Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Auburn Home In Waconia during CMS and state inspections, most recent first.
A resident with impaired cognition and serious medical conditions had an updated POLST indicating DNR status, but staff reference materials and the care plan incorrectly listed the resident as full code. Multiple staff confirmed they would have initiated CPR based on these inaccurate documents, resulting in a failure to honor the resident's advance directive.
Grievance forms and procedures were not posted in prominent locations, and residents were unaware of how to file grievances. Staff confirmed that forms were only available in the social service office, and the facility's policy lacked clear instructions for anonymous or independent grievance submission.
Surveyors found that food items were not properly labeled, dated, or discarded after expiration, and kitchen and kitchenette areas were not maintained in a clean and sanitary condition. The dietary manager confirmed that food storage and cleaning procedures were not consistently followed, with undated, uncovered, and expired food items present and visible spills and crumbs in multiple areas.
Staff failed to use required PPE during high-contact care for a resident with an indwelling catheter under enhanced barrier precautions, and did not perform hand hygiene or use proper technique when handling food and beverages during dining service. Staff lacked training on EBP, PPE use, and safe food handling, and facility policies did not address these areas, resulting in infection control deficiencies affecting all residents.
A resident with multiple chronic conditions received Bactrim DS for an extended period without appropriate review or documentation of ongoing need. Staff interviews revealed that the antibiotic was not monitored under an antibiotic stewardship program, and the facility had not established a process for regular review with the consultant pharmacist. The facility also lacked an infection preventionist to oversee antibiotic use, and relevant policies were not provided upon request.
Following the resignation of the infection preventionist, the DON and two nurse managers assumed infection control duties without having completed specialized infection prevention and control training, as required by facility policy. This lack of training was confirmed by interviews with the DON, a nurse manager, and the administrator, potentially impacting all residents.
A resident with multiple health conditions and a history of falls experienced several incidents where they were found on the floor. Although the resident's emergency contact or guardian was sometimes notified, there was no documentation that the provider was informed of these falls. Staff and DON interviews confirmed that provider notification was expected, but the facility's policy only required it under certain conditions, leading to missed notifications.
A resident with impaired cognition and multiple health conditions was found to have significant bruising of unknown origin on two occasions. Facility staff, including LPN, RN, DON, and the administrator, were unaware of the injuries, and no investigation or report to the State Agency was completed as required. The care plan lacked documentation on skin care and monitoring, and the facility's reporting policy was not provided when requested.
A resident with multiple health conditions and impaired cognition developed significant bruises of unknown origin on two occasions. Despite documentation of these injuries, staff including LPNs, RNs, the DON, and the administrator were unaware of the bruises and did not initiate an investigation or incident report as required. The care plan lacked documentation on skin care and monitoring, and the facility's policy on reporting and investigation was not provided.
A resident with impaired cognition and multiple chronic conditions developed several large bruises of unknown origin over several months. The care plan lacked documentation on skin care and monitoring, and nursing staff, including LPNs, RNs, and the DON, were unaware of the bruises. Required incident reports, comprehensive assessments, and investigations were not completed, and the facility could not provide a policy on comprehensive assessments.
A resident with impaired cognition and multiple comorbidities experienced repeated falls, but staff did not complete fall scene investigations or update fall prevention interventions as required. Despite the resident's need for supervision and assistance, documentation and staff interviews confirmed that after each fall, there was no assessment of the root cause or adjustment to the care plan, contrary to facility policy.
A resident with chronic heart failure, chronic kidney disease, and atrial fibrillation received Bactrim DS for an extended period without a documented diagnosis or ongoing need. Staff interviews confirmed the antibiotic was not reviewed monthly, and the facility lacked an active antibiotic stewardship program and infection preventionist to monitor unnecessary medication use.
Three residents who required assistance with ADLs, including shaving, were observed with significant facial hair growth and reported a preference for daily shaving. Staff were unaware of individual grooming preferences and typically provided shaving only on bath days, which occurred once a week. The DON and RN expected daily shaving, but this was not consistently practiced, and no grooming policy was available.
Survey results and plans of correction for the past three years were not readily accessible to residents or visitors. The survey binder only contained the most recent results without the required plan of correction, and previous years' documents were missing. The administrator and DON confirmed this was their standard process, and no policy on survey inspection results was available.
Failure to Accurately Document and Communicate Advance Directives
Penalty
Summary
The facility failed to ensure that a resident's advance directives were accurately documented and reflected the resident's current wishes. Specifically, a resident with moderately impaired cognition and multiple medical diagnoses, including atrial fibrillation, anemia, and coronary artery disease, had an updated Physician's Order for Life Sustaining Treatment (POLST) indicating a Do Not Resuscitate (DNR) status, as signed by a family member and the medical provider. However, the resident's care plan did not document resuscitation status, and both the report form used by staff and the three-ring binder at the nurses' station incorrectly indicated that the resident wanted cardiopulmonary resuscitation (CPR). Multiple staff interviews confirmed that in the event of an emergency, they would have referred to these inaccurate documents and initiated CPR, contrary to the resident's documented wishes in the electronic health record (EHR) and the updated POLST. The Director of Nursing (DON) acknowledged the discrepancy between the EHR, the report form, and the binder, confirming that staff would have followed the incorrect code status and performed CPR against the resident's wishes. The facility's policy required that the POLST be documented in both the EHR and the household binder, and that code status be reviewed at least quarterly and documented in the medical record. Despite these requirements, the lack of accurate and consistent documentation across all sources led to the deficiency, placing the resident at immediate risk of receiving unwanted life-sustaining treatment.
Removal Plan
- All residents' records were reviewed to ensure the POLST form and the electronic health records were updated to ensure resident's wishes for advance directives were accurate.
- R29's three ring binder was updated to match the current POLST and the code status for all residents was removed from the report form.
- All current licensed staff were educated on the policy for advance directives, updating the POLST, the EHR, and the three ring binder to reflect the resident's wishes.
- A process was implemented to assure all other nursing staff completed mandatory education prior to the start of their next shift, by notification of required education via phone/text. All staff would sign off once education had been completed.
- The advance directive policy was reviewed and determined no changes were required.
Grievance Forms and Procedures Not Accessible to Residents
Penalty
Summary
The facility failed to ensure that grievance forms and procedures were posted in prominent locations throughout the building, making it difficult for residents and their representatives to file grievances, including anonymously. During a resident council meeting, four residents reported being unaware of how to file a grievance. Observations by the surveyor confirmed that grievance forms were not visible or accessible in common areas of the facility. Interviews with the administrator, DON, SSD, and an RN revealed that grievance forms were kept in the social service office and were not available in other areas for residents or their representatives to access independently or anonymously. The facility's grievance policy did not provide clear instructions on how to file grievances anonymously or how to obtain a grievance form without staff assistance. This lack of accessible information and forms directly contributed to residents' lack of awareness and ability to file grievances.
Deficient Food Labeling, Storage, and Kitchen Sanitation
Penalty
Summary
Surveyors observed multiple deficiencies in food storage, labeling, and kitchen sanitation during a tour of the facility's kitchen and kitchenettes. Food items such as a large pan of fruit crisp and a tray of fruit cups were found covered but not dated in the walk-in refrigerator. Several refrigerators in the kitchenettes contained undated or expired food items, including sandwiches, Caesar dressing, Boost supplement, pistachio pudding, tomato slices, lettuce, and butter. Some items were not properly covered, and others were kept beyond the facility's stated policy of discarding unused food after five days. The dietary manager confirmed these findings and acknowledged that items should have been dated and discarded as per policy. Additionally, the kitchen and kitchenette areas were found to be unsanitary, with stainless steel cupboards and counters showing smears, spots, fingerprints, and crumbs. Refrigerators had irregular shaped spills and crumbs on shelves and bottoms. The dietary manager was unable to produce a cleaning schedule for the main kitchen and confirmed that cleaning expectations were not being met. The facility's policy required proper covering, dating, and timely disposal of food, as well as regular cleaning to maintain food safety, but these procedures were not consistently followed.
Deficient Infection Control: PPE and Food Handling Lapses
Penalty
Summary
The facility failed to ensure appropriate use of personal protective equipment (PPE) and safe food handling practices, resulting in deficiencies in infection prevention and control. During an observation, a nursing assistant assisted a resident with an indwelling catheter, who was under enhanced barrier precautions (EBP), by changing the catheter drainage bag and helping the resident get dressed. The nursing assistant only wore gloves and did not use a gown as required for high-contact care activities under EBP. The assistant was unaware of the resident's EBP status and had not received adequate training on PPE use for EBP. Documentation in the resident's care plan and care area assessment also lacked references to EBP requirements, despite the presence of an EBP sign and PPE bin outside the resident's room. Additionally, during a dining observation, another nursing assistant placed clothing protectors on multiple residents, touched their skin, and then proceeded to handle food and beverages without performing hand hygiene. The assistant touched the top rims of glasses while pouring and serving drinks, which could lead to contamination. The assistant admitted to not having received training on proper food and utensil handling and was unaware of the infection risks associated with touching the rims of glasses. The director of nursing confirmed that staff had not received formal training on EBP or PPE use beyond posted signs and acknowledged the expectation for proper PPE use and food handling to prevent infection. Facility policies reviewed did not include guidance on EBP or specific PPE use, and the hand hygiene policy referenced CDC recommendations but did not address the observed lapses. A requested policy on handling food and utensils was not provided. These deficiencies had the potential to affect all residents in the facility.
Failure to Monitor and Review Antibiotic Use
Penalty
Summary
The facility failed to establish and implement a process for reviewing antibiotic use, resulting in the ongoing administration of Bactrim DS to a resident without appropriate oversight. The resident, who had diagnoses including chronic heart failure, chronic kidney disease, and atrial fibrillation, was receiving Bactrim DS three times a week due to high-dose steroid use. However, there was no documentation of the diagnosis or ongoing need for the antibiotic on the medication administration record, and the order had not been reviewed for appropriateness since its initiation. Interviews with nursing staff, the pharmacy consultant, and the nurse practitioner confirmed that the antibiotic had not been reviewed as part of an antibiotic stewardship program, and the facility had not established a process for monthly antibiotic review with the consultant pharmacist. Further, the nurse practitioner noted that the Bactrim order was not present on the current medication list at the clinic, and if it had been, it would have been reviewed for possible discontinuation, especially since the resident's steroid use had decreased. The director of nursing confirmed that the resident was not being monitored for antibiotic stewardship and that the facility lacked an infection preventionist to track unnecessary antibiotic use. Requested policies on medication administration and unnecessary medication use were not provided, and the existing antibiotic stewardship policy identified responsibilities for oversight that were not being fulfilled.
Untrained Staff Assigned to Infection Preventionist Role
Penalty
Summary
The facility failed to ensure that the acting infection preventionist (IP) had completed specialized training in infection prevention and control. After the resignation of the previous IP, the director of nursing (DON) and two nurse managers assumed the infection control responsibilities. However, none of these individuals were enrolled in the Centers for Disease Control (CDC) infection preventionist course or any other specialized IP training at the time of the survey. This was confirmed through interviews with the DON, one of the nurse managers, and the facility administrator, all of whom acknowledged the lack of required training for those currently fulfilling the IP role. The facility's own infection control policy requires effective oversight of the Infection Prevention and Control program, including the development of an education component and training in infection prevention and control practices to ensure compliance with facility, state, and federal regulations. Despite this policy, the individuals responsible for the infection control program had not received the necessary specialized training, potentially affecting all 32 residents in the facility.
Failure to Notify Provider of Resident Falls
Penalty
Summary
The facility failed to provide timely notification to a provider regarding changes in condition related to falls for a resident with a history of falls and multiple comorbidities, including moderately impaired cognition, type two diabetes with chronic kidney disease, anemia, coronary artery disease, arthritis, and anxiety. The resident required supervision or assistance with mobility and toileting, as documented in the care plan. Progress notes revealed multiple incidents where the resident was found on the floor, including being found next to the bed and in front of the toilet on several occasions. While documentation showed that the resident's emergency contact or guardian was notified after some falls, there was a lack of documentation indicating that the provider was notified of these incidents. Interviews with nursing staff and the Director of Nursing confirmed that staff were expected to ensure resident safety after a fall, complete incident reports, and notify both the provider and the resident's representative. However, the Director of Nursing verified that the provider had not been updated on the resident's falls as required. The facility's policy on managing resident falls required provider notification only if injury was suspected, a head strike occurred, or the resident was on anticoagulants, and did not specify provider notification for all falls regardless of injury. This contributed to the failure to notify the provider in a timely manner following the resident's falls.
Failure to Report Bruises of Unknown Origin to State Agency
Penalty
Summary
The facility failed to report a bruise of unknown origin to the State Agency for a resident who was reviewed for falls. The resident had moderately impaired cognition and multiple medical diagnoses, including diabetes, chronic kidney disease, anemia, coronary artery disease, arthritis, and anxiety. The care plan identified mobility and self-care deficits but did not include documentation on skin care and monitoring. Progress notes documented two separate incidents of significant bruising to the resident's hip and sacral areas, with the resident unable to recall how the injuries occurred. Despite these findings, there was no evidence of an investigation into the causative factors or analysis of the bruises. Interviews with facility staff, including an LPN, RN, DON, and administrator, revealed that none were aware of the resident's bruises. Staff stated that their protocol would be to report such injuries to supervisory staff and complete an investigation report, but this was not done. The DON confirmed that a report to the State Agency had not been filed, as required. Additionally, the facility's policy on reporting was requested but not provided.
Failure to Investigate Bruises of Unknown Origin
Penalty
Summary
The facility failed to investigate and respond appropriately to bruises of unknown origin for a resident with multiple medical conditions, including moderately impaired cognition, diabetes, chronic kidney disease, anemia, coronary artery disease, arthritis, and anxiety. The resident required supervision and assistance with mobility and self-care. Despite documentation in progress notes of significant bruising on two separate occasions, there was no evidence that an investigation into the cause of the bruises was conducted. The resident was unable to recall how the injuries occurred, and the care plan lacked documentation on skin care and monitoring. Interviews with facility staff, including an LPN, RN, DON, and administrator, revealed that none were aware of the resident's bruises, and all confirmed that no investigation or incident report had been completed. The facility's policy on reporting and investigation was requested but not provided. The expectation, as confirmed by the DON, was that staff should complete an incident report, notify the physician and resident representative, and follow up with an investigation, none of which occurred in this case.
Failure to Assess and Monitor Bruises of Unknown Origin
Penalty
Summary
The facility failed to comprehensively assess and monitor bruises of unknown origin for a resident with moderately impaired cognition and multiple medical conditions, including diabetes, chronic kidney disease, anemia, coronary artery disease, arthritis, and anxiety. The resident required supervision and assistance with mobility and self-care. The care plan did not include documentation on skin care or monitoring, despite the resident's risk factors. Progress notes documented several large bruises on the resident's hips, buttock, and lower back over several months, with the resident often unable to recall the cause of the injuries. There was no evidence of comprehensive assessments or ongoing monitoring of these bruises in the resident's records. Interviews with nursing staff and the director of nursing revealed that they were unaware of the resident's bruises and confirmed that required incident reports, comprehensive assessments, and investigations had not been completed. The facility was unable to provide a policy on comprehensive assessments when requested. The lack of assessment and monitoring was acknowledged by staff as contrary to expectations for resident safety and care.
Failure to Complete Fall Scene Investigations and Update Interventions After Multiple Resident Falls
Penalty
Summary
The facility failed to provide a comprehensive assessment and review or adjustment of fall prevention interventions for a resident with a history of multiple falls. The resident, who had moderately impaired cognition and multiple diagnoses including diabetes, chronic kidney disease, coronary artery disease, arthritis, and an intellectual disorder, required supervision and assistance with mobility and toileting. Despite these needs, documentation revealed that after each of several falls, there was no evidence of a fall scene investigation to determine the root cause or to update the care plan with new or revised interventions. Progress notes spanning several months detailed repeated incidents where the resident was found on the floor in various locations, including the bathroom and next to the bed. In each instance, staff either assisted the resident after the fall or reminded them to use the call light, but there was a consistent lack of documented fall scene investigations or changes to the care plan. Some falls resulted in minor injuries, such as a contusion and pain, but still did not prompt a documented assessment or intervention review. Interviews with staff, including an LPN, RN, PT, and the DON, confirmed that the expected protocol was to complete a fall scene investigation after each fall and to implement or update interventions on the care plan. However, staff acknowledged that these steps were not taken following the resident's falls. The facility's own policy required immediate assessment and intervention review after a fall, but this was not followed, as evidenced by the lack of documentation and care plan updates.
Failure to Review and Discontinue Unnecessary Antibiotic Use
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary medications. One resident with diagnoses of chronic heart failure, chronic kidney disease, and atrial fibrillation was receiving Bactrim DS 800-160 mg three times a week since mid-January, with the order initiated due to high-dose steroid use. However, there was no documented diagnosis or ongoing indication for the continued use of this antibiotic on the medication administration record. Physician's orders and oncology notes were requested but not provided, and the medication had not been reviewed for necessity since its initiation. Interviews with facility staff, including a registered nurse, pharmacy consultant, nurse practitioner, and the director of nursing, confirmed that the resident's antibiotic use was not being monitored or reviewed monthly as required. The pharmacy consultant stated that an antibiotic stewardship program had not yet been established, and the nurse practitioner noted the medication was not on the current clinic medication list and should have been discontinued as steroid use decreased. The director of nursing acknowledged the lack of monthly review and monitoring for unnecessary medication use, and the facility did not have an infection preventionist to track antibiotic use. The facility's policy on medication administration and unnecessary medication use was requested but not received.
Failure to Provide Routine Grooming and Shaving Assistance
Penalty
Summary
The facility failed to provide adequate assistance with routine grooming care, specifically facial hair removal, for three residents who required help with activities of daily living (ADLs). Observations revealed that each of these residents had significant facial hair growth, despite their care plans indicating a need for moderate to maximal assistance with personal hygiene, including shaving. Interviews with the residents and their representatives confirmed that daily shaving was preferred, and the presence of facial hair was bothersome to them. Staff interviews indicated a lack of awareness regarding the residents' grooming preferences and the frequency with which shaving should be offered. Multiple nursing assistants, some of whom were new to the facility, reported that shaving was typically performed only on residents' bath days, which occurred once a week. None of the nursing assistants interviewed were aware of the specific preferences of the residents regarding shaving frequency, and they assumed that additional shaving would only be provided upon request. Further interviews with the RN and DON revealed that the expectation was for residents to be shaved every morning, but this was not being consistently implemented. The DON was unaware if residents' shaving preferences were assessed upon admission or included in their care plans. Additionally, when requested, the facility was unable to provide a policy for grooming or ADL care, indicating a lack of formal guidance for staff regarding these essential care practices.
Survey Results and Plan of Correction Not Accessible
Penalty
Summary
The facility failed to ensure that three years of survey results and corresponding plans of correction were readily accessible to residents or visitors. During an observation, the survey results binder was found on a shelf in a sitting area by the front door, but it only contained the most recent survey results and lacked the required plan of correction for those results. Additionally, the binder did not include survey results or plans of correction from previous years as required. The administrator and DON confirmed that their process was to keep only the most recent survey results in the binder and not the past three years. When asked, the facility was unable to provide a policy regarding survey inspection results.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Waconia
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Good Samaritan Society - Waconia And Westview Acre | 0.3 mi | — | 21 | 0 |
| Lake Minnetonka Shores | 10.1 mi | — | 0 | 0 |
| Auburn Manor | 10.4 mi | — | 8 | 0 |
| Haven Homes Of Maple Plain | 12 mi | — | 4 | 0 |
| The Estates At Excelsior Llc | 12.4 mi | — | 18 | 1 |
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