North Auburn Care: Catheter Left Without Assessment - WA
The inspection, completed April 21, 2025, found that the facility placed an indwelling urinary catheter on December 10, 2024, after draining 1,000 cubic centimeters of retained urine from the resident. That is roughly the equivalent of four cups of fluid that had built up in the bladder. The catheter was left in place. No one documented what came next in terms of any plan to get the resident off it.
What makes the timeline harder to read is what came before. The resident had been able to use a bedside commode multiple times. Staff knew this. But there is no record that anyone measured how much urine the resident produced, tracked output volume, or performed a post void residual, the standard procedure of catheterizing briefly after urination to check whether the bladder is emptying completely. The facility had no documentation of any urinary assessment between the time the problem began and December 10, when the retention had become severe enough to require emergency drainage.
A care plan dated December 6, 2024, four days before the catheter was placed, listed a urology consult as a potential intervention. It was never ordered. Inspectors found nothing in the record to show staff considered whether a specialist might identify a treatable cause for the retention. There was also no documentation that the resident had any prior history of bladder problems or untreatable blockage before the most recent hospitalization, which would have explained why a permanent catheter was considered the only option.
The concern inspectors raised is not simply that a catheter was placed. It is that once placed, no one appears to have asked whether it still needed to be there. Indwelling catheters, when left in place without monitoring or retraining efforts, reduce bladder tone and function over time, making it progressively harder for a resident to ever void independently again. The inspection record contains no evidence that staff considered this, or documented any plan to address it.
Staff C, identified in the report as a corporate nurse, was interviewed on April 18, 2025. She confirmed that no post void residuals had been obtained and that no bladder retraining was ever attempted. "We could have done better," she said. She also confirmed that staff had not followed the facility's own policy requiring verification that a catheter was necessary before leaving one in place.
That admission, offered by someone brought in at the corporate level, is notable for what it concedes. The failure was not a single missed step. It ran from the initial lack of monitoring, through the absence of any documented assessment, past the unused urology consult, and continued through months of catheter use with no recorded plan to reverse it.
The deficiency was cited at a level of minimal harm or potential for actual harm, and inspectors noted it affected few residents. But the classification of harm as minimal does not account for what a catheter left indefinitely can do to bladder function that might otherwise have recovered. The resident had been able to use a commode. That capacity existed. Whether it still does is not something the inspection report can answer, because the facility never tried to find out.
The corporate nurse's three words carry the weight of everything the record does not contain: no output logs, no residual measurements, no specialist, no retraining, no documented consideration of what the catheter was doing to a bladder that, as far as anyone had documented, had never been proven unable to work on its own.
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.
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Last verified: October 28, 2026 · Our methodology
North Auburn Care in AUBURN, WA was cited for violations during a health inspection on April 21, 2025.
That is roughly the equivalent of four cups of fluid that had built up in the bladder.
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.