Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Auburn Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with multiple chronic conditions had a documented Full Code status and an advance directive care plan requiring CPR to honor the resident’s wishes. When the resident was found unresponsive, not breathing, and cold to the touch, a KMA and an RN assessed the resident but did not initiate CPR, and no documentation showed that life-saving measures were attempted. Staff interviews revealed that the RN was unaware of the resident’s code status, the KMA did not verify it or initiate emergency procedures, and both relied on the KMA’s outside role as a deputy coroner rather than following the care plan, resulting in the resident’s death without implementation of the ordered Full Code interventions.
A resident with COPD, dementia, chronic kidney disease, and bilateral below-knee amputations had documented physician orders and a care plan indicating Full Code status, requiring CPR if found without vital signs. On one morning, an aide reported the resident was not doing well, an LPN initially found vital signs within normal limits, and later a KMA found the resident cold, not breathing, and assessed her as dead. The aide asked about starting CPR, but the KMA, who also worked as a deputy coroner outside the facility, stated nothing could be done. The RN and LPN, who did not know the resident’s code status at that time, relied on the KMA’s assessment, did not immediately verify the code status, and no CPR was initiated despite the absence of pulse and respirations. The resident’s daughter reported being told by phone that the resident’s eyes were glazed and then that she was deceased, and stated that no CPR was given, while multiple leaders and the medical director later confirmed staff failed to follow CPR protocol for a Full Code resident.
An LPN failed to perform hand hygiene between glove changes and did not use required PPE while providing wound care to a resident on contact precautions. The resident had multiple diagnoses, including osteomyelitis and pressure ulcers. The LPN was unaware of the contact isolation status and did not follow facility policies for infection control, as confirmed by interviews with the DON and Administrator.
Failure to Implement Full Code Advance Directive and Initiate CPR
Penalty
Summary
The deficiency involves the facility’s failure to implement a comprehensive care plan related to advance directives for one resident who had been admitted with diagnoses including COPD, unspecified dementia, chronic kidney disease, and bilateral below-knee amputations. The resident’s physician order and the Advanced Directives Comprehensive Care Plan identified the resident as Full Code, with goals to have the resident’s health care wishes honored and interventions that included communicating the resident’s choice and providing CPR. The facility’s policy required individualized comprehensive care plans with measurable objectives and timetables to meet residents’ needs, including honoring advance directives. On the day of the incident, a Kentucky Medication Technician (KMA) found the resident at approximately 10:25 AM not breathing and cold to the touch. The KMA called a Registered Nurse (RN) to the room, and the RN assessed the resident and found no heart rate, no breath sounds, and that the resident was cold to the touch. A progress note documented these findings but did not indicate that CPR was initiated, despite the resident’s Full Code status and the care plan intervention to provide CPR. A certified death certificate documented that the resident expired in the facility at 10:29 AM. Multiple staff interviews confirmed that CPR was not performed and that the resident’s care plan was not followed. The RN stated she did not know the resident’s code status, even though it was listed on the care plan, and acknowledged that staff failed to follow the care plan and perform CPR, relying instead on directions from the KMA, who also worked outside the facility as a deputy coroner. The KMA admitted she did not follow the care plan and did not verify the code status, call for help, obtain a crash cart, or begin CPR. Other staff, including an LPN, the MDS Coordinator, the Medical Director, the County Coroner, a Regional Nurse, the Interim DON, and the Administrator, all confirmed that staff did not implement the resident’s Full Code care plan by initiating CPR when the resident was found without pulse or respirations.
Failure to Initiate CPR for a Full Code Resident
Penalty
Summary
The deficiency involves the facility’s failure to initiate CPR for a resident who was documented as Full Code. Facility policy required staff to provide emergency basic life support, including CPR, to any resident needing such care, in accordance with physician orders and the resident’s advance directives. The resident was admitted with diagnoses including COPD, unspecified dementia, chronic kidney disease, and bilateral below-knee amputations, and had a physician’s order and care plan indicating Full Code status, with interventions to communicate the resident’s choice and provide CPR. On the morning of the incident, a nurse aide reported that the resident was not doing well, with an open mouth and no verbal response. An LPN assessed the resident around that time and documented normal vital signs, then returned to charting. Later, staff observed changes in the resident’s condition, including being cold and not breathing. A medication technician assessed the resident as cold and stiff and told staff the resident was dead. The aide asked whether CPR should be started, and the medication technician responded that nothing could be done. The LPN and RN did not know the resident’s code status at that moment and relied on the medication technician’s assessment instead of immediately verifying the code status and initiating CPR. The RN subsequently assessed the resident, found no heart rate or breath sounds, and confirmed that no one in the room performed CPR. Staff interviews revealed that the RN and LPN deferred to the medication technician, who also worked outside the facility as a deputy coroner, and that this influenced the decision not to initiate CPR despite the resident’s Full Code status. The resident’s daughter reported being informed by phone that her mother’s eyes were glazed and then shortly afterward that she was deceased, and stated that no CPR was given and that she overheard staff discussing not knowing the code status as the reason CPR was not performed. The medical director, regional nurse, interim DON, administrator, and county coroner all confirmed in interviews that staff did not follow the CPR protocol and that CPR should have been performed for a Full Code resident.
Failure to Follow Infection Control Protocols During Wound Care
Penalty
Summary
A deficiency was identified when a Licensed Practical Nurse (LPN) failed to follow established infection prevention and control protocols while providing wound care to a resident on contact precautions. The LPN did not sanitize her hands between glove changes and did not wear the required personal protective equipment (PPE), including a gown, mask, and eye protection, during the procedure. Observations showed that after removing soiled dressings and gloves, the LPN donned new gloves without hand hygiene and continued wound care activities without proper PPE. The resident involved had a medical history including osteomyelitis, type 2 diabetes mellitus with a foot ulcer, a pressure ulcer on the right buttock, and obesity. The LPN stated she was unaware the resident was on contact isolation and acknowledged she should have followed the correct protocols for hand hygiene and PPE use. Both the Director of Nursing and the Administrator confirmed their expectations that staff adhere to contact isolation and handwashing policies during resident care.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Auburn
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Creekwood Nursing & Rehabilitation | 10.1 mi | — | 4 | 0 |
| Hopkins Nursing And Rehabilitation Center | 10.2 mi | — | 0 | 0 |
| Franklin-simpson Nursing And Rehabilitation Center | 12.8 mi | — | 0 | 0 |
| Colonial Nursing And Rehabilitation Center | 15.1 mi | — | 2 | 0 |
| Magnolia Village Nursing And Rehabilitation Center | 15.9 mi | — | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.