North Auburn Care: Air Mattress Set Wrong for At-Risk Resident - WA
The resident, identified in inspection records as Resident 7, had no memory impairment. Their medical record showed they were at risk for pressure ulcers and had a pressure-reduction air mattress with bolsters on their bed. The physician had ordered the mattress set to 165 pounds with an alternating cycle, and staff were required to check those settings every shift.
The mattress was set to 340 pounds.
The Resident Care Manager, identified in inspection records as Staff L, confirmed the error in an interview with inspectors on April 18, 2025. The mattress was set incorrectly, Staff L said, and should not have been at 340 pounds. Staff L told inspectors that nursing staff are responsible for monitoring air mattress settings every shift to make sure they match the physician order, specifically to prevent skin breakdown.
Somewhere between that stated expectation and the actual practice, the checks weren't happening — or weren't catching what was wrong.
The facility's own care plan had documented a separate setting: 180 pounds with a 30-minute cycle time. That figure didn't match the physician order of 165 pounds either. So the mattress was operating outside both the care plan and the doctor's instructions, set nearly twice as high as what the physician prescribed.
Pressure ulcers, also called bedsores, develop when sustained pressure cuts off blood flow to skin and underlying tissue. For residents who spend extended time in bed, the type of mattress surface and how it's calibrated can be the difference between intact skin and a wound that becomes infected or requires surgical treatment. An alternating-pressure air mattress works by cycling inflation between different chambers, redistributing pressure across the body. The weight setting determines how firmly the mattress inflates. Set too high, the surface stops functioning as a pressure-relief device and can behave more like a conventional mattress.
Inspectors cited the facility under Washington state regulation WAC 388-97-1060(3)(b), which covers repositioning and pressure-relief practices. The deficiency was rated at the minimal harm level, meaning inspectors determined no actual injury had occurred or that any harm was minor.
That rating reflects what inspectors could document at the time of the survey. It does not establish how long the mattress had been set incorrectly, or whether Resident 7's skin had been examined closely enough, on enough shifts, to detect early-stage changes that might not yet have progressed to a formal wound.
The inspection was completed April 21, 2025. North Auburn Care is located at 2830 I Street Northeast in Auburn.
Resident 7 had no memory impairment. They were capable of knowing what was happening around them, capable of noticing discomfort, capable of asking questions. Whether they knew the device meant to protect them had been misconfigured, and for how long, the inspection report does not say.
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: 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.
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Last verified: October 27, 2026 · Our methodology
North Auburn Care in AUBURN, WA was cited for violations during a health inspection on April 21, 2025.
The resident, identified in inspection records as Resident 7, had no memory impairment.
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.