North Auburn Care: Air Mattress Safety Failures - WA
The April inspection at North Auburn Rehab & Health Center found nursing staff repeatedly failed to follow doctor's orders for specialized air mattresses designed to prevent pressure sores. One resident's mattress was set to the wrong pressure level for months.
Resident 6 told inspectors on April 14 that staff were supposed to reposition them every two to three hours "but often did not." The resident had three active pressure ulcers and depended entirely on staff to move them in bed.
During a continuous observation on April 17 from 7:56 AM until 12:06 PM, inspectors watched Resident 6 remain lying flat on their back the entire time.
A certified nursing assistant told inspectors they had repositioned Resident 6 off their left side and onto their back just before breakfast, then planned to get them into a wheelchair. The assistant acknowledged this was "not per Resident 6's CP instructions for repositioning."
The resident's doctor had ordered their air mattress be set to "alternate level 5" in April 2023, with staff required to check the settings every shift. When inspectors observed the mattress on April 14, they found it set to "float level 8" instead.
Staff S, a registered nurse, confirmed the mattress should be at alternate level 5 and said nursing staff were responsible for checking the settings every shift "to prevent skin breakdown."
Resident 7 faced similar problems. Their air mattress was supposed to be set at 165 pounds with alternating cycle time, according to doctor's orders. Staff were required to check the settings every shift.
Instead, inspectors found the mattress set at 340 pounds.
Staff L, the resident care manager, told inspectors on April 18 that Resident 7's bed "was set incorrectly and should not be set at 340 pounds." The manager confirmed nursing staff were supposed to monitor air mattress settings every shift according to physician orders to prevent skin breakdown.
The inspection also revealed widespread failures in foot care for diabetic residents. Three of four residents reviewed had not received proper podiatry services, leaving them at risk for serious complications.
Resident 30, who had diabetes and functional limitations in both legs, had not seen a podiatrist since admission. During an April 14 observation, inspectors found "a moderate amount of crusty reddish debris on the inside of their left great toe nail bed."
"I get ingrown toenails, I have to see a diabetic doctor to get my nails trimmed," the resident told inspectors. "No, I haven't seen a podiatrist since I've been here."
Staff C, the corporate nurse, told inspectors diabetic residents should be seen by podiatry quarterly. "So a resident admitted in September should have been seen twice by now," Staff C said, confirming Resident 30 should have received podiatry services but did not.
Staff B, the director of nursing services, observed during the inspection that Resident 30 appeared to have "ingrown toenails" and confirmed the resident should have been referred to podiatry upon admission.
Resident 17, also diabetic, had not received follow-up podiatry care despite a September 2024 consultation that recommended return visits in two to three months. The resident told inspectors, "It's been awhile since seeing a podiatrist."
Staff G, the social service director, provided inspectors with documentation of a February 2025 podiatry visit for Resident 17 that was not in the medical record. Staff G said there had been "problems with the previous Podiatrist which caused delay in services."
The most serious case involved Resident 23, who had diabetes, heart failure, kidney failure, and a diabetic foot ulcer. A wound care provider had recommended podiatry referrals in notes dated November 17, November 23, December 8, December 13, December 22, December 28, January 4, January 11, January 19, and January 24.
A doctor ordered the podiatry referral on January 14 for the resident's right foot wound. The wound provider wrote that foot deformity "may complicate wound healing" and required podiatry management.
Despite months of recommendations and a direct physician order, Resident 23 never saw a podiatrist.
Staff G confirmed on April 21 that Resident 23 had not been seen by a podiatrist since the November referral. The social service director said the facility "was having issues with podiatry services and did not currently have a date of when the podiatrist would be available."
Staff E, the assistant director of nursing, acknowledged staff should have followed the wound provider's recommendation for a podiatrist "but they did not."
The inspection found the facility had policies requiring proper wound prevention and pressure-reducing measures. A February 2023 policy stated the facility would "reduce the occurrence of pressure over bony prominence to minimize injury" and ensure residents received "continuous preventative interventions to promote healing and prevent skin issues."
Staff told inspectors they expected residents to be repositioned at minimum every two hours while in bed or chair. The assistant director of nursing confirmed this standard during an April 18 interview.
For Resident 6, who told inspectors they depended entirely on staff for repositioning, the four-hour observation period without movement represented a clear failure to meet basic care standards. The resident's three existing pressure ulcers remained at risk of worsening without proper pressure relief and positioning.
The air mattress failures affected residents already vulnerable to skin breakdown. Both residents with incorrectly set mattresses were assessed as being at risk for pressure ulcers, according to their assessment records.
Resident 30 continues waiting for podiatry care months after admission, with visible signs of ingrown toenails and debris around the nail bed. The resident's diabetes makes proper foot care essential to prevent serious infections or complications that could lead to amputation.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for North Auburn Care from 2025-04-21 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
North Auburn Care in AUBURN, WA was cited for violations during a health inspection on April 21, 2025.
One resident's mattress was set to the wrong pressure level for months.
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.