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Complaint Investigation

Birch Creek Post Acute & Rehabilitation

March 26, 2026 · Tacoma, WA · 5601 S Orchard Street
Citations 3
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 March 26, 2026.

Found 3 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

FF0689
Quality of Life and Care Deficiencies

call light, which according to Staff E, the resident used, occasionally.

During an interview on [DATE] at 3:06 PM, Staff B stated with Resident 6 that it would be difficult to ensure they did not fall without providing one-on-one supervision.

Even if staff were to ask Resident 6 if they needed to go to the bathroom, they would say no and then impulsively would get up without calling for assistance.During an interview on [DATE] at 4:35 PM, Staff A, Administrator, stated they did not feel there were any meaningful interventions that could have been implemented to minimize Resident 6's fall risk as the root cause was cancer; treatments and subsequent adverse effects.

Reference WAC 388-97-1060(3)(g).

505289 03/26/2026

Birch Creek Post Acute & Rehabilitation 5601 S Orchard Street Tacoma, WA 98409

for Post Void Residuals (PVRs - determine how much urine is left in the bladder after voiding) every shift and if greater than 300 MLs, then straight catheter (insert a single-use tube to empty the bladder and immediately remove). On the third straight catheter the nurse would notify the provider and put the urinary catheter back in.

During an interview on 03/26/2026 at 3:35 PM, Staff B, interim Director of Nursing, stated they would expect staff to try to reach the urologist's office to obtain orders, put on alert, perform PVRs using a bladder scan (non-invasive ultrasound) and document monitoring.

Reference WAC 388-97-1060 (3)(c).

505289 03/26/2026

Birch Creek Post Acute & Rehabilitation 5601 S Orchard Street Tacoma, WA 98409

Review of the narcotic book showed the last dose was documented as administered on [DATE] at 8:00 PM and 42 pills remained, but looking at the card of pills showed only 40 pills remaining.In an interview at that time, Staff I stated they gave the Tramadol at 8:00 AM, as ordered, but did not sign it out at that time.

Staff I then proceeded to sign out both the 8:00 AM and 2:00 PM doses.

During an interview on [DATE] at 4:35 PM, Staff A, Administrator, stated many of the medication concerns brought forward by residents involved agency/temporary nurses and they were actively recruiting nursing staff. REFERENCE: WAC 388-97-1080(1)

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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