North Auburn Care: Antipsychotic Order Ignored for Weeks - WA
The finding emerged during a federal inspection of North Auburn Care, a nursing facility at 2830 I Street Northeast, completed April 21, 2025.
The resident at the center of the first finding, identified in inspection records as Resident 54, had been taking an antipsychotic daily since a physician order dated February 6, 2025, prescribed it in connection with cancer. By late March, the care team had moved toward a change. A March 31 interdisciplinary team nursing progress note documented that the resident was receiving the antipsychotic for depression related to cancer, and that the provider had agreed to stop it and start an antidepressant instead.
That note sat in the record. Nothing followed from it.
When inspectors reviewed Resident 54's physician orders and medication administration records on April 17, there was no documentation that the antipsychotic had been discontinued. No antidepressant had been started. The provider's decision, recorded in the chart nearly three weeks earlier, had not been carried out.
A staff member identified as Staff C told inspectors that afternoon that the medication had come up during a psychiatric meeting and the provider had ordered it stopped. Then Staff C looked at the record and said what the record already showed: staff should have followed the provider's recommendation and discontinued the antipsychotic, but they did not.
The second finding involved a different resident and a different drug, but the same underlying failure to act.
Resident 35 had been living at the facility since at least June 2024, admitted with a diagnosis that included depression. A physician order for an antidepressant dated June 22, 2024, was in the record. So was a care plan from March 27, 2025, that included an intervention: attempt a gradual dose reduction, as recommended by the pharmacist.
The gradual dose reduction had never been attempted. Not once in the months since admission.
The Assistant Director of Nursing, identified as Staff E, reviewed Resident 35's records with inspectors on April 18 and confirmed it. Staff E said the facility had not attempted a gradual dose reduction for the antidepressant since the resident arrived. Then Staff E explained why it mattered: attempting reductions for psychotropic medications was important to make sure residents were not being overmedicated, and not receiving something they no longer needed.
The inspection rated both deficiencies at the level of minimal harm or potential for actual harm, and noted that some residents were affected.
What the record shows, across both findings, is a facility that documented the right intentions and then did not follow through on them. A care plan written in March said to attempt a dose reduction. A progress note written in March said to discontinue a medication. Neither instruction produced any action. In one case, a staff member acknowledged the failure directly. In the other, the Assistant Director of Nursing acknowledged it herself.
Resident 54 spent at least three weeks receiving a medication that the provider had agreed to stop, one prescribed in the context of cancer and depression, while the antidepressant meant to replace it was never ordered. The March 31 note describing the provider's decision remained in the chart, accurate and unacted upon, until inspectors arrived in April.
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 31, 2026 · Our methodology
North Auburn Care in AUBURN, WA was cited for violations during a health inspection on April 21, 2025.
The finding emerged during a federal inspection of North Auburn Care, a nursing facility at 2830 I Street Northeast, completed April 21, 2025.
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.