Auburn Oaks Care Center

In the surveyor’s words

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

• Actual harm, isolatedF689Feb 26, 2025

  Based on observation, interview and record review, the facility failed to provide safe supervision and assistance to prevent accidents for one of three sampled residents (Resident 1) when Resident 1 fell on the ground while being transferred from bed to shower chair by 2 Certified Nursing Assistants (CNA 1 and CNA 2) who failed to follow the proper maneuvering and operation of a Hoyer lift (a mechanical device used to lift and/or transfer a person from one surface to another) during the transfer and when CNA 2 was behind the shower chair away from the Hoyer lift. This failure resulted in Resident 1 sustaining a right ankle sprain (a soft tissue injury that occurs when ligaments are stretched or torn), back pain, and developed fear of being moved out of bed using a lift. […]

• No harm, potential for more than minimal, widespreadF730Oct 3, 2024

  Based on interview and record review, the facility failed to complete annual performance evaluations (PEs) for three of five sampled certified nursing assistants (CNAs; CNA 3, CNA 4, and CNA 5), for a census of 95. This failure increased the risk of residents receiving poor-quality care from the CNAs. Findings: During a concurrent interview and record review on 10/2/24 at 2:48 p.m. with the Director of Staffing Development (DSD) and the Consultant of Director of Staffing Development/Infection preventionist (CDSD/IP), the DSD and CDSD/IP reviewed CNA 3, CNA 4, and CNA 5's employee's files and found the following: CNA 3 was hired on 7/30/19, CNA 4 was hired on 12/26/20, and CNA 5 was hired on 8/31/09. All the CNAs files reviewed had no documented evidence the annual PEs were done. […]

• No harm, potential for more than minimal, patternF658Jan 8, 2026

  Based on observation, interview, and record review, the facility failed to follow physician orders for two of 24 sampled residents (Resident 41 and Resident 31), when:1. Resident 41's administered oxygen amount did not match the physician's order, and 2. Resident 31 received tramadol (an opioid analgesic for pain) on 12/6/25, 12/7/25, 12/27/25, and 12/28/25 without having scheduled physical therapy (PT) sessions as per physician order.These failures decreased the facility's potential to follow the residents' physician orders as prescribed.Findings: 1. […]

• No harm, potential for more than minimal, patternF812Jan 8, 2026

  Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for a census of 93 residents, when:1. Resident bowls and food containers were found stacked upright in the drying area;2. Unsealed bags of food were found in the refrigerator and freezer; and3. Unlabeled food items were found in the refrigerator.These failures decreased the facility's potential to prevent foodborne illness among vulnerable residents eating facility prepared food.Findings:1. During a concurrent observation and interview on 1/5/26 at 8:20 a.m. […]

• No harm, potential for more than minimal, patternF658Oct 3, 2024

  Based on observation, interview, and record review, the facility failed to ensure care and services in accordance with acceptable professional standards of quality were provided for four of 25 sampled residents (Resident 143, Resident 144, Resident 36, and Resident 85), when: 1. Medication and ointments were left at the nightstand of Resident 143; 2. Medication, hazardous liquids and ointments were left at the bedside of Resident 144; 3. A medication was not administered completely and left at the bedside, and oxygen tank was empty while in use for Resident 36; and 4. The oxygen (O2) saturation levels were not monitored for Resident 85. These failures had the potential risks to negatively affect the residents' health status. Findings: 1. […]