Auburn Manor

In the surveyor’s words

From the most serious findings on record at Auburn Manor, in the surveyor’s own words.

• Actual harm, isolatedF760Apr 2, 2025

  Based on interview and document review, the facility failed to ensure 1 of 3 residents (R1) physician orders were followed for parameters set by the physician. This resulted in actual harm for R1 who became unresponsive and required emergency transport and hospitalization after receiving insulin that should have been held. Findings include: R1's quarterly Minimum Data Set (MDS), dated [DATE], indicated R1 had diagnoses of diabetes mellitus, dementia, and mild cognitive impairment. R1's care plan, dated 9/13/24, directed administer insulin as ordered, monitor for side effects/effectiveness of medication and update provider as needed. […]

• Actual harm, isolatedF689May 17, 2023

  Based on observation, interview, and record review the facility failed to assess interventions to provide safe mechanical lift transfers resulting in fracture of distal radius and failed to follow the revised care plan to prevent impaired healing and further injury for 1 of 4 residents (R1) reviewed for accidents. Findings include: R1's care plan dated 1/26/23 indicated R1 required the assistance of one staff member with transfers, gait belt and railings. Mechanical standing lift with assistance of one staff member as needed (PRN). The care plan did not indicate any interventions for staff to monitor R1's left arm, R1's week side following CVA), with the use of the EZ-stand R1's significant change Minimum Data Set (MDS) dated [DATE] indicated R1 had moderate cognitive impairment. […]

• No harm, potential for more than minimal, widespreadF576Apr 30, 2026

  Based on interview and document review, the facility failed to ensure resident mail was delivered to residents on Saturdays for 4 of 4 residents (R33, R34, R14, R24) who voiced concerns with mail delivery during Resident Council. This had the potential to affect all residents residing in the facility.On 4/30/26 at 9:33 a.m., a Resident Council meeting was held with four residents from varied areas of the facility. R24 stated mail was not delivered to residents on Saturdays. This was confirmed by R33, R34 and R14. R24 indicated mail delivered by the post office on Saturdays would be left on the receptionist's desk near the front entrance. […]

• No harm, potential for more than minimal, widespreadF812Apr 30, 2026

  Based on observation, interview, and document review, the facility failed to store and label food properly, dispose of undated and expired food items to reduce the risk of foodborne illness. This had the potential to affect all the residents who were provided meals from the kitchen. Findings include:During initial tour and interview of kitchen on 4/27/26 at 1:03 p.m., with Dietary Director (DD) the following was observed inside the walk-in cooler: an opened box of undated chicken stock an opened box of undated turkey stock an approximately 4x4x8 inch metal dish containing sliced carrots lacked an open or use by date,an approximately 4x4x8 inch metal dish with contents identified by DD as pizza sauce lacked an open or used by date.DD stated he was unsure of what the food storage policy… […]

• No harm, potential for more than minimal, widespreadF725Feb 6, 2025

  Based on observation, interview, and document review, the facility failed to ensure sufficient nursing staff and leadership to meet assessed resident needs and facility processes for 2 of 2 residents (R5, R37) reviewed for pressure ulcer prevention, for R7, R42 reviewed for activities of daily living who were dependent on staff for their care, for R1 who was left exposed and nude on the toilet, and R18 who utilized an indwelling catheter reviewed for dignity. In addition, the facility failed to reassess and implement proactive interventions to reduce the risk of falls and injuries for R26 and R44 who sustained falls at the facility. Additionally, the facility failed to address ongoing staffing and long call light concerns identified during resident council meeting minutes. […]