Birch Creek Post Acute & Rehabilitation

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

with a goose egg (a visible bump) on their forehead. Resident 5 was also observed with bruising on their back. When asked, Resident 5 said they fell out of bed and a man picked them up. CC1 and CC2 said they reported it to the nurse at 9:00 AM, and management around 4:00 PM.On 11/07/2025 at 3:54 PM Resident 5 was observed with Staff C, Assistant Director of Nursing. Observed on Resident 5's right frontal forehead was a raised bump, green and yellow in color, which was the approximate size of a 50-cent piece. On Resident 5's back, on the right, was a red purple discoloration, which Staff C stated felt raised and looked like their skin was pinched. The bed had no side rails, instead there were soft side bolsters in place which Staff C stated they put on the bed a couple of days after Resident 5's admission.During an interview on 11/07/2025 at 4:08 PM, Staff D, Charge Nurse, stated that Resident 5 stated they fell but they were only oriented to self. Resident 5 stated a black man picked them up, but there were no men working. Staff D said

they did a neurological assessment, placed fall mats down at the request of the family and updated the care plan. Staff D stated the forehead bruise was yellow and green in color, indicating it was an old bruise. When asked what the expectation was for an injury of unknown origin, Staff D replied, call the provider and file a report. When asked if they had filed an incident report, Staff D replied no and noted their mindset was to find out if the resident fell.During an interview on 11/07/2025 at 4:13 PM, Staff E, Unit Manager, stated they interviewed staff, but there were still people they needed to talk to. Staff E stated they determined the resident did not fall. Staff E stated they were not able to determine what occurred.During an interview on 11/07/2025 at 4:21 PM, Staff B, Director of Nursing, stated Resident 5 said they fell on the floor and white men came and picked them up. Staff B stated Staff E talked to staff that worked the night prior and there were no white men on duty, the aids working denied the resident fell, none of them could have picked the resident up and put them to bed. Staff B stated Resident 5 was confused, cognitively impaired and what

they said occurred did not occur. Staff B stated the yellow bruise on their forehead which would be by definition more than seven days/a week old, and the resident was not in the facility that long. When asked if

the bruise was an unknown origin, in an area not vulnerable to trauma, Staff B replied yes.Reference WAC 388-97 -0640 (6)(a)(b).

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/19/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Birch Creek Post Acute & Rehabilitation

5601 S Orchard Street Tacoma, WA 98409

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0744 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

interventions to mitigate Resident 1's behaviors were re-direction, keeping them occupied, sitting at the front desk with the receptionist. Resident 1's family was involved and took Resident 1 out on outings. In addition, staff put up stop signs for residents whose rooms Resident 1 wandered into.RESIDENT 2Review of the 10/28/2025 MDS showed Resident 2 had a diagnosis of dementia, exhibited fluctuating levels of consciousness, and did not exhibit behavioral symptoms.Review of the 08/25/2025 Behaviors CP, revised 09/02/2025 showed Resident 2 exhibited behaviors of fidgeting, trying to pick up items on the floor that aren't there, refuses to sleep in bed, restlessness, anxiety, and refusal of skin checks. The listed goal was that the resident's behaviors will not cause them or other residents' distress. Interventions included approach with a calm quiet voice, divert attention, assure the resident they are safe and being cared for, redirect resident to subjects that matter to them when behaviors occur and monitor behavior episodes and attempt to determine the underlying cause.Review of the 08/21/2025 Risk for Pain CP directed staff to observe for signs and symptoms of nonverbal pain included but not limited to restlessness and yelling out.Review of progress notes dated 11/03/2025 at 12:15 PM showed Resident 2 was yelling out for assistance, looking for momma. Resident and roommate with disagreement due to Resident 2 yelling out.

An 11/04/2025 7:54 PM note showed Resident 2 became restless, agitated and yelling out getting ready for dialysis. A 11/04/2025 3:57 AM note showed Resident 2 was yelling out during the earlier parts of the evening shift. A 11/06/2025 4:00 PM note showed Resident 2 was yelling out Get me off this bed and requesting to go sit in their wheelchair.Review of the nursing assistant documented behavior monitoring showed Resident 2 exhibited yelling/screaming on night shift of 11/05/2025, day shift of 11/07/2025, evening shift 11/11/2025 and night shift 11/12/2025.Review of the resident's clinical record showed no detailed assessment of Resident 2's behavior of yelling out. Review of the 09/02/2025 Behavior CP showed there were not targeted and individualized interventions for the behavior of yelling out.During an interview

on 11/07/2025 at 10:50 AM, Resident 3 stated they did not like how the staff let Resident 2 yell out all night.

Staff don't go check and the screaming for help is what bothers me. Resident 3 stated that Resident 2 gets louder and louder the longer it goes on and noted that if the staff go in and talk to them then the screaming goes down.During an interview on 11/19/2025 at 11:00 AM, Resident 7 stated there was some lady down

the hallway that frequently loudly screamed help, help.During an interview on 11/19/2025 at 11:55 AM, Resident 10 stated their previous roommate, Resident 2, would shout all the time. Resident 10 stated Resident 2 had dementia so they ignored some of it, but it bothered them, Resident 2 would wake up screaming Help me, Help me! During an interview on 11/19/2025 at 11:07 AM, Staff H stated Resident 2 had called out in the past, it was hard for them to stay in their chair as they wanted to get out. Staff H noted that lately Resident 2 was pretty calm.REFERENCE: WAC 388-79-1040(1)(a-c)

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