Auburn Post Acute

In the surveyor’s words

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

• Immediate jeopardy, widespreadF880Jun 22, 2021

  Based on observation, interview and record review, the facility failed to operationalize all components of the infection prevention and control program, ensure residents were protected from COVID-19 (Coronavirus - a contagious disease). The facility did not have a system in place to ensure staff followed Infection Control (IC) practices to prevent exposure to or the spread of COVID-19, to include: (1) The facility failed to provide N95 mask fit testing and ensure the mask's proper use for 9 (A, B, D, E, F, G, H, I and J) of 10 staff who worked in the Isolation Unit and the COVID-19 Unit. (2) The facility failed to provide training to staff for the appropriate use of N95 respirators. […]

• Immediate jeopardy, patternF610Feb 26, 2026

  Based on observation, interview and record review the facility failed to ensure resident to resident altercations including alleged sexual, physical, and verbal abuse incidents the facility was aware of or witnessed was investigated, logged, and reported for 8 of 10 residents (Resident 9, 11, 16, 17, 6, 7, 4, 5) reviewed for abuse. The failure to investigate these incidents deterred the facility from preventing re-occurrence and taking appropriate corrective actions resulting in repeated abuse that placed all residents at risk for unidentified abuse and/or continued abuse, psychological harm, and diminished quality of life, and constituted an Immediate Jeopardy (IJ). […]

• Immediate jeopardy, patternF689Feb 26, 2026

  Based on observation, interview, and record review the facility failed to timely and accurately assess resident's ability to smoke safely; implement a resident specific care plan for smoking; secure smoking supplies; ensure a safe designated smoking area; and implement, and enforce the facility smoking policy for 7 of 9 residents (Residents 13, 8, 12, 14, 15, 18, & 19) reviewed for smoking. In addition, the facility failed to re-assess Resident 16's ability to smoke independently after a cigarette burn, and failed to provide supervision to 1 of 3 residents (Resident 8) who was assessed to require supervision outside of the facility, used a Wander Guard device (a device that sets off an alarm to notify staff if the resident is close to the exit door) and eloped from the facility five times. […]

• Immediate jeopardy, patternF689May 2, 2024

  Based on observation, interview, and record review the facility failed to provide consistent supervision and ensure a safe environment that was free from dangerous accident hazards for 6 of 14 residents (Resident 1, 4, 8, 3, 9 & 5) reviewed for smoking. The failure to: timely and accurately assess resident's ability to safely smoke; secure smoking paraphernalia; implement, and enforce the facility smoking policy when Resident 1 was found smoking in the facility and a common area repeatedly, including near a resident who required and was wearing oxygen, placed all residents at risk for serious adverse outcomes with the potential for fire and an explosion and/or serious bodily injury, and constituted an Immediate Jeopardy (IJ). […]

• Actual harm, patternF686Sep 28, 2023

  Based on observation, interview, and record review the facility failed to ensure residents received wound care consistent with professional standards of practice that prevented skin breakdown and the development and/or worsening of Pressure Ulcers (PUs) for 5 of 6 (Residents 55, 65, 32, 53 & 24) residents reviewed for treatment and services for PUs. Three residents (Residents 55, 65, & 32) experienced harm when the facility failed to identify, consistently assess, monitor changes in skin condition, and implement preventative measures and interventions timely, follow Physician Orders (PO) for treatment, and complete weekly documentation of PU progress to promote healing and prevent new or avoidable PUs from developing or existing PU from worsening. […]