Auburn Nursing and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Auburn Nursing and Rehabilitation Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF656Mar 7, 2026

  Based on interview, record review, and review of the facility's policy, the facility failed to implement the care plan related to advance directives for one (Resident (R) 1) of 19 sampled residents reviewed for care plans. R1's care plan identified the resident as a Full Code (indicating that Cardiopulmonary Resuscitation (CPR) should be performed if the resident was found without vital signs.); however, staff failed to implement the care plan, and no lifesaving measures were attempted.On [DATE], at 3:10 PM the Administrator was provided a copy of the CMS Immediate Jeopardy (IJ) Template and was notified that the failure to implement the resident's care plan by performing CPR in accordance was likely to cause serious injury, impairment, or death. […]

• Immediate jeopardy, isolatedF678Mar 7, 2026

  Based on interview, record review and review of the facility's policy, the facility failed to ensure Cardiopulmonary Resuscitation (CPR) was initiated for one (Resident (R) 1) of 19 sampled residents reviewed for Advance Directives. Staff found R1 unresponsive on 11/09/2025 without pulse or respiration. R1 was a Full Code status (indicating that CPR should be performed if the resident was found without vital signs); however, no lifesaving measures were attempted. On 03/04/2026 at 3:10 PM, the Administrator was provided a copy of the CMS Immediate Jeopardy (IJ) Template and was notified the failure to ensure residents were provided CPR was likely to cause serious injury, impairment, or death. […]

• No harm, potential for more than minimal, widespreadF645Sep 12, 2025

  Based on interview, record review, and facility policy review it was determined the facility failed to accurately complete the Preadmission Screening process for individuals with a mental disorder and/or individuals with intellectual disabilities for nine (Resident (R)3, R8, R9, R12, R15, R17, R25, R33, and R42) of nine sampled residents reviewed for Preadmission Screening and Resident Review (PASARR). The systemic failure to ensure the PASARR process is completed as required has the potential to affect all residents who must be screened using this process upon admission. […]

• No harm, potential for more than minimal, widespreadF842Sep 12, 2025

  Based on interview, record review, and review of the facility's policy's, it was determined the facility failed to ensure medical records were complete, accurate, and maintained for 8 of 25 sampled residents (R3, R4, R9, R12, R15, R17, R25, R58).The findings include: Review of an undated Medical Records policy revealed appropriate medical/clinical records should be maintained for each resident. Review of an undated facility policy, titled, Charting and Documentation, revealed All services provided to the resident, or any changes in the resident's medical or mental condition, should be documented in the resident's medical record. Per the policy, interpretation and implementation included that All observations, medications administered, services performed, etc. […]

• No harm, potential for more than minimal, widespreadF865Sep 12, 2025

  Based on interview, record review, and facility policy review, it was determined the facility failed to develop, implement, and maintain an effective, comprehensive, data-driven Quality Assurance and Performance Improvement (QAPI) program that focused on indicators of the outcomes of care and quality of life. The QAPI program failed to identify concerns regarding the Preadmission Screening and Resident Review (PASARR) process, affecting nine (Resident (R)3, R8, R9, R12, R15, R17, R25, R33, and R42) of nine sampled residents reviewed for this mandatory screening. […]