Salmon Creek Post Acute & Rehabilitation
Inspection Findings
F-Tag F0760
F 0760
Ensure that residents are free from significant medication errors.
Level of Harm - Minimal harm or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review, the facility failed to ensure residents were free from medication and/ or treatment errors when medications and or treatments were not administered in accordance with provider orders for 1 of 3 sampled residents (Resident 1) reviewed for medication errors. This failure placed residents at risk of adverse medical conditions, a change in health conditions, and a diminished quality of life. Findings included .Review of the facility policy, Medication Administration Section 7.1, General Guidelines, dated January 2023, noted, Medications are administered in accordance with written orders of
the prescriber . The individual who administers the medication dose records the administration on the resident's MAR [Medication Administration Record] immediately following the medication being given.Resident 1 was admitted to the facility on [DATE REDACTED] with diagnoses including Diabetes Mellitus II [a chronic condition characterized by high blood sugar] and Peripheral Vascular Disease [a chronic disease affecting the blood vessels, typically in the legs, causing narrowing of blood vessels and reduction of blood flow]. The admission Minimum Data Set (MDS- an assessment tool) assessment, dated 07/01/2025, showed Resident 1 had moderately impaired cognition.Record review of Resident 1's care plan, dated 08/20/2025, showed Resident 1 had a care focus area for skin impairment involving three open areas to their left lower extremity, an open area on the buttocks, and impaired skin integrity to the right heel.
Interventions included provide treatments as ordered.Record review of Resident 1's MAR and Treatment Administration Record (TAR), dated July and August 2025, showed Resident 1 had the following wound care orders:Once daily: Bilateral heels: cleanse with NS [normal saline] or wound cleanser, apply cut to fit calcium alginate [wound dressing to help absorb drainage and promote healing] to wound beds and cover with bordered foam dressing;Once daily: Bilateral heel wounds, cover wound with Betadine [skin disinfectant] soaked gauze, cover wet gauze with a layer of dry gauze. Wrap in kerlix (rolled gauze) to keep dressings in place.The MAR and TAR showed Resident 1 did not receive the above wound care treatments
on 07/16/2025, 08/06/2025, 08/11/2025, and 08/16/2025.Record review of Resident 1's progress notes, dated 06/01/2025-09/04/2025, showed no documentation that Resident 1 received their wound care treatments or why they did not receive their wound care treatments for 07/16/2025, 08/11/2025, and 08/16/2025. A progress note dated 08/06/2025 showed that wound care was provided by an outside provider, but was not noted on the MAR/TAR.In an interview on 10/09/2025 at 3:15PM, Staff B, Registered Nurse and interim Director of Nursing, said the expectation for nurses was to administer medications, care, or treatments according to the providers' orders.Reference WAC 388-97-1060 (3)(k)(iii)
Residents Affected - Few
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 REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99) Previous Versions Obsolete
Facility ID:
If continuation sheet
Event ID:
SALMON CREEK POST ACUTE & REHABILITATION in VANCOUVER, WA inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
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 VANCOUVER, 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 SALMON CREEK POST ACUTE & REHABILITATION or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.