Inspection Reports for
Auburn Village

This citation is related to complaint intake 2624266.3.1-3(a). The complaint involved a resident experiencing respiratory distress and staff failing to respond appropriately, including a nurse's dismissive attitude.

The facility failed to ensure respectful and dignified communication and care for 1 of 3 residents reviewed. Specifically, a nurse disregarded concerns about a resident's respiratory distress and made dismissive comments, causing distress to the resident.

The investigation was complaint-related, focusing on Resident 7's lack of range of motion care. The complaint was substantiated based on observations, interviews, and record reviews.

The facility failed to ensure that Resident 7 received range of motion exercises as required by their care plan. Documentation and interviews revealed that range of motion exercises were not performed or recorded due to the absence of an official restorative program and policy.

The facility was found deficient in respecting resident dining choices, providing appropriate range of motion care, implementing non-medication pain interventions, maintaining kitchen cleanliness, and ensuring massage therapy services were provided as requested by a resident.

The facility was found in compliance with Emergency Preparedness Requirements but was not in compliance with Life Safety Code requirements. Deficiencies included failure to maintain sprinkler system inspections, corridor doors propped open preventing smoke resistance, staff smoking in non-designated areas, and improper use of extension cords as substitutes for fixed wiring.

Complaint IN00437399 was substantiated with a deficiency related to infection prevention and control (F880). Complaints IN00436510 and IN00436296 had no deficiencies related to the allegations.

The facility was cited for deficiencies related to mental/psychosocial treatment of a trauma survivor resident and infection prevention and control, specifically failure to follow public health recommendations during a Legionella outbreak investigation. Complaint IN00437399 was substantiated with a severity level E deficiency (F880). No deficiencies were found related to the other complaints.

This tag relates to Complaint IN00437399. The complaint alleged Legionella bacteria presence in water samples and failure to follow prevention recommendations.

The facility failed to ensure proper education and adherence to public health recommendations during a Legionella outbreak investigation. Water samples tested positive for Legionella bacteria, and the facility did not fully implement recommended water precautions, including installation of point-of-use filters and resident notification.

The facility failed to adequately identify, assess, and determine the underlying causes of distress in a trauma survivor resident. Resident 3 exhibited multiple behavioral issues related to trauma and mental health diagnoses, but the care plan lacked specific interventions addressing obsessive compulsive disorder, depression, and trauma-related stressors.

This deficiency relates to Complaint IN00425572.

The facility failed to conduct a thorough investigation of injuries of unknown origin for Resident B. Multiple bruises in various stages of healing were observed, but the facility's investigation lacked documentation of cause, staff statements, and review of video footage.

Complaint IN00425572 was substantiated with federal/state deficiencies cited at F610. The investigation revealed multiple bruises on Resident B with no thorough investigation or documentation of cause, and failure to review video footage mentioned in the police report. The facility ruled out abuse and implemented corrective actions.

The facility failed to conduct a thorough investigation of injuries of unknown origin for one resident (Resident B). Multiple bruises in various stages of healing were observed on Resident B, and the investigation lacked documentation regarding the cause, characteristics, and potential involvement of other residents. The facility implemented corrective actions including reeducation of staff on abuse policies and investigation procedures, and monitoring through random skin observations.

Complaint IN00419195 was substantiated with federal/state deficiencies cited at F561 related to resident self-determination and choice of bedtime.

The facility failed to ensure a resident's choice of bedtime for 1 of 3 residents reviewed (Resident P). The resident was put to bed against her wishes after wandering, contrary to her care plan and rights.

This citation relates to Complaint IN00419195.

The facility failed to ensure that Resident P's preference for bedtime was respected, as staff placed the resident in bed against her wishes due to wandering behavior. Interviews and record reviews confirmed the resident's severely impaired cognition and the facility's care plan to honor resident choice was not followed.

The facility was found not in compliance with multiple Life Safety Code requirements including emergency preparedness policies, egress door locking, hazardous area enclosures, fire alarm system maintenance, sprinkler system maintenance, electrical safety, fire drills, and gas equipment storage.

The facility was found deficient in food safety requirements, specifically failing to ensure proper hand hygiene procedures during meal service in one of three observations. Dietary staff were observed not following proper glove use and hand hygiene protocols.

The facility failed to ensure proper hand hygiene during meal service in one of three observations. Dietary Aide 3 was observed touching multiple surfaces and food items with gloved hands without performing hand hygiene or changing gloves.

Complaint IN00400506 was substantiated with federal/state deficiencies cited at F812 related to food safety violations.

The facility failed to ensure food was stored, distributed, and served according to safety standards, including issues with dishwasher sanitation, improper food storage temperatures, uncovered and undated food items, and improper use of hair restraints by dietary staff.

The facility was found not in compliance with Life Safety Code requirements, including failure to test battery backup emergency lights annually, corridor doors not resisting smoke passage, missing inspection certificates for fuel-fired water heaters, and improper use of power strips for high current draw equipment.

The facility was found deficient in multiple areas including timely completion of quarterly Minimum Data Set (MDS) assessments, quarterly care plan meetings, provision of necessary ADL care, quality of care related to PICC line management, staple removal, hospice care planning, urinary output documentation for catheterized residents, monitoring of side effects for certain medications, proper garbage disposal, and maintenance of a comfortable environment.