Deficiency Records for North Auburn Rehab and Health Center
Updated as of March 01, 2024
A list of the most recent deficiencies for North Auburn Rehab and Health Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident?s advance directives. | Health | 2023-12-14 | 2023-12-07 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-08-30 | 2023-09-25 | Y |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2023-07-14 | 2023-08-02 | Y |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2023-07-14 | 2023-08-02 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-07-14 | 2023-08-02 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-05-26 | 2023-06-27 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-01-10 | 2023-01-26 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-12-12 | 2023-01-25 | N |
| Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made. | Health | 2022-12-12 | 2023-01-25 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2022-12-12 | 2023-01-25 | N |
| Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. | Health | 2022-12-12 | 2023-01-25 | N |
| Assure the security of all personal funds of residents deposited with the facility. | Health | 2022-12-12 | 2023-01-25 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2022-12-12 | 2023-01-25 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2022-12-12 | 2023-01-25 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2022-12-12 | 2023-01-25 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2022-12-12 | 2023-01-25 | N |
| Assess the resident when there is a significant change in condition | Health | 2022-12-12 | 2023-01-25 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-12-12 | 2023-01-25 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2022-12-12 | 2023-01-25 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2022-12-12 | 2023-01-25 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-12-12 | 2023-01-25 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-12-12 | 2023-01-25 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-12-12 | 2023-01-25 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-12-12 | 2023-01-25 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-12-12 | 2023-01-25 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-12-12 | 2023-01-25 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2022-12-12 | 2023-01-25 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2022-12-12 | 2023-01-25 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-12-12 | 2023-01-25 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2022-12-12 | 2023-01-25 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-12-12 | 2023-01-25 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2022-12-12 | 2023-01-25 | N |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2022-12-12 | 2023-01-25 | N |
| Provide or obtain dental services for each resident. | Health | 2022-12-12 | 2023-01-25 | N |
| Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. | Health | 2022-12-12 | 2023-01-25 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2022-12-12 | 2023-01-25 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-12-12 | 2023-01-25 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2022-12-12 | 2023-01-25 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2022-12-12 | 2023-01-25 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-12-12 | 2023-01-25 | N |
| Implement a program that monitors antibiotic use. | Health | 2022-12-12 | 2023-01-25 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-12-12 | 2023-01-25 | N |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2022-12-12 | 2023-01-25 | N |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2022-12-12 | 2023-01-25 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-12-12 | 2023-01-25 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-12-12 | 2023-01-25 | Y |
| Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care. | Health | 2022-12-12 | 2023-01-25 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2022-12-01 | 2023-01-05 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2022-12-01 | 2023-01-05 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2022-12-01 | 2023-01-05 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2022-12-01 | 2023-01-05 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2022-12-01 | 2023-01-05 | N |
| Establish policies and procedures including evacuation. | Fire Safety | 2022-12-01 | 2023-01-05 | N |
| Develop a communication plan. | Fire Safety | 2022-12-01 | 2023-01-05 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2022-12-01 | 2023-01-05 | N |
| Establish methods for sharing information. | Fire Safety | 2022-12-01 | 2023-01-05 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2022-12-01 | 2023-01-05 | N |
| Establish staff and initial training requirements. | Fire Safety | 2022-12-01 | 2023-01-05 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2022-12-01 | 2023-01-05 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2022-12-01 | 2023-01-05 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2022-12-01 | 2023-01-05 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-12-01 | 2023-01-05 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2022-12-01 | 2023-01-05 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2022-12-01 | 2022-12-22 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-12-01 | 2022-12-22 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2022-12-01 | 2022-12-22 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-12-01 | 2022-12-22 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2022-12-01 | 2022-12-22 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-12-01 | 2022-12-22 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-12-01 | 2022-12-22 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-12-01 | 2022-12-22 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-12-01 | 2022-12-22 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-12-01 | 2022-12-22 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2022-09-01 | 2022-09-28 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-09-01 | 2022-09-28 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-09-01 | 2022-09-28 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-06-30 | 2022-07-19 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-04-11 | 2022-04-25 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-04-06 | 2022-04-15 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-03-23 | 2022-04-04 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-03-23 | 2022-04-04 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-03-23 | 2022-04-04 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-03-23 | 2022-04-04 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-03-23 | 2022-04-04 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-12-07 | 2022-01-07 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-04-12 | 2021-05-13 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2021-04-12 | 2021-05-13 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-03-23 | 2021-05-13 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-03-23 | 2021-05-13 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-03-23 | 2021-05-13 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-03-23 | 2021-05-13 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2021-03-23 | 2021-05-13 | Y |
| Provide or get specialized rehabilitative services as required for a resident. | Health | 2021-03-23 | 2021-05-13 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2020-01-16 | 2020-02-26 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2020-01-16 | 2020-02-26 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2020-01-16 | 2020-02-26 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2020-01-16 | 2020-02-26 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2020-01-16 | 2020-02-26 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2020-01-16 | 2020-02-26 | N |
| Ensure each resident receives an accurate assessment. | Health | 2020-01-16 | 2020-02-26 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2020-01-16 | 2020-02-26 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2020-01-16 | 2020-02-26 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2020-01-16 | 2020-02-26 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2020-01-16 | 2020-02-26 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2020-01-16 | 2020-02-26 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2020-01-16 | 2020-02-26 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2020-01-16 | 2020-02-26 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2020-01-16 | 2020-02-26 | N |
| Provide appropriate foot care. | Health | 2020-01-16 | 2020-02-26 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2020-01-16 | 2020-02-26 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2020-01-16 | 2020-02-26 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2020-01-16 | 2020-02-26 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2020-01-16 | 2020-02-26 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2020-01-16 | 2020-02-26 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2020-01-16 | 2020-02-26 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2020-01-16 | 2020-02-26 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2020-01-16 | 2020-02-26 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2020-01-16 | 2020-02-26 | N |
| Ensure that residents are free from significant medication errors. | Health | 2020-01-16 | 2020-02-26 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2020-01-16 | 2020-02-26 | N |
| Keep complete, dated laboratory records in the resident's record. | Health | 2020-01-16 | 2020-02-26 | N |
| Provide or obtain x-rays/tests when ordered and promptly tell the ordering practitioner of the results. | Health | 2020-01-16 | 2020-02-26 | N |
| Provide or obtain dental services for each resident. | Health | 2020-01-16 | 2020-02-26 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-01-16 | 2020-02-26 | N |
| Dispose of garbage and refuse properly. | Health | 2020-01-16 | 2020-02-26 | N |
| Hire a qualified full-time social worker in a facility with more than 120 beds. | Health | 2020-01-16 | 2020-02-26 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-01-16 | 2020-02-26 | N |
| Implement a program that monitors antibiotic use. | Health | 2020-01-16 | 2020-02-26 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2020-01-06 | 2020-02-25 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2020-01-06 | 2020-02-03 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2020-01-06 | 2020-02-03 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2020-01-06 | 2020-02-03 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2020-01-06 | 2020-02-03 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2020-01-06 | 2020-02-03 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2020-01-06 | 2020-02-03 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2020-01-06 | 2020-02-03 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2018-10-12 | 2018-11-26 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2018-10-12 | 2018-11-26 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2018-10-12 | 2018-11-26 | N |
| Ensure each resident receives an accurate assessment. | Health | 2018-10-12 | 2018-11-26 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2018-10-12 | 2018-11-26 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2018-10-12 | 2018-11-26 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-10-12 | 2018-11-26 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2018-10-12 | 2018-11-26 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2018-10-12 | 2018-11-26 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2018-10-12 | 2018-11-26 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-10-12 | 2018-11-26 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2018-10-12 | 2018-11-26 | N |
| Provide appropriate foot care. | Health | 2018-10-12 | 2018-11-26 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2018-10-12 | 2018-11-26 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2018-10-12 | 2018-11-26 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2018-10-12 | 2018-11-26 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2018-10-12 | 2018-11-26 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2018-10-12 | 2018-11-26 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2018-10-12 | 2018-11-26 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2018-10-12 | 2018-11-26 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2018-10-12 | 2018-11-26 | N |
| Provide or obtain dental services for each resident. | Health | 2018-10-12 | 2018-11-26 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2018-10-12 | 2018-11-26 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2018-10-12 | 2018-11-26 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2018-10-12 | 2018-11-26 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-10-12 | 2018-11-26 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2018-10-12 | 2018-11-26 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-10-12 | 2018-11-26 | N |
| Implement a program that monitors antibiotic use. | Health | 2018-10-12 | 2018-11-26 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2018-10-12 | 2018-11-26 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2018-10-09 | 2018-11-08 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2018-10-09 | 2018-11-08 | N |
| Implement emergency and standby power systems. | Fire Safety | 2018-10-09 | 2018-11-08 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2018-10-09 | 2018-11-01 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2018-10-09 | 2018-11-01 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2018-10-09 | 2018-11-01 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-10-09 | 2018-11-01 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2018-10-09 | 2018-11-01 | N |
