North Auburn Care: Medication Errors Found in Inspection - WA
The April inspection, completed April 21, 2025, turned up two medication errors involving separate residents. Neither rose to the level of serious harm in inspectors' findings, but both reflected the same underlying failure: staff not following physician orders when administering medications.
The clearer of the two errors happened during a medication pass observed on April 16. Staff W, a licensed practical nurse, administered nine medications to a resident identified in the report as Resident 19. One of those nine medications had never been ordered for that resident. The physician had ordered a single stool softener. Staff W gave a combination tablet containing two stool softeners instead, and did not give the single stool softener at all.
When inspectors interviewed Staff W later that morning, the nurse did not dispute what had happened. "They administered the wrong stool softener to Resident 19," the report states, summarizing the admission. Staff W acknowledged they should have given the single stool softener and not the combination tablet.
The Assistant Director of Nursing, identified as Staff E, was interviewed two days later. Staff E said staff were expected to follow physician orders when giving medications, and that doing so was important to ensure residents received the correct drugs. The statement did not address why the error had occurred or what the facility planned to do about it.
The second error involved a blood sugar check and an injectable medication for Resident 30. The physician's order called for the blood sugar to be checked at 11:30 AM. On April 14, an observer watched Staff J obtain a reading of 230 from Resident 30 at 12:50 PM, after the resident had already started eating their meal. Staff J then administered an injectable medication based on the blood sugar result. The medication administration record confirmed the check and injection were documented as completed at 12:52 PM, more than 80 minutes after the scheduled time.
Two staff members, identified as Staff B and Staff C, told inspectors during an interview on April 16 that blood sugar checks and the related injectable medication should be completed within 30 minutes of the scheduled time. They were direct about what the delay meant. "If the injectable medication was done late, you need to call the doctor," Staff B and Staff C said. "Yes, that would be an error."
The inspection report does not indicate that a physician was called about the late administration. It does not say whether Resident 30 experienced any adverse effects from receiving the medication more than an hour behind schedule, after a meal had already begun.
Blood sugar levels and the timing of insulin-related medications are closely connected to eating. Administering a medication tied to a pre-meal blood sugar reading after a patient has started eating introduces a timing mismatch that physicians account for when writing orders. The 11:30 AM order existed precisely to coordinate the check and the medication with the resident's meal schedule.
The facility is located at 2830 I Street Northeast in Auburn. The inspection was conducted by the Washington State Department of Health on behalf of the Centers for Medicare and Medicaid Services.
Neither error was cited at the highest levels of harm. But the staff interviews in both cases told the same story: the nurses involved knew what the orders required, and the orders were not followed. Staff W gave a medication that wasn't prescribed and omitted the one that was. Staff J ran a scheduled check 80 minutes late and, according to the facility's own staff, should have called the doctor. Whether that call was ever made, the 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 28, 2026 · Our methodology
North Auburn Care in AUBURN, WA was cited for violations during a health inspection on April 21, 2025.
The April inspection, completed April 21, 2025, turned up two medication errors involving separate residents.
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.