North Auburn Care

In the surveyor’s words

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

• Immediate jeopardy, widespreadF835Dec 12, 2022

  Based on observation, interview, and record review the facility administration failed to act swiftly and effectively to ensure the Emergency Exit (EE) doors were operable and in compliance with federal regulatory requirements. The failure to prioritize the life safety component of repairing the EE doors when found locked and inaccessible in emergent situations placed residents' health and safety at risk for serious harm including death and resulted in Immediate Jeopardy (IJ) on 12/01/2021. Administration failed to ensure supplies, including linens, wound care supplies, and over-the-counter medications were available to staff to provide care in a clean and comfortable manner and according to physician orders. […]

• Immediate jeopardy, patternF678Dec 14, 2023

  Based on observation, interview, and record review the facility failed to ensure staff performed Cardio-Pulmonary Resuscitation (CPR) to 1 of 1 resident (Resident 1) who was found unresponsive and had a physician order to initiate CPR and signed POLST (Physician Order for Life Sustaining Treatment- a form indicating the resident's wishes to have or not have CPR) for life-sustaining care and services. The failure to train staff on the facility's expectation how to respond to a resident requiring CPR, locate, for immediate reference, resident POLST/Advanced Directives, and accurately assess signs of irreversible death, resulted in staff not following Resident 1's CPR directives, and placed 38 of 69 other current residents (Resident 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18,… […]

• Immediate jeopardy, patternF803Dec 12, 2022

  Based on observation, interview, and record review the facility failed to ensure food was prepared according to the required menu for modified food textures and thickened liquid consistencies and as ordered by the physician for 3 of 3 (Residents 42, 40, & 66) residents. This failure placed 27 total residents assessed to require altered food textures and/or thickened liquid consistencies, for safe swallowing, at risk for choking while eating, aspiration (inhalation of food/fluids into the lungs), pneumonia, and/or death. CFR 483.60 (c)(3)(5)(6) F-803 Menus meet Resident Needs/Prep in Advance/Followed. On 12/08/2022 at 5:31 PM, an Immediate Jeopardy was identified, and the Administrator was informed. On 12/09/2022 the immediacy was removed. […]

• Actual harm, isolatedF687Jul 16, 2026

  Based on observation, interview, and record review, the facility failed to implement preventive measures to protect residents' feet from injury, monitor the feet of high-risk residents, identify changes in skin integrity, report changes in wounds, seek treatment from the physician, ensure foot care treatments were completed consistently and according to physician orders, and arrange timely appointments with a podiatrist or wound care specialist for 2 of 3 Residents (Resident 1 and 2) reviewed for foot care. […]

• Actual harm, isolatedF561Jul 14, 2023

  Based on observation, interview, and record review the facility failed to ensure each resident had the opportunity to exercise their autonomy and Resident Rights regarding activities and preferences important to them. The failure to provide a safe designated smoking area on the campus that maintained quality of life for 3 of 3 residents (Residents 1, 2, & 3) who were not notified of the smoking policy on admission was a violation of their Resident Rights and placed them at risk for unnecessary frustration, feelings of discrimination, and diminished quality of life. […]