Auburn Ravine Healthcare Center

In the surveyor’s words

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

• No harm, potential for more than minimal, widespreadF755Aug 5, 2026

  Based on interview and record review, the facility failed to develop and implement policies and procedures for the safe and effective use of insulin (used to control blood glucose levels) when:Seven of seven residents (Residents 3, 38, 37, 29, 51, 9, and 32) receiving prandial insulin (mealtime insulin) had blood glucose results monitored using FSBS (finger stick test to check blood glucose) obtained up to 1.5 hours before meals instead of current mealtime readings.Four of four residents (Residents 3, 38, 37, and 29) receiving insulin had insulin doses administered up to 1.5 hours before scheduled meals, not in accordance with physician orders or manufacturer guidelines, and outdated FSBS values were used to determine sliding scale insulin doses (correctional insulin based on the current… […]

• No harm, potential for more than minimal, widespreadF656Jul 19, 2024

  Based on observations, interviews and record reviews the facility failed to develop and implement person-centered comprehensive care plans for four (4) residents (Resident 2, Resident 36, Resident 10, and Resident 56,) of 15 sampled residents when: 1. Resident 2 and Resident 36 did not have a care plan for the use of psychotropic (medication that affects the brain associated with mental processes and behavior) medications; 2. Resident 10 did not have a care plan for the use of a Wander/Elopement Alarm (WEA, a wearable device that alerts when the wearer wanders or elopes out of the building); 3. […]

• No harm, potential for more than minimal, widespreadF658Jul 19, 2024

  Based on observations, interviews, and record review the facility failed to provide care and services in accordance with acceptable professional standards of quality for seven residents (Residents 2, 36, 19, 10, 34, 56, and 110) out of 15 sampled residents when: 1. Psychotropic medications (medication that affects the brain associated with mental processes and behavior) were prescribed for Resident 2 and 36 without appropriate indications, manifestations or monitoring of behaviors. 2. Resident 19, 14 and 110 nasal cannulas (a plastic tube that delivers extra oxygen into your nose) and humidifiers (devices used to humidify supplemental oxygen) were not labeled or dated, and oxygen was not provided per the physician order. 3. […]

• No harm, potential for more than minimal, widespreadF801Jul 19, 2024

  Based on observation, interview and record review, the facility failed to ensure the Dietary Supervisor (DS) met the state's education qualification requirements, as required per federal regulation, to be the DS to carry out the functions of the food and nutrition services. In addition, the facility failed to ensure the Registered Dietitian (RD) provided frequently scheduled consultations with the DS to include overseeing food safety and sanitation, food preparation, meal service and food storage. […]

• No harm, potential for more than minimal, widespreadF812Jul 19, 2024

  Based on observation, interview, and record review, the facility failed to store, prepare, and distribute food in accordance with professional standards for food service safety when: 1) Cool down process was not performed for meat leftovers (any food that was prepared for service but was not served), 2) Procedure for cooling down method for ambient (room temperature) food was not being followed, 3) Metal serving pans had brown and white substances on the inside surface; serving pans were found stacked wet, 4) Expired bread had not been discarded, 5) Microwave had food debris on upper interior surface, 6) Several cutting boards had gouges, black smudges, and rancid odor, 7) Employees' beverage containers were stored in residents' food and drink preparation area, and 8) Ice machines in… […]