Auburn Skilled Nursing And Rehab

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Based on observation, policy review, and staff/Resident interviews, the facility failed to maintain the dignity and privacy of one resident (Resident #07) of five residents reviewed for dignity and privacy. The facility census was 42.Findings Include: Review of medical record of Resident #07 revealed initial admission to facility on 04/22/25 for diagnosis including metabolic encephalopathy, pneumonia, chronic respiratory failure, high blood pressure, major depression and anxiety, spinal cord injury, and chronic lung disease.

Review of the medical record for Resident #07 revealed the Minimum Data Set 3.0 (MDS 3.0) indicated Resident #07 required moderate to substantial assistance with personal care and was dependent on wheelchair for mobility. Observation on 09/02/25 at 9:50 A.M. revealed Resident #07 in bed with bilateral heel boots on and flannel pajama pants noted to be pulled down to below the resident ' s knees, above the boots and a sheet laying across the resident's midsection. Resident #07 reported that they do this at night

in case I have an accident, and I need changed, it makes it easier. Resident #07 then adjusted his sheet to cover up the pulled down flannel pants. Observation on 09/03/25 at 8:24 A.M. revealed Resident #07 lying

in bed covered with a linen sheet with heel boots on bilaterally. Observation of Resident #07 revealed he was wearing flannel pajama pants pulled down to below the knees and above the boots. Resident #07 reported this was done at night to make it easier to change him if he had an accident since he was wearing heel boots while in bed. Interview on 09/03/05 at 8:26 A.M. with Assistant Director of Nursing (ADON) #160 confirmed Resident #07 pajamas being pulled down below knees and above boots. ADON #160 was not able to explain reason for this and stated the aides must be doing it. Review of facility policy titled Quality of Life-Dignity revised August 2009 revealed all residents will be treated with dignity and respect at all times including, providing for bodily privacy during assistance with personal care and during treatments procedures.This deficiency represents non-compliance investigated under Complaint Number 2578619.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

(X6) DATE

FORM CMS-2567 (02/99) Previous Versions Obsolete

Facility ID:

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Event ID:

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/09/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Auburn Skilled Nursing and Rehab

451 Valley Road Salem, OH 44460

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

needed assistance, she would pull the string which was on the arm of the recliner. This string was for the room light.On 09/02/25 at 1:59 P.M., an observation of Resident #12's room revealed the string for the light was on the recliner and the recliner was in the reclined position. The other call light for the room was under

the bed covers. Resident #12 was observed in a wheelchair. Her recliner was in the reclined position, and

she reported she had issues getting out of the chair and could not get out without the assistance of her son. The footrest of the recliner would not close without significant force.On 09/02/2025 at 2:03 P.M., an

observation and interview with RN #105 confirmed Resident #12's call lights were on the floor and on the bed and they were out of reach of the resident. RN #105 also confirmed Resident #12's recliner was too difficult for the resident to close and a resident who had knee surgery should have a functional chair for safety.On 09/04/2025 at 9:01 A.M., an interview with the DON revealed Resident #12 and Resident #16 had call lights which were easily confused with the light cords. She further confirmed Resident #12's recliner in her room was too difficult for a resident post knee surgery to operate safely.Review of facility policy titled Call System, Resident, dated September 2022, revealed residents were provided with a means to call staff for assistance through a communication system that directly calls a staff member or a centralized workstation. The policy further revealed each resident would be provided with a means to call staff directly for assistance from his/her bed, from toileting/bathing facilities and from the floor.

Event ID:

Facility ID:

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