Auburn Manor: Care Plan Failure for Vulnerable Resident - MN
Federal inspectors who visited the facility on February 6, 2025 found that Auburn Manor failed to develop and maintain an individualized comprehensive care plan for one resident, identified in inspection records as Resident 42. The resident required staff assistance with activities of daily living and was at risk for pressure ulcers, the kind of wounds that form when prolonged pressure cuts off blood flow to skin and tissue, often in people who cannot reposition themselves.
Pressure ulcers are among the most preventable injuries in nursing home care. They are also among the most serious. Left unaddressed, they can progress from surface redness to deep wounds that reach bone, cause systemic infection, and contribute to death. The prevention of pressure ulcers depends on consistent, coordinated care, which is exactly what a care plan is supposed to ensure.
The violation cited was F656, which covers the requirement that nursing homes create and maintain care plans tailored to each resident's specific needs, conditions, and goals. The plans are supposed to guide every member of the care team, from nurses to aides to therapists, so that nothing falls through the gap between one shift and the next.
Inspectors based their finding on interviews and document review. The inspection report does not describe what happened to Resident 42 as a result of the missing plan, but it documents that the failure existed.
Auburn Manor is a nursing facility in Chaska, a city of roughly 26,000 people southwest of Minneapolis. The February inspection was a standard health survey.
Care planning failures are not abstract paperwork problems. When a resident needs help turning in bed, repositioning in a wheelchair, or keeping skin clean and dry, the care plan is what tells staff how often to do it, what to watch for, and who is responsible. Without one, those tasks can be done inconsistently, skipped during busy shifts, or handed off between staff members who each assume someone else handled it.
For a resident already dependent on staff for activities of daily living, that inconsistency carries real consequences. Skin that is not repositioned regularly breaks down. Skin that is not kept dry develops moisture damage. Wounds that are not caught early become wounds that are very hard to close.
The inspection report identifies one resident affected. Whether others at Auburn Manor faced similar gaps in their care documentation, the February survey did not say.
What the record does say is that one person living at Auburn Manor, a person who needed help getting through each day, did not have the written plan that was supposed to make sure that help was organized, consistent, and complete.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Auburn Manor from 2025-02-06 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: August 9, 2026 · Our methodology
Auburn Manor in CHASKA, MN was cited for violations during a health inspection on February 6, 2025.
Pressure ulcers are among the most preventable injuries in nursing home care.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.