North Auburn Care: Podiatry Referral Failures - Auburn, WA
The resident, identified in federal inspection records only as Resident 23, had heart failure, end-stage kidney failure, and diabetes. They also had a diabetic foot ulcer and a foot deformity, hammer toes, that the wound provider warned could complicate healing. The first recommendation for a podiatry referral came in November 2024. Then came another. And another.
By the time federal inspectors arrived at North Auburn Care in April 2025, the wound provider had written nine separate notes recommending podiatry, spanning November 17, 2024 through January 24, 2025. A physician had issued a formal order on January 14, 2025 directing staff to refer Resident 23 to a podiatrist for the right foot wound. Inspectors reviewed the resident's comprehensive records and found no progress notes, no orders, no scanned documents showing anyone had followed through.
Not one.
The staff member responsible for arranging podiatry services at the facility, identified in inspection records as Staff G, confirmed during an interview on April 21 that Resident 23 had not been seen by a podiatrist since the referral was first made in November 2024. Staff G told inspectors the facility had been having problems with podiatry services and had no date for when a podiatrist would next be available.
The Assistant Director of Nursing, Staff E, said the same thing more plainly: staff should have followed the wound provider's recommendation, and they did not.
Resident 23 was not the only one.
Resident 17 also needed podiatry care. A September 2024 visit had come with a recommendation for follow-up within two to three months. Staff C, interviewed on April 18, acknowledged the follow-up never happened. A podiatry consult dated February 26, 2025 turned up during the inspection, but it had not been placed in the resident's medical record. Staff G said problems with the previous podiatrist had caused delays in services, and that the facility now had a new podiatrist.
The inspection was conducted on April 21, 2025. The deficiency was tagged at a level of minimal harm or potential for actual harm, affecting a small number of residents.
That designation reflects regulatory language, not medical reality. For a person managing a diabetic foot ulcer alongside end-stage kidney failure and heart failure, foot complications carry a different weight. Diabetes impairs circulation and nerve function in the extremities, making wounds slower to heal and faster to worsen. Hammer toes pressing against a wound is not an incidental concern. The wound provider who kept writing those referrals understood that. They wrote it nine times.
What the inspection record shows is a facility that knew what its own wound specialist was asking for, received a physician's order reinforcing that request, and still did not arrange the appointment. The explanation offered, problems with the previous podiatrist, does not account for the months that passed or for the absence of any documented effort to find an alternative or escalate the situation internally.
Staff E did not offer an explanation beyond acknowledging the failure. Staff G did not have a timeline for when the gap would be closed.
Resident 23, carrying a wound on their right foot that a specialist had flagged as complicated by deformity and underlying disease, waited through November, December, January, February, March, and into April. The wound provider kept showing up and kept writing the same thing down. The podiatrist never came.
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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Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
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 resident, identified in federal inspection records only as Resident 23, had heart failure, end-stage kidney failure, and diabetes.
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.