Auburn Village

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure timely family notification of a resident's death for 1 of 3 residents reviewed (Resident C). Findings include:On [DATE] at 12:13 P.M., Resident C's record was reviewed. Diagnoses included cancer and diseased arteries. The resident admitted to the facility with hospice services due to expected decline and had orders to not resuscitate if found without a pulse or respirations. Resident C's face sheet had a Power of Attorney (POA) listed as the 1st contact for notifications of changes in condition and a family member as his 2nd contact for notifications of changes in condition. A nurse note, dated [DATE] at 3:40 a.m., indicated the resident was observed lying in bed without a pulse or respirations. A second nurse verified he was deceased and the hospice nurse contacted. The note indicated Resident C's POA was aware of the resident's death. An on-call Nurse Practitioner (NP) note, dated [DATE] at 4:10 a.m., indicated facility staff reported Resident…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure respectful and dignified communication and care for 1 of 3 residents reviewed. (Resident A)A record review for Resident A's began on 10/16/25 at 9:30 AM. Diagnoses included anxiety, depression, and respiratory failure.A review of Resident A's current quarterly MDS, dated [DATE], indicated their BIMS (Basic Interview for Mental Status) score was 15 (cognitively intact). The MDS indicated the resident had a tracheostomy and ventilator. A review of Resident A's current Care Plan indicated Resident A had potential to be manipulative, exhibit attention-seeking behaviors, and display emotional overreaction to minor events. Interventions included calm, consistent communication with firm boundaries.A review of Resident A's current Care Plan indicated Resident A had a problem of an anxiety disorder. Resident A could have racing thoughts, feel overwhelmed, and stressed. Interventions included encourage Resident A to engage in deep breathing exercises,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and interview, the facility failed to ensure kitchen cleanliness was maintianed. 70 of 81 residents residing in the facility ate food prepared in the kitchen. Findings include: During an observation, on 06/11/25 at 09:13 AM, there was moisture in 2 of 3 pans on drying rack, the stand mixer located in the cooking and clean storage area had yellow particles and yellow discoloration on the bowl, paddle, and on the main unit. An unlabeled fruit cup had a red liquid puddle underneath on the top drawer of the mini fridge in the south hall. Employee 9 had their hair unrestrained During an interivew, on 06/11/25 at 10:25 AM, The Dietary Manager indicated the kitchen staff needed to restrain their hair with a hairnet. During an observation, on 06/11/25 at 10:30 AM, Employee 9 took the lid off the food processor and placed it right side up on top of the toaster next to it. The top of the toaster had crumbs and dry brown particles on the top surface. The rim of the lid is an interior surface and touches the food inside the food processor. Food and liquid were transferred…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure dining choices were respected for 1 of 8 residents reviewed (Resident 60). Findings include: During an observation on 6/11/25 at 11:35 AM, Resident 60 was observed seated at a table in the assisted dining room with two other residents. Three staff members were seated at the table assisting the residents with their lunch. During an observation on 6/12/25 at 11:56 AM, Resident 60 was observed seated at a table in the assisted dining room with two other residents. Three staff members were seated at the table assisting the residents with their lunch. During an interview on 6/12/25 at 10:47 AM Resident 60 indicated he had notified staff during a resident council meeting he wished to dine in the main dining room, so he had the opportunity to meet more residents and increase his socialization. He indicated he had expressed to staff he would like to have the choice of where to dine. During an interview on 6/12/25 at 11:32 AM, Registered…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to ensure the treatment to maintain or prevent further loss of range of motion for 1 of 1 resident reviewed (Resident 7). Findings include: In an interview, on 6/11/25 at 10:23 AM, Resident 7 indicated they were unable to participate in bingo due to limited use of their hands. On 6/11/25 at 10:25 AM, Resident 7 was observed to have contractures (rigid joints) of both of their wrists. Resident 7's record was reviewed on 6/16/25 at 9:36 AM. Diagnoses included rheumatoid arthritis (a condition that causes stiff joints) and Parkinson's Syndrome (a condition that affects movement and coordination due to stiffness and tremors). Resident 7's Quarterly Minimum Data Set, (MDS)dated 5/20/25 indicated their Brief Interview of Mental Status (BIMS) score was 2 (severe cognitive impairment). The MDS indicated Resident 7 required substantial to maximum staff assistance for eating. The MDS indicated Resident 7 was dependent on staff assistance for oral care, mobility, bathing and toileting. The MDS indicated Resident 7 had no…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to ensure non-medication pain interventions were implemented as ordered by the physician for 1 of 1 resident reviewed (Resident 30). Findings include: Resident 30's record was reviewed on 6/16/25 at 10:56 AM. Diagnoses included chronic pain syndrome, low back pain, right leg pain and polyneuropathy (damage to multiple nerves). Resident 30's Quarterly Minimum Data Set, (MDS) date 4/11/25, indicated the resident's Brief Interview for Mental Status (BIMS) score was 14 (no cognitive impairment). The MDS indicated Resident 30 had not been administered routine pain medication. The MDS indicated Resident 30 had been administered pain medication as needed. The MDS indicated Resident 30 frequently had pain. The pain frequently interfered with Resident 30's sleep at night. The MDS indicated Resident 30 had not been offered non-medication pain interventions. Resident 30's care plan, dated 3/10/25, indicated the resident was at risk for pain due to impaired mobility, diabetes with polyneuropathy, chronic pain syndrome, low back pain, and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure massage therapy was provided for 1 of 24 residents reviewed (Resident 60). Findings include: During an interview on 6/12/25 at 10:17 AM, Resident 60 indicated he had notified facility staff of desire to receive massage therapy services for discomfort related to muscular dystrophy. He indicated he could receive the services for free at the Veterans Affairs Hospital. He indicated he had inquired about massage therapy during a Resident Council meeting. After the meeting, the facility driver had told him the facility could not assist him with transportation due to it not being a medically necessary service, but the facility might be able to offer massage in house. He indicated the conversation was several weeks ago and he had not received any further information from the facility. During an interview on 6/12/25 at 1:32 PM, Resident 60 indicated he had not received any massage therapy from facility staff or heard of any plans to be provided with this…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to identify, assess and determine underlying cause of specific expressions of distress of a trauma survivor for 1 of 2 residents reviewed (Resident 3). Findings include: On 6/27/24 at 12:10 PM, Resident 3 was observed sitting in the doorway of their room in their wheelchair. Resident 3 greeted a staff member pleasantly. Resident 3 greeted this writer, then quickly looked away. Resident 3 began to speak softly in nonsensical terms while looking at the palms of their hands. Resident 3's record was reviewed on 7/1/24 at 11:36 AM. Resident 3's diagnoses included anxiety, major depressive disorder, paranoid schizophrenia, insomnia, obsessive compulsive disorder, morbid obesity, tracheostomy, (surgical opening for breathing) mechanical ventilator (breathing machine) at night. Resident 12 was a survivor of childhood sexual trauma. Resident 3's Annual Minimum Data Set (MDS) dated [DATE] indicated the resident's Brief Interview for Mental Status (BIMS)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure education about and follow public health authority recommendations during investigation of a communicable disease outbreak. This alleged deficient practice affected 1 of 3 residents reviewed (Resident M).and had the potential to affect of 68 residents residing in the facility. Findings include: An anonymous complaint to the Indiana Department of Health (IDOH), dated 6/25/24, indicated Legionella bacteria had been found in water samples collected at the facility and recommendations made to prevent disease were not being followed. Legionnaires' Disease, retrieved from CDC.gov (Centers for Disease Control) on 6/27/24, indicated Legionnaires' disease was a very serious type of pneumonia caused by Legionella bacteria. Legionnaires' disease could cause pneumonia symptoms of cough, muscle aches, fever, shortness of breath, and headache. Legionella bacteria lived in fresh water and man-made settings such as large or complex water systems found in…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to conduct a thorough investigation of injuries of unknown origin for 1 of 2 residents reviewed (Resident B). Findings include: An Indiana report form, dated 1/7/24 at 12:17 p.m., indicated the local police had come to the facility for a reported assault on a dependent resident. The resident had an injury to her pubic area which had been determined to have been caused by incontinence and skin allergy. A head to toe assessment had been completed with no suspicious areas identified. On 1/10/24 at 2:43 P.M., Resident B was observed lying in bed attended by the facility wound nurse and Nurse 5. Upon hearing Nurse 5's voice, she opened her eyes, raised her eyebrows and smiled in response. Per Nurse 5, the resident was non-verbal and had the mentality of an infant due to her condition. The resident was observed to have multiple fading bruises that were brown, yellow, and green in color and were in discrete round shapes. She had 2 round bruises on her left upper arm that appeared about 1 inch long. Her right knee had 5…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to ensure a resident's choice of bedtime for 1 of 3 residents reviewed (Resident P). Findings include: An Indiana report, dated 10/9/23, indicated on 10/8/23 at 8:15 p.m., Resident P had been wandering in the facility and refused to go to bed. She was put into bed against her wishes. On 10/26/23 at 10:18 A.M., Resident P's daughter was interviewed. She indicated on 10/8/23 around 8:06 p.m., the nurse caring for her mother called and indicated the resident had been going into other resident's rooms and had been taken back to her room where staff were trying to get her into bed. She tried to speak to her mother via the nurse's cell phone but the resident indicated she wanted to go home and hadn't wanted to go to bed. The nurse indicated the resident had to go to bed because of her wandering and she was transferred into bed. On 10/26/23 at 11:40 A.M., Resident P's record was reviewed. Diagnoses included vascular dementia, anxiety and depressive disorders. A significant change MDS (Minimum Data Set) assessment, dated 9/1/23,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure hand hygiene procedures were performed during meal service during 1 of 3 observations. Findings include: In an observation on 7/26/23 at 11:24 AM, 14 residents were in the 300 hall dining room for lunch. During the observation, Dietary Aide 3 gloved both her hands. Dietary Aide 3 touched her glasses, moved around food containers, touched the tortillas, touched the handle of 2 utensils, then plated shredded cheese and lettuce without a utensil with both gloved hands. Dietary Aide 3 handed the 2 plates of food to another dietary aide to be served to residents. The Surveyor then intervened. In an interview on 7/26/23 at 11:28 PM, Dietary Aide 3 indicated she should have only touched food with one gloved hand. Dietary Aide 3 also indicated she should have used hand hygiene or changed her gloves after touching other items with her gloved hands. A current policy, dated 5/17, titled Hand Hygiene, was provided by the Administrator on 7/26/23 at 2:51 PM. The policy indicated hand hygiene is performed before and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.