North Auburn Care
North Auburn Care in AUBURN, WA — inspection on December 29, 2025.
Found 1 citation. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
was an on-call provider number staff should call to report.
Staff B stated when the on-call provider was called a progress note was automatically generated into the medical record.
Staff B stated there was no progress note in Resident 1's record showing the on-call provider was notified of the hip fracture.
Staff B stated the NP notified them on 12/13/2025 at about 7:30 AM that Resident 1 had a hip fracture.
Staff B stated the NP gave directions to send Resident 1 to the hospital.
Staff B stated they called the facility nurse assigned to Resident 1.
Staff B stated the nurse was not aware of Resident 1's x-ray results and told Staff B Resident 1 was at their dialysis appointment.
Staff B said they directed the nurse to call the dialysis clinic to send Resident 1 to the hospital.In an interview on 12/30/2025 at 9:58 AM, the NP stated they expected the nursing staff to review the x-ray results and report a fracture immediately to the provider, including calling the on-call provider if the report was after hours.
The NP stated the facility did not notify the provider of the fracture.
The NP stated they looked up the x-ray report in Resident 1's medical record on 12/13/2025 at 7:30 AM and tried calling the facility.
The NP stated when they could not reach the facility staff, they called Staff B to instruct the facility to send Resident 1 to the hospital immediately for the hip fracture from the 12/11/2025 incident.
The NP stated a hip fracture was a severe injury requiring ambulance transportation to the hospital for immediate intervention. In an interview on 12/30/2025 at 10:16 AM, Staff C stated they were the evening shift nurse on 12/12/2025 and received a phone call and report from the x-ray company about 10:00 PM, which was shift change.
Staff C stated they did not report the fracture to the Medical Provider. In an interview on 12/30/2025 at 10:21 AM, Staff D (LPN) stated they were the night shift nurse on 12/12/2025 and they were not informed by the prior shift that Resident 1 had a fracture.
Staff D stated when a report of a fracture was received the nurse was expected to notify the Medical Provider immediately.
Staff D stated there was an after-hours number to call the on-call provider.
Staff D stated Resident 1 should not have gone to dialysis on 12/13/2025 and should have gone to the hospital when the report of a fracture was received by the facility. In an interview on 12/30/2025 at 12:25 PM, Staff B stated they called the x-ray company to verify the report of Resident 1's x-ray results.
Staff B stated the x-ray company notified the facility of the fracture on 12/12/2025 at 10:30 PM and spoke with Staff C.
Staff B stated the nursing staff did not notify the NP or the on-call provider as required. In an interview on 12/30/2025 at 12:47 PM, Staff A (Director of Nursing) stated the investigation of Resident 1's injury did not identify the delay of nursing staff to process the Medical Provider's x-ray orders and did not identify the error of nursing staff to immediately notify the provider of Resident 1's fracture.
Staff A stated the nurse was expected to call the x-ray company right away when the NP provided the STAT x-ray order.
Staff A stated STAT x-rays should be completed within four hours of notification of the x-ray company.
Staff A stated the nurse was expected to notify the on-call provider immediately upon the report of Resident 1's fracture.
Staff A stated if Staff C notified the on-call provider as required, Resident 1 would have gone to the hospital on [DATE] and would not have been transported to dialysis on 12/13/2025.Reference: WAC 388-97-1060.
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.