Auburn Home in Waconia: Family Not Told as Resident Neared Death - MN
Three hours passed. The man's condition did not improve. At 3:31 a.m., staff sent him to the hospital. Only then did someone call his family.
Federal inspectors cited Auburn Home for failing to notify the family of a resident, identified only as R1, in time to allow them to be involved in decisions about his end-of-life care. The complaint inspection was completed November 25, 2025.
The details documented in the inspection report describe a man who was gravely ill. His blood pressure reading of 72/32 millimeters of mercury fell far below the threshold at which the brain begins to lose oxygen and nutrients. He had pain in his right upper quadrant rated at 7 out of 10. He was short of breath. A nurse left a voice message for the nurse practitioner and notified on-call administrative staff. The progress note from 12:47 a.m. contained no indication that anyone called R1's daughter.
The registered nurse who was present, identified as RN-A, told inspectors she did not call the daughter right away, even though she was worried about R1's condition. She acknowledged the low blood pressure was what concerned her enough to contact the on-call provider in the first place.
Every other clinician interviewed by inspectors said the same thing: the family should have been called immediately.
RN-B told inspectors that R1's low blood pressure indicated he may have been dying, and that family should have been notified right away so they could be with him. RN-C said the family should have been called when the change in condition occurred, around 12:47 a.m. The director of nursing said R1's daughter was involved in her father's care and would have wanted to know when he was not doing well. The nurse practitioner said R1's daughter liked to know what was going on with him, and that the family should have been notified right away when his condition changed.
The consensus among staff was unanimous. The action taken that night was not.
R1 was cognitively intact, according to his most recent assessment on file. He had Parkinson's disease, used a wheelchair, and required substantial assistance from staff to move. He was someone who knew what was happening to him.
The facility's own change-of-condition policy, dated July 29, 2025, eight days after the incident, states that family representatives shall be notified as applicable when a resident's condition changes. The policy was updated after the night in question.
What the inspection report does not say is whether R1's daughter made it to the hospital in time, or what decisions she might have made differently if she had received a call at 12:47 a.m. instead of 3:31 a.m. Those two hours and forty-four minutes are not accounted for in the public record.
What is documented is that a nurse, alone in the early hours of a July morning, recognized she was looking at a man whose body was failing. She called the people she worked with. She did not call the person who loved him.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Auburn Home In Waconia from 2025-11-25 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
AUBURN HOME IN WACONIA in WACONIA, MN was cited for immediate jeopardy violations during a health inspection on November 25, 2025.
The man's condition did not improve.
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.