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Complaint Investigation

Birch Creek Post Acute & Rehabilitation

November 19, 2025 · Tacoma, WA · 5601 S Orchard Street
Citations 2
CMS Rating 1/5
Beds 124
Provider ID 505289
Healthcare Facility
Birch Creek Post Acute & Rehabilitation
Tacoma, WA  ·  View full profile →
Inspection Summary

BIRCH CREEK POST ACUTE & REHABILITATION in TACOMA, WA — inspection on November 19, 2025.

Found 2 citations. 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.

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Inspection Findings

FF0610
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Potential for More Than Minimal Harm

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).

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

11/19/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Birch Creek Post Acute & Rehabilitation

5601 S Orchard Street Tacoma, WA 98409

SUMMARY STATEMENT OF DEFICIENCIES

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)

Facility ID:

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in TACOMA, WA, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from BIRCH CREEK POST ACUTE & REHABILITATION or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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