who had moderately impaired cognition and required assistance with daily activities, was observed in bed with their incontinence brief exposed and visible from the hallway. The privacy curtain was partially open, and the resident expressed embarrassment about being seen in such a state. Staff interviews confirmed that Resident #29 preferred to be dressed and that it was inappropriate for any resident to be visible in a brief from the hallway. Resident #282, who was continent of urine and required assistance for toileting, experienced a delay in having their call bell answered, resulting in urination in bed. The resident expressed embarrassment and a desire for quicker response times from staff. Interviews with staff members revealed that some staff did not respond promptly to call bells, contributing to the resident's incontinence incident. The facility's policies emphasized the importance of timely care and maintaining resident dignity, which were not upheld in these instances. The facility's failure to provide timely assistance and maintain privacy for these residents violated their rights to dignity and respect. The Director of Nursing acknowledged the expectation for timely call bell responses and recognized the dignity issues arising from the incidents. These deficiencies highlight the need for the facility to adhere to its policies and ensure residents' rights to a dignified existence are respected.
Inadequate Supervision Leads to Medication Safety Concerns
Penalty
Summary
The facility failed to ensure adequate supervision to prevent accidents by leaving medications at the bedsides of residents who were not approved for self-medication administration. Resident #57, who had severely impaired cognition and required assistance for daily activities, was found with a medication cup containing seven medications on their over-the-bed table. The resident was not aware of how long the medications had been there, and there was no order for self-medication administration. Licensed Practical Nurse #21 confirmed that the medications should not have been left at the bedside, as no residents were on a self-medication administration protocol. Similarly, Resident #50, who had mildly impaired cognition and required assistance for daily activities, was observed with a Breo inhaler at their bedside. The resident was not approved for self-medication administration, and the inhaler was removed by Licensed Practical Nurse #20. Staff interviews revealed that medications were sometimes found on the floors in resident rooms, posing a safety risk, especially with wandering residents who could potentially take medications that were not theirs. The Director of Nursing confirmed that no residents were approved for self-medication administration, and medications should not be left at the bedside.
Failure to Timely Assess and Treat Pressure Ulcers
Penalty
Summary
The facility failed to ensure that a resident with pressure ulcers received necessary treatment and services consistent with professional standards of practice. Specifically, a resident with a history of [DIAGNOSES REDACTED] and moderate cognitive impairment developed a new skin impairment that was not assessed and treated in a timely manner by a qualified individual. The resident was at risk for developing pressure ulcers due to their condition, which included being bedfast most of the time, having an indwelling urinary catheter, and being frequently incontinent of bowel. The facility's policy required a registered nurse to conduct a comprehensive skin assessment when a significant change was identified, and to document a comprehensive nursing note when a pressure ulcer was identified. However, there was no documented evidence that the sheared areas on the resident's buttocks, identified on 9/29/2024, were assessed by a qualified professional until 10/1/2024. Furthermore, there was no treatment ordered for the shearing until 10/2/2024, despite the facility's policy and the resident's high risk for pressure ulcers. Interviews with facility staff revealed a lack of clarity and communication regarding the resident's condition and the necessary assessments. The Licensed Practical Nurse Unit Manager and Certified Nurse Aide both indicated that the resident required total care and often resisted care, but there was uncertainty about whether the resident was admitted with a wound. The Director of Nursing and Registered Nurse Unit Manager acknowledged that the resident's pressure ulcer should have been monitored and assessed more promptly, and the Medical Director confirmed that a skin assessment should have been completed upon admission with appropriate notification to the wound care team.
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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) |
|---|---|---|---|---|
| The Commons On St Anthony, A S N F & Short T R C | 0.3 mi | ★★★★★ | 0 | 0 |
| Finger Lakes Center For Living | 2.1 mi | ★★★★★ | 4 | 3 |
| Seneca Nursing & Rehabilitation Center, Llc | 13.6 mi | ★★★★★ | 0 | 0 |
| Northwoods Rehab And Nursing Center At Moravia | 15.9 mi | ★★★★★ | 14 | 0 |
| Syracuse Home Association | 19.8 mi | ★★★★★ | 12 | 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.