Inspection Reports for North Auburn Rehabilitation & Health Center
WA, 98002
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
16.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
162% worse than Washington average
Washington average: 6.3 deficiencies/yearDeficiencies per year
36
27
18
9
0
Census
Latest occupancy rate
69 residents
Based on a December 2023 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Dec 29, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to ensure timely care and treatment prescribed by the Medical Provider for a change in condition for one resident.
Complaint Details
The complaint investigation found that the facility failed to ensure timely care and treatment for Resident 1 after a reported injury during transport to dialysis. The STAT x-ray was delayed by over 33 hours, and the nursing staff failed to notify the Medical Provider or on-call provider immediately upon receiving the fracture report. Resident 1 was sent to dialysis instead of the hospital, increasing risk of harm. The complaint was substantiated.
Findings
The facility failed to provide timely x-ray and notification of an acute hip fracture for Resident 1, resulting in delayed hospital transfer and potential harm. Nursing staff did not promptly initiate the STAT x-ray order nor notify the Medical Provider or on-call provider of the fracture as required.
Deficiencies (1)
Failure to provide appropriate treatment and care according to orders, resident’s preferences and goals, specifically delayed x-ray and notification of hip fracture for Resident 1.
Report Facts
Hours delay for STAT x-ray completion: 33
Number of residents reviewed for accidents and injury: 3
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Assistant Director of Nursing | Interviewed regarding notification procedures and timeline for Resident 1's fracture |
| Staff C | Licensed Practical Nurse (LPN) | Evening shift nurse who received fracture report but did not notify Medical Provider |
| Staff D | Licensed Practical Nurse (LPN) | Night shift nurse not informed of fracture and expected to notify Medical Provider |
| Staff F | Licensed Practical Nurse (LPN) | Received call from dialysis clinic reporting Resident 1's pain |
| NP | Nurse Practitioner | Ordered STAT x-ray and expected timely notification of fracture |
| Staff A | Director of Nursing | Interviewed about investigation findings and nursing expectations |
| Staff E | Licensed Practical Nurse (LPN) | Confirmed STAT x-ray order several hours after NP order |
Inspection Report
Routine
Deficiencies: 21
Date: Apr 21, 2025
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident care, safety, medication management, infection control, and other aspects of facility operations.
Findings
The facility was found deficient in multiple areas including failure to obtain resident consent for vaccinations, psychotropic medications, and safety devices; inadequate grievance investigation and follow-up; failure to notify the Long-Term Care Ombudsman and residents about transfers and bed hold policies; inaccurate resident assessments; delays and failures in coordinating PASRR Level 2 evaluations; incomplete and untimely care plan updates and meetings; failure to meet professional standards of care including medication administration errors, inadequate pressure ulcer prevention, insufficient assistance with activities of daily living, and inadequate foot care; medication storage and labeling issues; infection prevention and control deficiencies including hand hygiene and mask use; and failure to maintain complete and accurate resident records.
Deficiencies (21)
Failure to obtain resident consent for vaccinations, psychotropic medications, and safety devices for multiple residents.
Failure to have a system in place to thoroughly investigate and resolve resident grievances.
Failure to timely notify the Long-Term Care Ombudsman and provide written transfer/discharge notices to residents or representatives.
Failure to provide written notice of bed hold policy and obtain consent for bed holds for residents transferred to hospital.
Failure to accurately assess residents' cognitive patterns, language, oral status, vision, behaviors, dental status, and discharge status.
Failure to ensure completion and coordination of required PASRR Level 2 evaluations prior to or upon admission for residents with serious mental illness or related conditions.
Failure to ensure care plans were updated and revised as needed, and failure to provide care plan meetings for residents.
Failure to meet professional standards of care including failure to follow or clarify physician orders, monitor medication effects, follow up on outside provider recommendations, and monitor side effects.
Failure to provide assistance with activities of daily living including bathing, oral care, and nail care for dependent residents.
Failure to provide appropriate treatment and care according to orders, resident preferences, and goals including wound care, edema management, hydration, and medication administration.
Failure to assist residents in gaining access to vision and hearing services.
Failure to provide appropriate pressure ulcer care and consistent repositioning.
Failure to provide appropriate foot care including timely podiatry services and nail care.
Failure to ensure safe discharge planning including documentation of reason for leaving and risks for residents leaving Against Medical Advice.
Failure to ensure medication error rate was less than 5% including improper administration of eye drops, inhalers, and medications given at incorrect times or doses.
Failure to ensure drugs and biologicals were labeled and stored according to professional standards including presence of discontinued medications and unsecured medications at bedside.
Failure to provide and implement an infection prevention and control program including hand hygiene, proper labeling and containment of personal care items, medication administration infection control, and appropriate mask use.
Failure to ensure indwelling urinary catheters had valid medical justification and plan for discontinuation.
Failure to ensure residents were free from unnecessary psychotropic medications including lack of clinical justification for dose increases and failure to attempt gradual dose reductions.
Failure to ensure residents received adequate food and fluids to maintain health including failure to provide consistent weights and hydration services.
Failure to ensure residents were free from accident hazards and provided adequate supervision to prevent accidents related to smoking and smoking materials.
Report Facts
Medication error rate: 20
Weight loss: 14.2
Weight loss percentage: 6.25
Edema assessment: 1
Medication administration frequency: 7
Medication administration frequency: 4
Medication administration frequency: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff P | Infection Preventionist | Expected staff to wear surgical masks in resident areas and perform hand hygiene |
| Staff G | Social Service Director | Responsible for coordinating PASRR evaluations and arranging podiatry services |
| Staff C | Corporate Nurse | Reviewed medication errors, care plans, and PASRR coordination |
| Staff E | Assistant Director of Nursing | Reviewed grievances, care plans, medication administration, and infection control |
| Staff O | Resident Care Manager | Discussed pain medication parameters and bed rail consent issues |
| Staff B | Director of Nursing | Confirmed medication administration errors and resident care observations |
| Staff J | Licensed Practical Nurse | Observed medication administration errors and medication cart issues |
| Staff L | Resident Care Manager | Discussed bed rail settings and monitoring |
| Staff H | Maintenance | Assessed bed rails and discussed maintenance responsibilities |
| Staff V | Certified Nursing Assistant | Discussed repositioning per care plan and hand hygiene |
| Staff S | Registered Nurse | Discussed medication cart issues and air mattress settings |
| Staff I | Dishwasher | Observed sanitizer levels and failure to report |
Inspection Report
Routine
Deficiencies: 2
Date: Mar 17, 2024
Visit Reason
The inspection was conducted to assess compliance with care planning, staffing adequacy, and resident care standards at North Auburn Rehab & Health Center.
Findings
The facility failed to develop and implement comprehensive, person-centered care plans for several residents, including discharge planning. Additionally, the facility lacked sufficient nursing staff to provide timely assistance with toileting and call light response, and restorative nursing programs were not consistently provided as ordered. These deficiencies placed residents at risk for unmet care needs and decreased quality of life.
Deficiencies (2)
Failed to develop and implement a complete care plan that meets all the resident's needs, including discharge planning for Residents 30, 226, and 71.
Failed to have sufficient nursing staff to provide timely assistance with toileting and call light response, and failed to ensure restorative nursing programs were provided as ordered.
Report Facts
Residents reviewed for care plans: 21
Residents affected by care plan deficiency: 3
Residents interviewed regarding staffing: 8
Resident Council members interviewed: 2
Grievance forms reviewed: 4
Call light reports reviewed: 4
Nurses on duty: 3
Splint application observations: 4
Call light wait times: 44
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff NN | Certified Nursing Assistant | Observed caring for Resident 30 despite care plan specifying female staff only |
| Staff C | Assistant Director of Nursing | Interviewed regarding care plan implementation and staffing |
| Staff L | Chief Nursing Officer | Interviewed regarding care plan implementation and staffing |
| Staff O | Social Services Director | Interviewed regarding discharge planning for Residents 226 and 71 |
| Staff KK | Certified Nursing Assistant | Interviewed regarding staffing shortages |
| Staff MM | Registered Nurse | Interviewed regarding staffing shortages |
| Staff N | Licensed Practical Nurse | Interviewed regarding staffing shortages and responsibilities |
| Staff J | Certified Nursing Assistant | Interviewed regarding restorative nursing program responsibilities |
| Staff B | Director of Nursing | Interviewed regarding call light response expectations and staffing |
Inspection Report
Abbreviated Survey
Census: 69
Deficiencies: 1
Date: Dec 14, 2023
Visit Reason
The inspection was conducted due to an Immediate Jeopardy situation involving failure to perform CPR on a resident with a physician order and POLST for life-sustaining treatment, which placed multiple residents at risk.
Findings
The facility failed to ensure staff performed CPR on Resident 1 who was found unresponsive despite having physician orders and a signed POLST for CPR. Staff did not locate the POLST form promptly, did not assess for irreversible death signs properly, and did not initiate CPR, resulting in an Immediate Jeopardy that affected 38 other residents with CPR directives. The facility corrected the deficiency prior to the survey by auditing records, educating staff, performing CPR drills, and implementing a plan of correction.
Deficiencies (1)
Failure to perform CPR on Resident 1 with physician orders and signed POLST for CPR, failure to locate POLST form promptly, and failure to assess signs of irreversible death properly.
Report Facts
Residents affected: 39
Residents with CPR orders: 38
Census: 69
Time delay: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Licensed Practical Nurse (LPN) | Did not perform CPR on Resident 1, failed to locate POLST form, notified physician and power of attorney, called 911 |
| Staff A | Interim Director of Nursing | Stated staff were expected to follow physician orders and initiate CPR; described corrective actions taken by facility |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Aug 30, 2023
Visit Reason
The inspection was conducted to investigate complaints regarding the facility's failure to provide pharmaceutical services that meet the needs of residents, including medication acquisition, administration, reconciliation, storage, and disposition.
Complaint Details
The visit was complaint-related, triggered by concerns about medication errors and omissions. The complaint was substantiated based on findings that medications were not administered as ordered, medication reconciliation was inadequate, and improper medication was dispensed and sent to the facility.
Findings
The facility failed to ensure medications were administered on the day of admission, reconcile medications accurately, and properly manage medication storage and disposition, placing residents at risk for adverse health complications and medication errors. Multiple residents had documented missed medications without proper explanation or follow-up.
Deficiencies (1)
Failure to ensure pharmacy services met residents' needs for 4 of 5 residents reviewed, including medication acquisition, administration on admission day, reconciliation, storage, and disposition.
Report Facts
Medications not administered: 3
Wrong anti-coagulant tablets dispensed: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Assistant Director of Nursing | Interviewed regarding medication administration failures and pharmacy reconciliation issues. |
| Staff D | Resident Care Manager | Interviewed about admission order error and medication reconciliation. |
| Staff E | Resident Care Manager | Conducted discharge for Resident 1 but unavailable for interview. |
| Staff B | Commented on licensed staff access to medication dispensing system and medication availability. | |
| Staff A | Stated licensed staff should have called pharmacy or physician to ensure medication administration. |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Jul 14, 2023
Visit Reason
The inspection was conducted due to complaints and grievances regarding resident rights violations, grievance handling failures, and failure to appropriately investigate and report alleged abuse and neglect.
Complaint Details
The complaint investigation was triggered by multiple grievances and resident complaints about smoking policy enforcement, grievance handling failures, and allegations of abuse and neglect. The investigation found failures in honoring resident rights, grievance resolution, and reporting and investigating alleged violations.
Findings
The facility failed to ensure residents' rights to self-determination regarding smoking, failed to properly implement and resolve grievances for numerous residents, and failed to timely report and investigate allegations of abuse, neglect, and misappropriation. These failures caused psychological harm to residents and placed them at risk for unmet care needs and diminished quality of life.
Deficiencies (3)
Failure to honor resident self-determination and provide a safe designated smoking area, causing psychological harm to residents.
Failure to implement grievance policy, resulting in unresolved grievances and lack of timely investigation and resolution for multiple residents.
Failure to respond appropriately to alleged violations including abuse, neglect, and misappropriation, with incomplete investigations and failure to report to State Agency.
Report Facts
Residents affected: 3
Grievances logged: 29
Grievances logged: 15
Days delayed: 41
Minutes: 45
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Social Services Director and Grievance Officer | Named in relation to smoking policy enforcement failures and grievance handling deficiencies |
| Staff A | Administrator | Named in relation to grievance backlog and failure to ensure grievance system functioning |
| Staff D | Assistant Director of Nursing | Named in relation to investigation of Resident 1's self-harm incident |
| Staff E | Social Services Assistant | Mentioned regarding staff smoking area location |
| Staff B | Director of Nursing | Mentioned regarding assumption of reporting Resident 1's incident |
Inspection Report
Annual Inspection
Deficiencies: 1
Date: May 26, 2023
Visit Reason
The inspection was conducted to assess the facility's compliance with pressure ulcer care and prevention policies, focusing on wound care management and skin integrity for residents at risk or with existing pressure ulcers.
Findings
The facility failed to implement its policies to provide appropriate pressure ulcer care and prevention for 5 sampled residents, resulting in inadequate monitoring, documentation, care planning, and treatment implementation. Weekly skin evaluations and wound measurements were often not completed, and pressure redistribution devices were not consistently used as ordered. The facility lacked a system to track and trend pressure ulcers and non-pressure wounds, leading to risks of delayed healing, new ulcers, infections, pain, and diminished quality of life.
Deficiencies (1)
Failure to provide appropriate pressure ulcer care and prevent new ulcers from developing, including inadequate monitoring, documentation, care planning, and treatment implementation for 5 residents.
Report Facts
Pressure ulcer measurements: 13.5
Pressure ulcer measurements: 9
Pressure ulcer measurements: 1
Pressure ulcer measurements: 10
BPURS score: 16
BPURS score: 12
BPURS score: 10
Pressure ulcer measurements: 3
Pressure ulcer measurements: 2
Pressure ulcer measurements: 0.5
Pressure ulcer measurements: 0.2
BPURS score: 14
Pressure ulcer measurements: 2.9
Pressure ulcer measurements: 3.2
Pressure ulcer measurements: 2
Pressure ulcer measurements: 2
Pressure ulcer measurements: 2.5
Braden score: 10
Pressure ulcer measurements: 1
Pressure ulcer measurements: 2
BPURS score: 10
Pressure ulcer measurements: 2.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Assistant Director of Nursing (ADON) | Interviewed regarding wound report awareness, wound documentation, and facility processes for wound care. |
| Staff B | Interim Director of Nursing Services (DNS) | Interviewed about expectations for weekly skin evaluations. |
| Staff A | Administrator | Notified about Resident 1's need for air mattress and wound care assistance. |
| Staff D | Registered Nurse (RN) | Interviewed about facility processes for ordering air mattresses and wound care. |
Inspection Report
Census: 18
Deficiencies: 36
Date: Dec 12, 2022
Visit Reason
The inspection was conducted to evaluate compliance with resident rights, care and services, resident self-determination, notification of room changes, bathing preferences, financial management, advance directives, environment, grievance procedures, assessments, care planning, medication management, infection control, emergency exit doors, and other regulatory requirements.
Findings
The facility was found deficient in multiple areas including failure to honor resident rights and dignity, failure to provide written notice for room changes, failure to ensure resident self-determination in bathing preferences, failure to timely reimburse resident funds, failure to secure resident funds with surety bond, failure to provide advance directives, failure to provide timely notice of Medicare/Medicaid coverage changes, failure to maintain a clean and homelike environment, failure to address resident grievances, failure to complete timely significant change assessments, failure to ensure accurate assessments and care plans, failure to provide nursing services within professional standards, failure to plan and implement discharge plans, failure to provide adequate ADL assistance, failure to provide pharmaceutical services including medication availability and controlled substance accountability, failure to provide timely laboratory services, failure to provide dental services, failure to provide and implement infection prevention and control program, failure to provide food according to resident preferences and safe diet textures, failure to maintain emergency exit doors, and failure to implement a quality assurance program.
Deficiencies (36)
Failure to honor resident rights and dignity including privacy and communication.
Failure to provide advanced written notice for room changes to residents.
Failure to ensure residents had ability to exercise self-determination related to bathing preferences.
Failure to timely reimburse resident funds to the state Office of Financial Recovery and notify residents of Medicaid balances.
Failure to ensure resident funds were covered by a surety bond.
Failure to ensure residents were informed and provided written information concerning their rights to accept, refuse, or formulate an Advance Directive.
Failure to provide timely notice of changes in Medicare/Medicaid coverage and potential charges for services not covered.
Failure to ensure a clean, comfortable, homelike environment including adequate linens, clean hallways, intact furniture, working hand sanitizer dispensers, accessible call lights, accurate clocks, and clean blood pressure cuffs.
Failure to implement a system to ensure resident concerns were identified, addressed timely, and outcomes communicated including concerns from Resident Council meetings.
Failure to complete Significant Change in Status Assessments within 14 days for residents with significant changes in condition.
Failure to ensure Minimum Data Sets were complete and accurate for residents reviewed.
Failure to ensure Pre-admission Screening and Resident Review (PASRR) assessments were obtained, implemented, and incorporated into care plans.
Failure to develop and implement comprehensive, person-centered, and individualized care plans that accurately reflected resident needs.
Failure to revise and implement care plans timely and include resident and representative participation.
Failure to provide nursing services within professional standards including following physician orders, clarifying orders, and signing for tasks not performed.
Failure to plan and implement effective discharge planning to meet resident goals and needs.
Failure to provide assistance with activities of daily living including bathing, nail care, oral care, and grooming.
Failure to assess falls timely, identify causes, implement interventions, provide supervision while eating, supervise unsecured emergency exits, maintain handrails, and secure construction materials.
Failure to ensure residents that can eat orally are not fed by feeding tubes unnecessarily and failure to provide appropriate care for residents with feeding tubes.
Failure to provide pharmaceutical services to meet resident needs including medication availability and controlled substance accountability.
Failure to provide timely, quality laboratory services/tests to meet resident needs.
Failure to provide or obtain dental services for residents including emergent dental care.
Failure to develop and implement infection prevention and control program including hand hygiene and wound care.
Failure to provide foods according to resident preferences and prescribed modified diets.
Failure to maintain emergency exit doors operable and compliant with federal regulations.
Failure to implement a quality assurance and performance improvement program that is comprehensive and sustainable.
Failure to provide enough food/fluids to maintain resident health including consistent weights, physician notification, and implementation of interventions.
Failure to obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care including follow-up on referrals and monitoring.
Failure to provide appropriate pressure ulcer care including weekly skin assessments, wound monitoring, and availability of wound care supplies.
Failure to provide appropriate treatment and services according to orders, resident preferences and goals including edema monitoring and medication administration.
Failure to ensure drugs and biologicals are labeled and stored according to professional principles including disposal of expired medications and supplies.
Failure to provide and implement an infection prevention and control program including hand hygiene and wound care.
Failure to ensure medication error rates are less than 5 percent.
Failure to provide timely, quality laboratory services/tests to meet resident needs.
Failure to provide or obtain dental services for residents including emergent dental care.
Failure to educate residents and staff on COVID-19 vaccination, offer the vaccine to eligible residents and staff, and properly document vaccination status.
Report Facts
Residents reviewed: 18
Residents reviewed: 8
Residents reviewed: 5
Residents reviewed: 10
Residents reviewed: 3
Residents reviewed: 6
Residents reviewed: 20
Residents reviewed: 8
Residents reviewed: 1
Residents reviewed: 5
Medication error rate: 11.54
Medication carts with missing signatures: 4
Medication carts reviewed: 3
Medication room refrigerators with expired food: 1
Medication room refrigerators with temperature above 41F: 2
Residents with weight loss: 4
Residents with falls: 4
Residents with wound care needs: 1
Residents with medication availability issues: 8
Residents with delayed lab services: 3
Residents with dental care needs: 1
Residents with COVID-19 vaccination issues: 2
Residents with feeding supervision issues: 5
Residents with unmet discharge planning: 3
Residents with incomplete advance directives: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff Y | Certified Nursing Assistant | Named in failure to honor resident rights and dignity, and inadequate linen supply |
| Staff C | Licensed Practical Nurse, Unit Manager | Named in multiple findings including failure to honor resident rights, bathing preferences, room change notification, care plan accuracy, medication administration, wound care, and discharge planning |
| Staff B | Director of Nursing | Named in multiple findings including failure to honor resident rights, complaint investigations, care plan accuracy, medication administration, discharge planning, infection control, and quality assurance |
| Staff G | Business Office Manager | Named in failure to reimburse resident funds timely and Medicaid balance notification |
| Staff L | Social Service Assistant | Named in failure to ensure advance directives, grievance processing, PASRR Level 2 evaluation referral, and discharge planning |
| Staff A | Administrator | Named in failure to notify residents of room changes, linen supply, wound care supplies, emergency exit door issues, and quality assurance |
| Staff NN | MDS Specialist, Licensed Practical Nurse | Named in failure to complete timely significant change assessments and accurate MDS assessments |
| Staff EE | Dietary Manager | Named in failure to address resident food preferences and food texture preparation |
| Staff S | Certified Nursing Assistant | Named in failure to provide eating supervision and hand hygiene |
| Staff Q | Licensed Practical Nurse | Named in failure to clarify physician orders, medication administration, hand hygiene, and medication availability |
| Staff F | Infection Control Preventionist | Named in failure to ensure infection control program, hand hygiene, and COVID-19 vaccination education |
| Staff JJ | Certified Nursing Assistant | Named in failure to ensure dental appointment communication and transportation |
| Staff PP | Certified Nursing Assistant | Named in failure to provide eating supervision and hand hygiene |
| Staff X | Certified Nursing Assistant | Named in failure to provide eating supervision and hand hygiene |
| Staff DD | Certified Nursing Assistant | Named in failure to perform hand hygiene during incontinence care |
| Staff E | Registered Nurse Unit Manager | Named in failure to perform wound care with gloves and hand hygiene |
| Staff TT | Corporate Nurse | Named in failure to ensure refrigerator cleanliness and temperature monitoring |
| Staff MM | Laundry Assistant | Named in failure to maintain adequate linen supply |
| Staff I | Maintenance Assistant | Named in failure to maintain emergency exit doors |
| Staff FF | Regional Maintenance Director | Named in failure to maintain emergency exit doors |
| Staff KK | Chief Nursing Officer | Named in failure to provide infection control surveillance data |
| Staff T | Licensed Speech Therapist | Named in failure to provide appropriate diet texture and supervision |
| Staff U | Licensed Practical Nurse | Named in medication availability |
| Staff N | Licensed Practical Nurse | Named in medication availability |
| Staff DD | Certified Nursing Assistant | Named in failure to perform hand hygiene during incontinence care |
Report
Mar 22, 2024
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