A list of the most recent deficiencies for Auburn Post Acute. 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? |
|---|---|---|---|---|
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-11-08 | 2023-12-01 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-09-28 | 2023-11-16 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2023-09-28 | 2023-11-16 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2023-09-28 | 2023-11-16 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2023-09-28 | 2023-11-16 | 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 | 2023-09-28 | 2023-11-16 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-09-28 | 2023-11-16 | N |
| Respond appropriately to all alleged violations. | Health | 2023-09-28 | 2023-11-16 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-09-28 | 2023-11-16 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2023-09-28 | 2023-11-16 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2023-09-28 | 2023-11-16 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2023-09-28 | 2023-11-16 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-09-28 | 2023-11-16 | N |
| Ensure a qualified health professional conducts resident assessments. | Health | 2023-09-28 | 2023-11-16 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2023-09-28 | 2023-11-16 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-09-28 | 2023-11-16 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-09-28 | 2023-11-16 | 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 | 2023-09-28 | 2023-11-16 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-09-28 | 2023-11-16 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-09-28 | 2023-11-16 | N |
| Provide activities to meet all resident's needs. | Health | 2023-09-28 | 2023-11-16 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2023-09-28 | 2023-11-16 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-09-28 | 2023-11-16 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-09-28 | 2023-11-16 | 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 | 2023-09-28 | 2023-11-16 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-09-28 | 2023-11-16 | 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 | 2023-09-28 | 2023-11-16 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-09-28 | 2023-11-16 | 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 | 2023-09-28 | 2023-11-16 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-09-28 | 2023-11-16 | 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 | 2023-09-28 | 2023-11-16 | N |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2023-09-28 | 2023-11-16 | N |
| Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. | Health | 2023-09-28 | 2023-11-16 | 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 | 2023-09-28 | 2023-11-16 | 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 | 2023-09-28 | 2023-11-16 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-09-28 | 2023-11-16 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-09-28 | 2023-11-16 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-09-28 | 2023-11-16 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-09-28 | 2023-11-16 | N |
| Implement a program that monitors antibiotic use. | Health | 2023-09-28 | 2023-11-16 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-09-28 | 2023-11-16 | 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 | 2023-09-28 | 2023-11-16 | N |
| Keep all essential equipment working safely. | Health | 2023-09-28 | 2023-11-16 | 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 | 2023-09-28 | 2023-11-16 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-09-28 | 2023-11-16 | Y |
| Address subsistence needs for staff and patients. | Fire Safety | 2023-09-25 | 2023-10-25 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2023-09-25 | 2023-10-25 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2023-09-25 | 2023-10-25 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2023-09-25 | 2023-10-25 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2023-09-25 | 2023-10-25 | N |
| Establish emergency prep training and testing. | Fire Safety | 2023-09-25 | 2023-10-25 | N |
| Establish staff and initial training requirements. | Fire Safety | 2023-09-25 | 2023-10-25 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-09-25 | 2023-10-25 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-09-25 | 2023-10-25 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2023-09-25 | 2023-10-25 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-09-25 | 2023-10-25 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-09-25 | 2023-10-25 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-09-25 | 2023-10-25 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-09-25 | 2023-10-25 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2023-09-25 | 2023-10-25 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-09-25 | 2023-10-25 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-09-25 | 2023-10-25 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2023-09-25 | 2023-10-25 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2023-09-25 | 2023-10-25 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-07-27 | 2023-08-11 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2023-07-27 | 2023-08-11 | Y |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2023-07-27 | 2023-08-11 | Y |
| Have an agreement with at least one or more hospitals certified by Medicare or Medicaid to make sure residents can be moved quickly to the hospital when they need medical care. | Health | 2023-07-27 | 2023-08-11 | Y |
| Develop, implement, and/or maintain an effective training program for all new and existing staff members. | Health | 2023-07-27 | 2023-08-11 | Y |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2023-07-27 | 2023-08-11 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-06-02 | 2023-07-14 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-03-21 | 2023-04-14 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-08-19 | 2022-09-16 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-08-19 | 2022-09-16 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-08-19 | 2022-09-16 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-07-18 | 2022-08-12 | Y |
| Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame. | Health | 2022-07-18 | 2022-08-12 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-06-28 | 2022-07-20 | Y |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2022-01-12 | 2022-02-28 | 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 | 2022-01-12 | 2022-02-28 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2022-01-12 | 2022-02-28 | 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 | 2022-01-12 | 2022-02-28 | N |
| Respond appropriately to all alleged violations. | Health | 2022-01-12 | 2022-02-28 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-01-12 | 2022-02-28 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2022-01-12 | 2022-02-28 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2022-01-12 | 2022-02-28 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2022-01-12 | 2022-02-28 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-01-12 | 2022-02-28 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2022-01-12 | 2022-02-28 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2022-01-12 | 2022-02-28 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-01-12 | 2022-02-28 | 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 | 2022-01-12 | 2022-02-28 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-01-12 | 2022-02-28 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-01-12 | 2022-02-28 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-01-12 | 2022-02-28 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2022-01-12 | 2022-02-28 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-01-12 | 2022-02-28 | 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 | 2022-01-12 | 2022-02-28 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-01-12 | 2022-02-28 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-01-12 | 2022-02-28 | 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 | 2022-01-12 | 2022-02-28 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-01-12 | 2022-02-28 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-01-12 | 2022-02-28 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-01-12 | 2022-02-28 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2022-01-12 | 2022-02-28 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2022-01-12 | 2022-02-28 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2022-01-12 | 2022-02-28 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2022-01-12 | 2022-02-28 | 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 | 2022-01-12 | 2022-02-28 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-01-12 | 2022-02-28 | 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 | 2022-01-12 | 2022-02-28 | N |
| Provide or obtain dental services for each resident. | Health | 2022-01-12 | 2022-02-28 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-01-12 | 2022-02-28 | 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 | 2022-01-12 | 2022-02-28 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-01-12 | 2022-02-28 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-01-12 | 2022-02-28 | Y |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2022-01-12 | 2022-02-28 | Y |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2022-01-06 | 2022-02-10 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2022-01-06 | 2022-02-10 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-01-06 | 2022-02-10 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-01-06 | 2022-02-10 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-01-06 | 2022-02-10 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2022-01-06 | 2022-02-10 | 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 | 2021-12-10 | 2022-01-13 | Y |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2021-10-18 | 2021-11-12 | 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 | 2021-07-26 | 2021-08-03 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-07-13 | 2021-08-03 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-07-13 | 2021-08-03 | Y |
| Report COVID19 data to residents and families. | Health | 2021-07-13 | 2021-08-03 | Y |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2021-06-22 | 2021-08-03 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-06-22 | 2021-08-03 | Y |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2021-06-22 | 2021-08-03 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-03-17 | 2021-04-16 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2021-03-17 | 2021-04-16 | Y |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2021-03-17 | 2021-04-16 | Y |
| Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. | Health | 2019-08-29 | 2019-10-08 | 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 | 2019-08-29 | 2019-10-08 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2019-08-29 | 2019-10-08 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-08-29 | 2019-10-08 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2019-08-29 | 2019-10-08 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-08-29 | 2019-10-08 | 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 | 2019-08-29 | 2019-10-08 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-08-29 | 2019-10-08 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-08-29 | 2019-10-08 | N |
| Provide activities to meet all resident's needs. | Health | 2019-08-29 | 2019-10-08 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-08-29 | 2019-10-08 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-08-29 | 2019-10-08 | 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 | 2019-08-29 | 2019-10-08 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-08-29 | 2019-10-08 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-08-29 | 2019-10-08 | 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 | 2019-08-29 | 2019-10-08 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2019-08-29 | 2019-10-08 | 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 | 2019-08-29 | 2019-10-08 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-08-29 | 2019-10-08 | 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 | 2019-08-29 | 2019-10-08 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-08-29 | 2019-10-08 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2019-08-29 | 2019-10-08 | N |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2019-08-29 | 2019-10-08 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-09-03 | 2019-09-27 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-09-03 | 2019-09-27 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-09-03 | 2019-09-27 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-09-03 | 2019-09-27 | N |
