Birch Creek Post Acute & Rehabilitation
BIRCH CREEK POST ACUTE & REHABILITATION in TACOMA, WA — inspection on March 13, 2026.
Found 19 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.
Inspection Findings
Findings included.Resident 5
Review of the electronic health record (EHR) showed Resident 5 admitted on [DATE] with diagnoses to include Parkinson's disease (a progressive movement disorder that occurs when nerve cells in the brain die) and adult failure to thrive. Resident 5 was able to make needs known.
Review of a Multidisciplinary Care Conference form, dated 07/23/2025, showed Resident 5's advanced directive was reviewed and assistance offered.
Review of a progress note, dated 03/11/2026, showed Resident 5 believed they had established a durable power of attorney, but the facility had not obtained this document.
Resident 4
Review of the EHR showed Resident 4 admitted to the facility on [DATE] with diagnoses to include multiple sclerosis (a chronic autoimmune disease of the central nervous system) and dementia (a decline in mental ability, such as memory loss, poor judgment, or confusion). Resident 4 could not make needs known.
Review of a Social Service Initial Evaluation, dated 12/03/2025, showed Resident 4 did not have an advanced directive, but would like to establish one.
Review of a progress note, dated 03/11/2025, showed Resident 4 believed they had an advanced directive, but was unsure.
During an interview on 03/11/2026 at 11:05 AM, Staff J, Social Services Director, stated the facility asked residents about their advanced directive during the initial care conference and would obtain a copy of any advanced directive a resident had established.
Staff J stated if a resident did not have an advanced directive, they would provide information on how to establish one using an advanced directive information sheet.
Staff J stated residents' advanced directive choices would be reviewed quarterly with care conferences.
During a follow-up interview on 03/12/2026 at 12:13 PM, Staff J stated Resident 5 had not had an advanced directive review between 07/23/2025 and 03/11/2026 and Resident 4 had not had follow-up on their advanced directive between 12/03/2025 and 03/11/2026.
During an interview on 03/13/2026 at 9:26 AM, Staff A, Administrator, stated advanced directives should be reviewed quarterly with care conferences.
Reference WAC 388-97-0280(3)(c)(i)(ii), -0300(1)(b)(3)(a)-(c)
505289 03/13/2026
Birch Creek Post Acute & Rehabilitation 5601 S Orchard Street Tacoma, WA 98409
Findings included.
Resident 18Review of a Notice of Medicare Non-Coverage (NOMNC), dated 10/23/2025, showed the facility informed Resident 93 and/or representative that skilled nursing services would end on 10/27/2025.
Review of Resident 18's SNF ABN dated 03/09/2025 showed, Beginning on 10/28/2026 you may have to pay out of pocket for this care if you do not have other insurance that may cover these costs.
However, the section of the form that was to list Care was blank.
Review showed the form was provided and signed by Resident 18 on 03/09/2026.
Resident 54Review of a NOMNC, dated 02/13/2025, showed the facility informed Resident 54 that skilled nursing services would end on 02/16/2025.
Review of Resident 54's SNF ABN dated 03/09/2025 showed, Beginning on 02/17/2026 you may have to pay out of pocket for this care if you do not have other insurance that may cover these costs.
However, the section of the form that was to list Care was blank.
Review showed the form was provided and signed by Resident 54 on 03/09/2026.
During an interview on 03/11/2026 at 12:06 PM, Staff J, Director of Social Services, stated Resident 18's SNF ABN and Resident 54's SNF ABN both dated 03/09/2026 did not meet expectations because the section for Care on both forms had no care listed and should have been provided and signed by Resident 18 and Resident 54 sooner than 03/09/2026.
During an interview on 03/11/2026 at 12:18 PM, Staff A, Administrator, stated Resident 18's SNF ABN dated 03/09/2026 was missing listed Care on the form and should have been provided when their NOMNC was provided on 10/23/2025.
Staff A stated Resident 54's SNF ABN dated 03/09/2026 was missing listed Care on the form and should have been provided when their NOMNC was provided on 02/13/2025.
Staff A stated their expectation was that SNF ABN forms were filled out completely and provided as required when NOMNCs were issued.
Reference WAC 388-97-0300(1)(e)(5)(6)
505289 03/13/2026
Birch Creek Post Acute & Rehabilitation 5601 S Orchard Street Tacoma, WA 98409
Findings included.Observation and interview on 03/08/2026 at 1:07 PM showed room [ROOM NUMBER]'s bathroom with a gouge in the floor at the entry way and two large scrapes and gouges, black scrapes, and chipped paint on the wall to the right of the sink. Resident 11 stated they were surprised the gouge in the floor did not interfere with entering or leaving the bathroom when using their wheelchair.
Observation of room [ROOM NUMBER] on 03/08/2026 at 1:13 PM showed Resident 31's closet was missing a door exposing all items in the closet.
During an interview on 03/13/2026 at 9:14 AM, Resident 31 stated they were not aware that their closet door was missing.
Observation of room [ROOM NUMBER] on 03/08/2026 at 1:18 PM showed both closets were missing doors exposing Resident 71's and Resident 98's items in the closets.
During an interview on 03/13/2026 at 9:17 AM, Resident 71 stated they would prefer to have a closet door, but the closet had not had one since being admitted to the facility.
During an interview on 03/13/2026 at 1:20 PM, Resident 98 stated the closets in the room had been missing for about a year. Resident 98 stated, It would be nice to have closet doors if they had any to spare.
Observation and interview on 03/08/2026 at 2:22 PM showed a closet door in room [ROOM NUMBER] was missing, exposing Resident 121's personal items. Resident 121 stated they would like to have a closet door and did not know why they did not have one.
During an interview on 03/13/2026 at 9:23 AM, Staff S, Certified Nursing Assistant, stated room [ROOM NUMBER]'s bathroom entry was missing a piece out of the floor and the wall was dented, had chipped paint and scrapes.
Staff S stated they had not noticed it before and did not document it in TELS (electronic system to put in a work order for items/issues to be fixed, repaired, or replaced).
Staff S stated that closet doors were missing in rooms [ROOM NUMBER], and that they had been that way for a while.
Staff S stated they did not document it in TELS because maintenance should have been checking the environment for those issues and fixed them.
During an interview on 03/13/2026 at 9:33 AM, Staff T, Maintenance Director, stated if staff were to notice items in need of repair or replacement then they should put in a work order in the TELS system.
Staff T was able to show the TELS system on their mobile device and stated they checked work orders throughout the day to resolve reported issues.
Staff T stated that closet doors were missing in rooms [ROOM NUMBER], and they were only aware of room [ROOM NUMBER]'s missing closet door; however, they were not aware of the other missing closet doors on the 200 hall.
Staff T stated these issues did not create a homelike environment and should have been addressed sooner.
During an interview on 03/13/2026 at 9:46 AM, Staff A, Administrator, stated their expectation was for staff to put in a work order into TELS when there were issues needing to be fixed/repaired or replaced.
Staff A stated they were not aware of areas in need of repair in room [ROOM NUMBER]'s bathroom or of missing closet doors on the 200 hall.
Staff A stated issues on the 200 hall should have been addressed with a work order completed in TELS and these issues were not their idea of a homelike environment.
Reference WAC 388-97-0880, -2040
505289 03/13/2026
Birch Creek Post Acute & Rehabilitation 5601 S Orchard Street Tacoma, WA 98409
During an interview on 03/10/2026 at 9:55 AM, Staff D, Licensed Practical Nurse, stated Resident 88
but did not.
During an interview on 03/10/2026 at 2:43 PM, Staff B, DNS, stated it was their expectation that Resident 88 be monitored for adverse side effects of antianxiety and antidepressant medications and should have had a behavior monitor in place.
Reference WAC 388-07-1060(3)(k)(i) -0620(1)(a)
505289 03/13/2026
Birch Creek Post Acute & Rehabilitation 5601 S Orchard Street Tacoma, WA 98409
Review of the
12/18/2025, 12/21/2025, 12/22/2025, 12/24/2025, 01/01/2026, 01/10/2026, 01/21/2026,
dates showed the following investigations did not include witness statements and/or interviews with assigned facility staff members: 10/05/2025,10/11/2025, 11/12/2025, 11/24/2025, 12/17/2025, 12/18/2025, 12/21/2025, 12/22/2025,12/24/2025, 01/01/2026, 01/21/2026, 01/25/2026, and 01/27/2026.
Review of two incident reports for unwitnessed falls by Resident 32, which were not included in the incident log, dated 12/05/2025 and 02/14/2026, showed they did not include witness statements and/or interviews with assigned facility staff members.
During an interview on 03/13/2026 at 9:28 AM, Staff A, Administrator, stated staff should be interviewed after an unwitnessed fall to assist in ruling out abuse/neglect.
Reference WAC 388-97-0640(6)(a)(b)
505289 03/13/2026
Birch Creek Post Acute & Rehabilitation 5601 S Orchard Street Tacoma, WA 98409
During an interview on 03/12/2026 at 11:58 AM, Staff E, MDSC/Registered Nurse, stated Resident 40 should not have been marked Yes for anticoagulant.
Reference WAC 388-97-1000(1)(a)(b)(4)(a)
505289 03/13/2026
Birch Creek Post Acute & Rehabilitation 5601 S Orchard Street Tacoma, WA 98409
making it difficult to breathe), depression, bipolar disorder, and post-traumatic stress disorder (a
09/18/2024, showed it was completed by the admitting hospital and referral for a level two PASSAR
interview on 03/13/2026 at 9:27 AM, Staff A, Administrator, stated if the PASSAR was completed by the hospital prior to admission, the facility would re-complete the PASSAR if it was inaccurate.
Staff A stated if a resident received a new mental health diagnosis, social services would re-complete the PASSAR.
Reference WAC 388-97-1915(1)(2)(a)-(c)
505289 03/13/2026
Birch Creek Post Acute & Rehabilitation 5601 S Orchard Street Tacoma, WA 98409
During an interview on 03/11/2026 at 11:48 AM, Staff B, DNS, stated the care plan should be developed based on the assessment and needs.
Reference WAC 388-07-1020(1)(2)(a)(b)
505289 03/13/2026
Birch Creek Post Acute & Rehabilitation 5601 S Orchard Street Tacoma, WA 98409
During an interview on 03/11/2026 at 11:52 AM, Staff B, Director of Nursing Services, stated the expectation was for the care plans to be updated timely.
Reference WAC 388-07 -1020(2)(c)(d)
505289 03/13/2026
Birch Creek Post Acute & Rehabilitation 5601 S Orchard Street Tacoma, WA 98409
During an interview on 03/11/2026 at 11:43 AM, Staff B, Director of Nursing Services (DNS), stated the medications were to be administered following the orders and holding the medications per the provider's order.
Reference WAC 388-07- 1060(1)-(3)
505289 03/13/2026
Birch Creek Post Acute & Rehabilitation 5601 S Orchard Street Tacoma, WA 98409
Review of the admission minimum data set (MDS) a required assessment dated [DATE], showed Resident 111 was admitted to the facility with one sacral (large triangular bone at the base of the spine) stage two pressure ulcers (loss of partial thickness of the skin related to pressure injury).
Air Mattress Observation on 03/08/2026 at 12:10 PM, showed Resident 111 lying in bed with air mattress that was set at the highest pressure and had a blinking light signaling low pressure.
Observation on 03/09/206 at 1:35 Pm showed Resident 111 in bed with air mattress set at the highest pressure and signaling with blinking light low pressure.
During an interview on 03/09/2026 at 2:28 PM, Staff D, Licensed Practical Nurse (LPN), stated the air mattress was rental and that was set up by the company and its correct.
During an observation and interview on 03/10/2026 at 9:56 AM, Resident 111 was receiving care from hospice team.
Air mattress was set up on highest pressure and had blinking light about low pressure.
Staff Q, Hospice RN, stated that it was in error and would contact the company.
During an interview on 03/11/2026 at 11:57 AM, Staff A, Administrator, stated the air mattresses should be used according to the manufacture settings, and Resident 111 air mattress low pressure signal did not meet expectations.
Lack of Documentation Review of the care plan dated 12/12/2025, showed Resident 111 had a skin impairment to the right forehead, and no pressure ulcer or potential for it.
Review of the wound evaluation weekly form dated 12/22/2025, showed abrasion (skin Injury) to right side of forehead and did not show sacral pressure ulcer.
Review of the weekly skin observations completed on 12/17/2026,12/25/2025, 01/01/2026, 01/08/2026, 01/21/2026, 01/29/2026 and 02/04/2026 did not describe size, color, secretion of the sacral pressure ulcer
During an interview on 03/10/2026 at 1:38 PM, Staff D, Licensed Practical Nurse (LPN), stated monitoring of pressure ulcers is documented in the weekly skin observation by the nurses, and it should have measurements and appearance.
During an interview on 03/11/2026 at 11:53 AM< Staff B, Director of Nursing Services, stated pressure ulcers should be assessed on admission and then weekly after to include measurements and appearance.
Reference WAC 388-07- 1060(3)(b)
505289 03/13/2026
Birch Creek Post Acute & Rehabilitation 5601 S Orchard Street Tacoma, WA 98409
Findings included.
Review of the electronic health record (EHR) showed Resident 5 admitted on [DATE] with diagnoses to include Parkinson's disease (a progressive movement disorder that occurs when nerve cells in the brain die) and adult failure to thrive. Resident 5 was able to make needs known.
During an interview and observation on 03/08/2026 at 10:46 AM, Resident 5 stated a staff member had been transferring them from the bed to a wheelchair and the resident's leg had been scratched on the wheelchair.
Observation showed Resident 5's leg was bandaged from ankle to knee.
Review of the Accident and Incident Log showed an incident for Resident 5 on 02/27/2026 with superficial injury, related to the resident's condition.
Review of the care plan, initiated 11/18/2024, showed a focus area for skin impairment to the left lower leg with an intervention for referral to an outside wound care provider.
Review of the incident report, dated 03/03/2026, showed, Nursing Description: Resident observed with a skin tear to [their] left lower leg, and Resident Description: Resident stated [they] accidently bumped [their] leg on the side of [their] bed railing.
Review did not show a resident statement or witness statements were included.
Review showed the conclusion was Resident 5 hit their leg on the bed rail.
Review of the outside wound care provider's wound assessment progress note, dated 03/04/2026, showed Resident 5 reported they were injured getting into their wheelchair.
During an interview on 03/12/2026 at 11:04 AM, Staff K, Certified Nursing Assistant (CNA), stated they were assisting Resident 5 transfer into a wheelchair on 02/27/2026 when the resident's leg was scratched by the wheelchair.
Staff K stated they were not interviewed as part of the investigation and were not asked to write a statement of events.
During an interview on 03/12/2026 at 12:29 PM, Staff B, Director of Nursing Services, stated when a resident was injured the facility would generally interview the resident and staff, collect statements, and review the record.
Staff B stated Resident 5 was not reassessed for level of support required for transfer to reduce the likelihood of recurrence.
Reference WAC 388-97-1060(3)(g)
505289 03/13/2026
Birch Creek Post Acute & Rehabilitation 5601 S Orchard Street Tacoma, WA 98409
Findings included.
Review of the electronic health record (EHR) showed Resident 26 was admitted to the facility on [DATE] with diagnoses to include heart failure, end stage renal disease (kidney failure), and dependence on renal dialysis (life sustaining treatment that filters waste and excess fluid from the blood). Resident 26 was able to communicate their needs.
Observation on 03/08/2026 at 10:10 AM showed Resident 26 sitting in their chair with a small water bottle on top of the overbed table. Resident 26 stated they were on a fluid restriction because of their health condition.
Review of a provider's order, dated 02/18/2026, showed Resident 26 was on a fluid restriction of 1000 milliliters (ml) per day to include breakfast, lunch, dinner, and supplements, with dietary/kitchen to provide 720 ml and nursing staff to provide up to 280 ml a day.
Review of the March 2026 medication administration record (MAR) showed total consumed discrepancies on the following dates:03/01/2026 - Day 1000 ml, Night 140 ml, and total consumed 420 ml.03/02/2026 - Day 140 ml, Night 1000 ml, and total consumed 1000 ml.03/03/2026 - Day 140 ml, Night 280 ml, and total consumed 300 ml.03/04/2026 - Day 300 ml, Night 240 ml, and total consumed 120 ml.
Continued review of March 2026 MAR showed this discrepancy in documentation continued until 03/11/2026.
During an interview on 03/11/2026 at 11:09 AM, Staff H, Licensed Practical Nurse, stated residents with fluid restrictions did not receive water pitchers and the total amount consumed was documented in the MAR.
During an interview on 03/11/2026 at 11:37 AM, Staff B, Director of Nursing Services, stated license nurses were to follow the orders and document clearly in the MAR.
Reference WAC 388-07-1060(3)(i)
505289 03/13/2026
Birch Creek Post Acute & Rehabilitation 5601 S Orchard Street Tacoma, WA 98409
The facility failed to have a system in place which ensured the amount of enteral formula (liquid food product) a resident received was reconciled with the amount they were ordered to receive.
This failure placed the residents at risk for inadequate nutrition, dehydration, and adverse outcomes.
Findings included.
Review of the electronic health record (EHR) showed Resident 87 was admitted to the facility on [DATE] with diagnoses to include cerebral infarction (blockage of blood flow to the brain causing cell death), gastrostomy (feeding tube inserted directly into the stomach through the abdominal wall to provide nutrition and medication), anxiety, and depression. Resident 87 could not communicate their needs.
Observation on 03/10/2026 at 1:12 PM showed Resident 87 in bed with tube feeding formula being infused through the gastrostomy.
Review of providers orders for March 2026 showed Resident 87 to receive enteral feed with Jevity (tube feeding formula) 55 milliliters (ml) for 20 hours every day for a total of 1100 ml in 24 hours, and flush with 100 ml water every four hours for a total of 500 ml in 24 hours.
Feeding started at 2:00 PM and was turned off when completing the amount at 10:00 AM.
License nurses were to document totals with a start date of 02/17/2026.
Review of the March 2026 medication administration record (MAR) showed the following amounts:03/01/2026 - 10:00 AM formula 1050 ml and water 300 ml and at 2:00 PM formula 1050 ml and water 300 ml (total of 2100 ml of formula and 600 ml of water).03/02/2026 - 10:00 AM formula 1050 ml and water 300 ml and at 2:00 PM formula 1050 ml and water 300 ml (total of 2100 ml of formula and 600 ml of water).03/03/2026 - 10:00 AM formula 825 ml and water 300 ml and at 2:00 PM formula 1050 ml and water 300 ml (total of 1875 ml of formula and 600 ml of water).
Review of the March 2026 MAR showed similar documentation through 03/10/2026.
During an interview on 03/10/2026 at 1:12 PM, Staff P, Registered Nurse (RN), stated Resident 87 received nutrition for 20 hours a day and the documentation was at 10:00 AM when the LPN documented what the amount was based on the infusion amount on the machine.
Staff P could not explain why there was documentation at 2:00 PM and stated that it should be zero.
During an interview on 03/10/2026 at 1:29 PM, Staff D, Licensed Practical Nurse, stated that the machine was making the nurses document the amount.
During an interview on 03/11/2026 at 10:50 AM, Staff B, Director of Nursing Services, stated the tube feeding should be administered by the orders and should have a clear amount.
Reference WAC 388-07-1060(3)(f)
505289 03/13/2026
Birch Creek Post Acute & Rehabilitation 5601 S Orchard Street Tacoma, WA 98409
Observation on 03/10/2026 at 11:10 AM
03/09/2026 to have O2 at 2-4 liters continuous via NC to keep O2 above 92% every shift.
Review
routinely.
During an interview on 03/11/2026 at 2:43 PM, Staff B, DNS, stated Resident 67 was missing orders to change O2 tubing and to clean the O2 concentrator filter and they needed to be obtained from the provider.
Reference WAC 388-97 -1060(3)(j)(iv)-(vi)
505289 03/13/2026
Birch Creek Post Acute & Rehabilitation 5601 S Orchard Street Tacoma, WA 98409
505289 03/13/2026
Birch Creek Post Acute & Rehabilitation 5601 S Orchard Street Tacoma, WA 98409
Findings included.
Review of the electronic health record showed Resident 13 admitted to the facility on [DATE] with diagnoses to include anxiety disorder, dementia (a decline in mental ability, such as memory loss, poor judgment, or confusion), and schizophrenia (a chronic, severe mental disorder characterized by disruptions in thought processes, perceptions, and emotional responsiveness, causing individuals to lose touch with reality). Resident 13 was able to make needs known.
During an interview on 03/08/2026 at 12:25 PM, Resident 13 stated their dentures had been left in their rental when they moved into the facility and there was no way for them to retrieve them.
Review of a Preventative Report from an outside dental provider, dated 06/05/2025, showed, [Resident 13] would like to enroll to see if [they] can get a new set of dentures and based on clinical need it was ASAP (as soon as possible).
Review of the care plan, initiated 11/23/2021, showed Resident 13 had no teeth with an intervention to refer to dentist as needed.
Review showed no documentation of Resident 13's need for dentures.
During an interview on 03/12/2026 at 1:15 PM, Staff O, Assistant Director of Nursing (ADON), stated Resident 13 had a dental report from 06/05/2025 which showed the resident requested new dentures.
Staff O stated they were unsure if this request had follow-up.
During an interview on 03/13/2026 at 10:22 AM, Staff V, Transportation Aid, stated they scheduled follow-up dental appointments for residents.
Staff V stated Resident 13 did not have any dental appointments after 06/05/2025.
During an interview on 03/13/2026 at 10:33 AM, Staff B, Director of Nursing Services, stated when a resident needed dentures they would be referred to a dentist as soon as the facility was aware.
Staff B stated dental services should be provided at the time the resident requests it.
During an interview on 03/12/2026 at 10:53 AM, Staff O, ADON, stated the facility did not follow up on Resident 13's request for dentures.
Reference WAC 388-97-1060(1)(3)(j)(vii)
Findings included .
Review of the Resident Council meeting minutes for October 2025 showed, Would like to see honesty with the names of foods on the menus and what is served.
Review of the Resident Council meeting minutes for November 2025 showed, Menu does not always seem to match what is served.
Soup is frequently not what is on the menu for the day and the serving sizes vary.
Sometimes the bowl is full and sometimes the bowl is half full and frequently not warm enough.
If changes are to be made to the menu or brands, such as the coffee, please notify patients prior to any changes.
Review of the Resident Council Minutes for January 2026 showed, Frequently do not get what is on the menu- example: western omelet, only egg and cheese, was not omelet, it was baked.
Review of the Resident Council Minutes for February 2026 showed, Request notification on days when the menu needs to be changed for any reason.
Review of the menu for 03/11/2026 showed chicken legs would be served as the lunch protein with 4 ounces (oz) of scalloped potatoes and 4 oz of peas.
Observation on 03/11/2026 at 11:48 AM showed Staff R, Cook, serving chicken thighs, peas with a long-handled four oz scoop, and potatoes with a green handled scoop.
Observation showed Staff R filled the long-handled scoop approximately two thirds full when serving.
During an interview on 03/11/2026 at 1:14 PM, Staff R, Cook, stated the long-handled scoop used for peas was four oz and they believed the green handled scoop was also 4 oz.
During an interview on 03/11/2026 at 1:16 PM, Staff N, Dietary Manager, stated they were unsure what size the green handled scoop was and would need to check.
During an interview on 03/11/2026 at 2:38 PM, Staff U, Registered Dietician, stated the facility ensured the meals had enough nutrition by following the menu, which included portion sizes.
Staff U stated the green handled scoop used to serve potatoes at lunch was two and two thirds an ounce and the grey handled scoop was four oz and should have been used.
During an interview on 03/12/2026 at 1:58 PM, Staff N, Dietary Manager, stated facility kitchen staff were trained on portion sizes before working in the kitchen.
Staff N stated Staff R, Cook, should have filled the long-handled scoop fully when serving.
Staff N stated they were unsure whether the scoop used to serve potatoes was correct.
Staff N stated chicken thighs were served instead of chicken legs because the facility could not order chicken legs and thighs were the closest they could get.
During an interview on 03/12/2026 at 2:42 PM, Staff A, Administrator, stated the kitchen staff should follow the menu designated portion sizes, and the menu should be altered prior to publication if the facility was unable to purchase a product.
Reference WAC 388-97-1160(1)(a)(b), -1120(3)(c)(4) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.
For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE
505289 03/13/2026
Birch Creek Post Acute & Rehabilitation 5601 S Orchard Street Tacoma, WA 98409
Review of the Resident Council Minutes for December 2025 showed a concern, Hit or miss with the quality of salads.
Resident RefrigeratorsObservation on 03/11/2026 at 2:00 PM showed the North Hall resident refrigerator contained the following: three nutrient drinks frozen in the freezer which showed Do not freeze labeling, one bag of fast food with no date label, a blue bag with two containers soup and one plastic food container without date label, one plastic food container without date label, one cardboard box of Asian food with 03/07 date label, one box pecan pie opened with once slice left with no name or date label, and one Tupperware of unidentifiable food without date label.
Observation showed no temperature log to monitor the temperature of the refrigerator.
Observation on 03/11/2026 at 2:09 PM showed the South Hall resident refrigerator contained the following: two nutrient drinks frozen in the freezer which showed Do not freeze labeling, a large coffee cup wrapped in a plastic bag without name or date label, a bag with three plastic containers of food with a 03/07/2025 date label, a plastic bag with two takeout containers without date label, a bag of grapes dated 02/16 with white film on the product, a large bag of groceries to include cherry tomatoes, grapes, cucumber, and lunch meat without date label, a whole pizza box with three slices of pizza without date label, a box of lemon glycerin swab sticks (used for temporary oral lubrication and refreshing the mouth, often for patients with dry mouth or restricted fluid intake), a plastic container of fried rice without date label, a paper bag with sandwich and fruit with 03/01 date label, and a bag with plastic container of Asian food and chopped salad kit with a best by date of 02/26/2026.
Observation showed the temperature log was for February 2026 and had a single temperature logged.
During an interview on 03/12/2026 at 1:58 PM, Staff N, Dietary Manager, stated food items should not be stored on the floor of the freezer or kitchen and should be date labeled when opened.
Staff N stated food items should be covered when stored and the observations of food left uncovered in the refrigerator and freezer did not meet expectations.
Staff N stated personal items, such as cellphones and accessories, should not be in the kitchen.
Staff N stated cold foods, such as cubed meat, hardboiled eggs, and cottage cheese should be stored with temperature controls and not left out.
Staff N stated Staff R, Cook, should use sanitation wipes between foods and the observation of wiping the thermometer on a dry rag did not meet expectations.
Staff N stated staff should use hair/beard nets to ensure hair did not contaminate food, and the observation of Staff R with uncovered beard did not meet expectations.
Staff N stated maintenance should have been consulted after the temperatures under the expected range were logged on the washing machine log.
During an interview on 03/12/2026 at 2:42 PM, Staff A, Administrator, stated food should be closed and date labeled while stored, and should not be stored on the ground.
Staff A stated cold foods should be held in a temperature-controlled environment before being served and staff personal items should not be stored in the kitchen area.
Staff A stated staff with beards should have them covered and sanitation wipes should be used between taking the temperature of different food items.
Staff A stated when the washing machine was not reaching the required temperature, maintenance should be contacted and chemical cleaners used until repairs were made.
Staff A stated nursing staff was responsible for the monitoring and cleaning of the resident refrigerators.
Staff A stated the resident refrigerators should be monitored for temperature daily, and the lack of temperature monitoring did not meet expectations.
Reference WAC 388-97-1100(3), -2980
505289 03/13/2026
Birch Creek Post Acute & Rehabilitation 5601 S Orchard Street Tacoma, WA 98409