Above average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Auburn Skilled Nursing And Rehab during CMS and state inspections, most recent first.
Surveyors found that the unit refrigerator used for resident food contained undated and unlabeled items, including orange juice, tuna salad, and egg salad, as well as a container labeled only with a date and a last name. An LPN confirmed the lack of labeling and stated housekeeping was responsible for the refrigerator. The housekeeping supervisor acknowledged the salads were from the prior weekend and should have been removed, and explained that staff checked temperatures daily but the temperature log did not direct staff to review or discard expired or unlabeled food. The DON noted that two residents were NPO and did not use the refrigerator, and review of facility policy showed that all refrigerated foods were required to be covered, labeled, and dated.
Improper Food Storage and Unsanitary Kitchen Conditions: Surveyors observed an opened and uncovered box of barley in the dry pantry, a dented can of soup, and frozen foods left open and unsealed in the freezer, including hot dogs and seasoned beef patties. Surveyors also found white, crusted debris on the ice machine, including the lid and outer surfaces, and the DM stated this buildup happened often. The facility policy required food storage areas to be kept clean and foods in the refrigerator or freezer to be covered, labeled, and dated.
Infection control failures occurred when a resident with C. diff was not timely placed on documented contact isolation and staff did not consistently wear required PPE in the resident’s room. A housekeeper cleaned the room without a gown while the resident was present, and an LPN failed to perform hand hygiene before preparing meds and between administering meds to multiple residents. The DON confirmed the isolation order was delayed and that hand hygiene was required before medication preparation.
A resident with significant medical needs was repeatedly observed in bed with pajama pants pulled down below the knees and above heel boots, a practice reportedly done to facilitate easier changing by staff at night. The ADON confirmed the observation but could not explain the rationale, and this practice was not consistent with the facility's policy requiring dignity and bodily privacy during personal care.
Two residents with mobility and sensory impairments did not have accessible call lights, as the cords were either out of reach or easily confused with light switches. Additionally, one resident recovering from joint replacement surgery was provided with a recliner that was too difficult to operate safely, limiting her ability to get up without assistance. Nursing staff and the DON confirmed these deficiencies, which were not in accordance with facility policy.
A resident with intact cognition and diagnoses including thoracic vertebra collapse, DM, concussion, depression, morbid obesity, and asthma did not have paper towels in the bathroom. The resident said nursing staff had been told the dispenser was empty the day before, but it was still empty when observed. A CNA said housekeeping would be notified, and the housekeeping supervisor stated bathroom paper towels were to be checked daily. The facility policy stated residents are to be provided a safe, clean, comfortable, and homelike environment.
A resident with multiple diagnoses, intact cognition, and ADL assistance needs did not have a timely activities assessment completed after admission. The resident said she had not attended any activities and was bored, while the AD confirmed the EMR lacked an activities assessment even though she knew the resident's likes and dislikes. The written participation record showed mostly individual activities rather than group activities, and the facility policy required the AD to maintain the activity assessment and related documentation.
Pharmacy medication regimen review recommendations were not clearly addressed for three residents with significant psychiatric and medical histories. One resident with dementia and agitation had a pharmacist recommendation for a trazodone GDR, but the PCP deferred to psych services and the psych NP stated she did not review pharmacy recommendations. Another resident with schizoaffective disorder, depression, PTSD, and dementia had repeated pharmacy GDR recommendations for multiple psych meds, yet responses only referenced psych notes without clear documentation of review or agreement. A third resident with depression and an elevated PHQ score had a pharmacy recommendation for further evaluation, but the issue was deferred to psych services with no documented follow-through.
Improper storage of self-administered medications was identified for a resident assessed as cognitively intact and able to safely manage her own meds. An LPN placed pills in an unlocked drawer, and later observation found a white cup with pills, eye drops, and cough drops stored in an unlocked cabinet beside the resident’s chair. The nurse manager confirmed the drawer was not locked while the medications were kept there, allowing unauthorized access.
Inaccurate vaccine consent documentation was found for three residents. One resident with multiple respiratory and psychiatric diagnoses had duplicate influenza/pneumococcal consent forms with conflicting prior vaccine history and vaccine dates, while two other residents had incomplete or inconsistent consent documentation for pneumococcal and influenza VIS information. The ADON verified the discrepancies during interview.
Failure to Maintain Sanitary and Properly Labeled Unit Refrigerator Food
Penalty
Summary
The facility failed to maintain the unit refrigerator used for resident food in a sanitary manner consistent with its policy and acceptable food safety standards. During an observation with an LPN, surveyors found an opened bottle of Amish orange juice that was undated, an undated and unlabeled tub of tuna salad, an undated and unlabeled tub of egg salad, and a black Styrofoam container labeled only with a date and a resident’s last name. The LPN confirmed at the time of observation that these items were unlabeled and undated and stated that housekeeping staff were responsible for maintaining this refrigerator. The Housekeeping and Laundry Supervisor reported that the egg salad and tuna salad were from the previous weekend and acknowledged they should have been removed before the observation. The supervisor explained that housekeeping staff were expected to check the refrigerator daily when recording temperatures and to review the food inside at that time. However, the Storage Room Temperature Log used for documenting refrigerator and freezer temperatures contained no guidance or sign-off section for checking food items for labels, dates, or for discarding expired or unlabeled food. The DON confirmed that two residents were NPO and therefore did not use the unit refrigerator. Review of the facility’s “Food Receiving and Storage” policy showed that all foods stored in the refrigerator or freezer were required to be covered, labeled, and dated, and that food storage areas were to be kept clean at all times.
Improper Food Storage and Unsanitary Kitchen Conditions
Penalty
Summary
The facility failed to maintain proper food storage in the kitchen. During observation on 09/02/2025, surveyors found a 16-ounce box of barley that was opened and uncovered in the dry pantry, a dented 50-ounce can of Campbell's Chicken Noodle Soup on the dry pantry shelf, and a package of approximately 25 frozen hot dogs in the stand-up freezer that was opened and unsealed, exposing the hot dogs to freezer air. These observations were verified by DM #165 at the time they were made. Surveyors also observed a large box of frozen seasoned beef patties in the stand-up freezer that was approximately 3/4 full and open and unsealed. On 09/02/2025, the ice machine had white, crusted debris around the outer aspects and on the inside of the lid, described as flakey and falling off when touched; DM #165 stated this happened often and would run down the sides of the machine as well. A later observation on 09/03/2025 again found the box of frozen seasoned beef patties open and unsealed, and DM #165 verified it. The facility policy titled Food Receiving and Storage, revised October 2017, stated that food service or other designated staff would maintain clean food storage areas at all times and that all foods stored in the refrigerator or freezer would be covered, labeled, and dated.
Infection Control and Hand Hygiene Failures
Penalty
Summary
The facility failed to timely implement contact isolation for a resident with a positive C. difficile result and failed to ensure staff used adequate PPE when entering the resident’s room. Resident #9 was admitted with diagnoses including dementia, atrial fibrillation, and dysphagia. After the resident had loose stool or diarrhea, the physician was notified, and later laboratory results were positive for C. diff. Progress notes stated the resident was placed on precautions and remained on isolation, but the physician’s order for contact isolation was not entered until 09/02/25 with an effective date of 08/14/25, and there was no evidence of prior orders for transmission-based precautions or isolation. During observation, the resident’s room had PPE outside the door and signs on the door frame, but there was no sign indicating contact precautions were in place. RN #105 stated the resident was on full contact precautions for C. diff. The DON confirmed the contact precautions order was not added until 09/02/25 and that the earlier progress notes did not specify what type of transmission-based precautions were implemented. On a later observation, Housekeeper #163 cleaned the resident’s room without wearing a gown while the resident was sitting in the room. The housekeeper stated she did not have to gown up because she was not providing direct care, and the ADON confirmed housekeeping staff should wear gowns while the resident remained on contact precautions. The facility also failed to ensure appropriate hand hygiene during medication administration. During observation of medication pass, LPN #138 did not perform hand hygiene before preparing medications or between administering medications to Residents #27, #21, and #7, and did not perform hand hygiene after placing medications in Resident #16’s room for self-administration. The LPN confirmed she did not perform hand hygiene prior to or between residents and stated she was required to sanitize after providing care to three residents. The DON stated hand washing or sanitizing must be completed prior to preparing medications.
Failure to Maintain Resident Dignity and Privacy During Personal Care
Penalty
Summary
A deficiency was identified when a resident with multiple medical conditions, including metabolic encephalopathy, pneumonia, chronic respiratory failure, major depression, anxiety, spinal cord injury, and chronic lung disease, was observed in bed with flannel pajama pants pulled down below the knees and above heel boots. The resident, who required moderate to substantial assistance with personal care and was dependent on a wheelchair for mobility, was found in this state on two separate occasions. The resident explained that the pajama pants were left pulled down at night to make it easier for staff to change him in case of an accident, as he wore heel boots while in bed. During an interview, the Assistant Director of Nursing confirmed the observation of the resident's pajama pants being pulled down and was unable to provide a reason for this practice, stating that the aides must be responsible. Review of the facility's policy on dignity indicated that all residents should be treated with dignity and respect at all times, including providing bodily privacy during personal care and treatments. The failure to maintain the resident's dignity and privacy constituted a deficiency as it did not align with the facility's stated policy.
Failure to Provide Accessible Call Lights and Functional Furniture
Penalty
Summary
The facility failed to ensure that call lights were within reach and that functional furniture was provided to accommodate the needs of two residents. For one resident with multiple diagnoses including cognitive communication deficit, unsteadiness, and moderate hearing and vision impairment, observations revealed that the call light was not accessible. The call light cord was found on the floor behind the nightstand, out of the resident's reach, and was easily confused with the cord for the overhead light. The resident demonstrated that she could only access the light switch cord, not the actual call light, and this was confirmed by both nursing staff and the Director of Nursing. Another resident, who had undergone joint replacement and required substantial assistance for mobility and personal care, also did not have access to a call light while seated in her recliner or wheelchair. Observations showed that the call light was under the bed covers or on the floor, both out of reach. The resident indicated she would use a string on the recliner arm, but this was for the room light, not the call system. Additionally, the recliner provided to this resident was not functional for her needs post-surgery, as she was unable to close the footrest without significant force and could not get out of the chair without assistance. Interviews with nursing staff and the DON confirmed that the call light cords were easily confused with light cords and that the recliner was not suitable for a resident recovering from knee surgery. Facility policy required that each resident be provided with a means to call staff for assistance from their bed and other locations, but this was not followed for the two residents involved.
Empty Bathroom Paper Towel Dispenser
Penalty
Summary
The facility failed to ensure a resident had access to paper towels in the bathroom, affecting one resident reviewed for environment. The resident was admitted with diagnoses including collapsed vertebra of the thoracic region, diabetes mellitus, concussion, depression, morbid obesity, and asthma. The 5-Day MDS dated 08/25/25 showed the resident had intact cognition and required staff assistance with ADLs. The care plan dated 08/25/25 noted interventions related to activities of choice and quarterly interviews as needed. During interview on 09/02/25, the resident stated there were no paper towels in the bathroom and that nursing staff had been told early the previous day that the dispenser was empty, but it remained empty. Observation shortly afterward confirmed the paper towel dispenser in the resident's bathroom was empty. A CNA stated the dispenser was empty and that housekeeping would be notified to refill it. The housekeeping supervisor later stated it was housekeeping's responsibility to check the paper towels in resident bathrooms daily. The facility policy titled Quality of Life-Homelike Environment stated residents are to be provided with a safe, clean, comfortable, and homelike environment.
Delayed Activities Assessment and Incomplete Participation Documentation
Penalty
Summary
The facility failed to complete an activities assessment timely for Resident #8 to ensure participation in group activities and/or preferred activities. Resident #8 was admitted with diagnoses including collapsed vertebra of the thoracic region, diabetes mellitus, concussion, depression, morbid obesity, and asthma. The 5-Day MDS dated 08/25/25 showed intact cognition and need for staff assistance with ADLs. The care plan dated 08/25/25 identified a potential alteration in activities and included interventions to allow the resident to express opinions of activities of choice and to interview the resident quarterly and as needed for activities of choice. During interview, Resident #8 stated she had not attended any activities since her most recent admission and that she was bored and would like to go to an activity. The Activities Director confirmed the resident's EMR did not contain an activities assessment and stated she had spoken with the resident and knew her likes and dislikes, but had not yet completed the assessment after the recent admission. The Activities Director also stated the resident always attended activities, while the written Activities Individual Participation Record showed the resident's activities were primarily individual activities and not group activities. The facility policy titled Activities Documentation stated the AD is responsible for maintaining departmental documentation, including the activity assessment, attendance records, and activity progress notes.
Pharmacy GDR Recommendations Not Addressed
Penalty
Summary
The facility failed to ensure that pharmacy medication regimen review recommendations were addressed for three residents reviewed for gradual dose reduction (GDR) monitoring. The facility policy stated that pharmacists’ recommendations would be addressed timely by the physician and that medication regimen review reports, including physician responses, would be maintained in the permanent medical record. However, the record showed multiple pharmacy recommendations for GDRs or medication evaluation that were not clearly addressed in the chart or in psychiatric service documentation. For one resident with diagnoses including heart attack, dementia with moderate agitation, protein malnutrition, repeated falls, high blood pressure, abdominal cancer, heart failure, and anxiety, a pharmacist recommended a GDR for trazodone used for sleep. The primary care provider documented that psychiatric services should provide GDR recommendations, but the psychiatric nurse practitioner stated she did not receive GDR requisitions, did not review pharmacy recommendations, and used a standard note template that included a GDR contraindication section. The resident’s trazodone was later increased rather than reduced. For another resident with diagnoses including suicidal ideation, schizoaffective disorder bipolar type, depression, PTSD, anxiety, insomnia, cerebral infarction, dementia, and brief psychotic disorder, pharmacy reviews repeatedly identified no GDR attempt for divalproex, topiramate, aripiprazole, and venlafaxine, with responses such as “see ViaQuest notes” or “followed by psychiatric services,” but without clear agreement, disagreement, or documentation that the recommendations were reviewed. Psychiatric notes did not show that the pharmacy recommendations were addressed, and the DON confirmed there was no documentation to support the psychiatric provider’s review of GDRs. For a third resident with depression, anxiety, type II diabetes, COPD, respiratory failure, malnutrition, and cerebral infarction/stroke, the pharmacy noted an elevated PHQ score and recommended evaluation for worsening depression, but the response was deferred to psychiatric services and there was no documentation that the recommendation was addressed.
Improper Storage of Self-Administered Medications
Penalty
Summary
Drugs and biologicals were not stored in accordance with accepted professional principles for a resident who was assessed as able to self-administer medications. Resident #16 was admitted with diagnoses including alopecia, cognitive communication deficit, unsteadiness on feet, hyperlipidemia, generalized anxiety disorder, essential hypertension, glaucoma, and cataracts. The resident’s MDS showed a BIMS of 14, and a Self-Administration Skills Assessment dated 04/16/2025 indicated she could correctly administer and secure her medications safely and did not have topicals, patches, inhalers, injections, or other similar medications. During observation, an LPN prepared the resident’s lunch-time pills, placed them in a medication cup, and put the cup in the resident’s nightstand drawer after the resident said she would take them with lunch. The resident later stated she took medications left in a white medication cup after each meal and could not identify the pills, and she reported the drawer was never locked. A later observation found the cabinet beside the recliner unlocked with a white cup containing seven pills, a bottle of eye drops, and several pill bottles holding cough drops. The nurse manager confirmed the drawer had a lock but was not locked throughout the day while the medications were in it, allowing unauthorized access.
Inaccurate Vaccine Consent Documentation
Penalty
Summary
The facility failed to accurately document influenza, pneumococcal, and COVID-19 vaccination consents for three residents reviewed for vaccinations. For one resident admitted with diagnoses including metabolic encephalopathy, pneumonia, chronic respiratory failure, high blood pressure, major depression and anxiety, spinal cord injury, and chronic lung disease, the record contained two influenza/pneumococcal consent forms with conflicting responses about prior vaccination history. One consent dated 04/23/25 showed the resident had not received the vaccines prior and had no prior pneumococcal dates entered, while a later consent dated 09/02/25 showed the resident had received Pneumovac on 04/09/25 and Prevnar 20 on 05/21/25. For two other residents, the vaccination consent documentation was incomplete. One resident admitted with diagnoses including bilateral primary osteoarthritis of the knee, left knee joint replacement, post-traumatic osteoarthritis of the left shoulder, pulmonary embolism, aortic aneurysm, depression, benign neoplasm of the brain, anxiety disorder, and aftercare following joint replacement surgery had a consent form with no answer marked to whether the pneumococcal vaccine had been received prior. Another resident admitted with diagnoses including osteoarthritis of the knee and hip, muscle weakness, repeated falls, chronic pain, anemia, depression, age-related physical debility, atherosclerotic heart disease with angina pectoris, carotid artery occlusion and stenosis, hypercholesterolemia, malaise and fatigue had a consent form showing VIS dates entered for pneumococcal and influenza vaccines. During interview, the ADON verified the documentation discrepancies, including duplicate pneumococcal/influenza consent copies for the first 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 Salem
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Crandall Nursing Home | 3.7 mi | ★★★★★ | 6 | 0 |
| Blossom Nursing And Rehab Center | 5 mi | ★★★★★ | 8 | 0 |
| Circle Of Care | 6.2 mi | ★★★★★ | 0 | 0 |
| Salem North Healthcare Center | 6.6 mi | ★★★★★ | 7 | 0 |
| Salem West Healthcare Center | 6.6 mi | ★★★★★ | 10 | 0 |
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