Birch Creek Post Acute: Feeding Safety Failures - WA
The resident, identified in inspection records only as Resident 1, was on a pureed diet. Her son believed the mashed food looked wrong, unrecognizable. He wanted to bring her food that looked like food. "When everything is mashed up, you cannot even see what it is," he told staff during a visit on July 30, 2025.
What he did about that belief is what brought state investigators to the facility.
During a previous stay at Birch Creek, the son had been feeding his mother non-pureed food. Staff responded by supervising his visits while he fed her. The son acknowledged this arrangement to investigators. He said it was inconvenient, but he did not object to being watched.
When Resident 1 returned to the facility for a second admission, nobody reinstated the supervision requirement. The restriction that staff had put in place specifically because of what the son had done was not carried over. He came back to visit. The same thing happened again.
At 3:33 PM on July 30, a staff member identified as Staff F told the son that his mother's diet could not be upgraded from pureed without additional therapy sessions, and that he should not be bringing in outside food. The son told Staff F that nobody had warned him of this before.
Fourteen minutes later, Staff F met with two other employees to discuss the situation. Staff F said the facility needed to make sure any food the son brought in was safe, and that staff would continue seeing Resident 1 during his visits.
Investigators reviewed the facility's own incident investigation summary, sent August 1, 2025. That document found the son had poor comprehension of why forcing a resident's mouth open to let it empty could cause harm. It also noted he was disregarding his mother's right to refuse food and drink, and that his actions could lead to aspiration, physical or mental harm.
Then it concluded there was "no willful action or inaction that inflicts injury."
Investigators disagreed. Their concerns, shared with the facility, were specific: the prior feeding restrictions had not been implemented when Resident 1 was readmitted, the incident was therefore preventable and happened anyway, and after it occurred, staff failed to document any monitoring of the situation.
Aspiration, the risk the facility's own summary named, occurs when food or liquid enters the airway instead of the esophagus. For residents on pureed diets, the texture modification exists precisely because swallowing something of the wrong consistency can send it into the lungs. The consequences range from pneumonia to death.
The inspection was conducted as a complaint investigation and completed August 11, 2025. The level of harm was classified as minimal harm or potential for actual harm, and the number of residents affected was listed as few.
What the records do not show is any documented evidence that staff checked on Resident 1 after the second incident to confirm she had not been harmed. They show a facility that wrote up what happened, named the risk, and still found a way to conclude that no one had done anything wrong.
The son told investigators he had not been informed of the restrictions. Staff said they would keep working with him. Resident 1's own right to refuse what was being put into her mouth went unmentioned in any of those conversations, at least as far as the inspection record shows.
She was the one whose mouth was being forced open.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Birch Creek Post Acute & Rehabilitation from 2025-08-11 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
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Last verified: November 3, 2026 · Our methodology
Birch Creek Post Acute & Rehabilitation in TACOMA, WA was cited for violations during a health inspection on August 11, 2025.
The resident, identified in inspection records only as Resident 1, was on a pureed diet.
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.