AUBURN, WA - State health inspectors documented significant care deficiencies at North Auburn Rehab & Health Center during an April 2025 inspection, finding that nursing staff failed to properly administer medications, provide basic hygiene care, and monitor residents with serious medical conditions. The violations affected multiple residents and created risks for medication errors, untreated medical issues, and deteriorating health conditions.
Critical Medication Administration Errors Documented
The inspection revealed systematic failures in medication management that affected seven residents. Most concerning was the case of a resident receiving cancer treatment who returned from oncology appointments with an intravenous catheter and chemotherapy pump that facility staff were unaware of and had no physician orders to monitor.
When questioned about the resident's IV catheter visible on their chest, the Assistant Director of Nursing stated "they were not aware Resident 54 had an IV catheter on their right chest area or a pump for medication." The inspection found no documentation of orders to monitor the IV site for infection, manage the dressing changes, or observe for chemotherapy side effects - critical oversights for a cancer patient receiving active treatment.
Another resident experienced multiple medication errors involving pain patches. Staff applied patches for 15 hours daily instead of the prescribed 12-hour maximum, potentially exposing the resident to excessive medication. Inspectors also discovered staff had applied a pain patch to the resident's neck without any physician order for that location. The patches on the resident's knees were dated April 14 but still in place on April 16, despite documentation claiming they had been changed daily.
The facility's own Nurse Consultant confirmed these were serious errors, acknowledging that staff had signed for tasks not performed and that applying medicated patches without physician orders violated professional standards.
Widespread Neglect of Basic Hygiene and Personal Care
Inspectors documented disturbing patterns of neglect in basic hygiene care across multiple residents who depended on staff assistance. Five residents who required help with activities of daily living were found with long, dirty fingernails and toenails, inadequate bathing, and poor oral hygiene.
One resident who was completely dependent on staff for all care and fed through a tube was observed with "long fingernails to both hands and dried debris along the left side of their mouth" with "yellow film/debris on their teeth and along the gum line." These conditions persisted across multiple observation days. When the Director of Nursing examined this resident, they stated the resident "has really bad breath, the teeth look brown and do not look clean" and confirmed "It does not look like oral care has been happening."
Another resident who preferred twice-weekly showers received only four bed baths in 30 days, with no showers provided despite their care plan specifications. The resident told inspectors that "staff did not wash their feet for a few weeks." The resident's legs were wrapped in elastic bandages, but staff failed to remove them for proper bathing as required.
These hygiene failures create serious health risks. Poor oral care in tube-fed residents can lead to aspiration pneumonia, a potentially fatal lung infection that occurs when bacteria from the mouth enters the lungs. Inadequate foot care in residents with circulatory problems or diabetes significantly increases infection risks and can lead to serious complications including amputation. Long, dirty fingernails harbor bacteria that can cause infections, particularly dangerous for elderly residents with compromised immune systems.
Untreated Medical Conditions and Missed Appointments
The inspection uncovered multiple instances where residents' medical conditions went unmonitored or untreated, creating potentially serious health consequences. A diabetic resident with a foot ulcer and documented bone infection never attended a crucial infectious disease consultation that had been ordered in November 2024 and rescheduled to January 2025.
The Assistant Director of Nursing confirmed the missed appointment was critical, stating "it was important for staff to ensure Resident 23 attended their infectious disease appointment to ensure the resident did not have an underlying infection." Untreated bone infections in diabetic patients can progress rapidly, potentially leading to sepsis, amputation, or death. The delay of over five months in obtaining specialist care for an active bone infection represents a serious lapse in medical management.
Another resident with documented edema (fluid retention) in their legs was supposed to receive compression stockings daily and have their edema monitored. However, inspectors observed the resident on multiple days without compression stockings applied, with visibly swollen legs that weren't elevated as ordered. Staff had been documenting minimal edema levels of "1+" when the actual swelling was "3+" - a significant discrepancy that prevented proper medical assessment of the resident's cardiovascular condition.
Unmanaged edema can indicate worsening heart failure, kidney disease, or blood clots. Without proper compression therapy and accurate monitoring, fluid can accumulate in the lungs causing breathing difficulties, or lead to skin breakdown and painful ulcers that are difficult to heal.
Additional Issues Identified
Beyond the major violations, inspectors documented numerous other care failures including:
- Staff administering muscle relaxants and pain medications simultaneously without proper protocols - A resident receiving seven times the intended dose of Vitamin D due to transcription errors - Blood sugar checks performed after meals began rather than before, leading to inappropriate insulin dosing - Residents with ingrown toenails showing signs of infection going untreated - Vision care requests ignored for months despite documented need - Physician orders lacking critical parameters for pain medication maximum dosages - Staff documenting completion of tasks never performed, including recording that a resident on strict "nothing by mouth" orders consumed "100% of snacks" on multiple occasions
The pattern of documentation falsification is particularly troubling, as accurate medical records are essential for continuity of care, proper medical decision-making, and legal compliance. When staff document care that wasn't provided, it prevents identification of problems and delays necessary interventions.
Industry Standards and Regulatory Requirements
Professional nursing standards require careful verification of physician orders, accurate documentation, and systematic monitoring of residents receiving new medications or treatments. Federal and state regulations mandate that nursing homes must ensure services meet professional quality standards and that residents receive necessary care for their highest practicable physical, mental, and psychosocial well-being.
The failures documented at North Auburn Rehab & Health Center violated multiple regulatory standards including Washington Administrative Code provisions requiring facilities to provide necessary care and services. These weren't isolated incidents but rather systematic failures affecting multiple residents across different units and involving various levels of nursing staff.
The inspection findings have been forwarded to state regulators who will determine what penalties or corrective actions the facility must undertake. The facility is required to submit a plan of correction addressing each deficiency identified during the inspection.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for North Auburn Rehab & Health Center from 2025-04-21 including all violations, facility responses, and corrective action plans.
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