Federal Nursing-Home Survey Record
BIRCH CREEK POST ACUTE & REHABILITATION
Does BIRCH CREEK POST ACUTE & REHABILITATION have a federal violation or abuse history?
According to the public federal record on file with the Centers for Medicare & Medicaid Services (CMS), BIRCH CREEK POST ACUTE & REHABILITATION (CCN 505289), in TACOMA, WA, has federal inspection findings on its record.
In its current inspection cycle, CMS cited the facility for 28 deficiencies; the most serious carries scope/severity G on CMS's A–L scale, a level CMS classifies as actual harm. The most recent federal survey on file is dated 2026-03-13. Citations from earlier inspection cycles appear in the dated timeline below as historical findings, not current ones. This page restates the federal record as published by CMS and draws no conclusion of its own. Federal nursing-home surveys are conducted on a recurring cycle by state survey agencies acting on CMS's behalf, and the figures on this page are compiled from CMS's published provider data, as on file with CMS; the federal record may understate what actually occurred, and inspection findings are point-in-time survey results, not a determination that any specific resident was harmed.
The Federal Record
At its most recent federal inspection, CMS cited this facility for 2 actual-harm deficiencies.
Below is this facility's federal survey record as on file with CMS.
Scope & Severity — current cycle
Overall CMS star rating: this facility vs the CMS-published state average
This facility: 2 · CMS state average: 3.3
Deficiency timeline — full federal history
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
PASARR screening for Mental disorders or Intellectual Disabilities
Respond appropriately to all alleged violations.
Provide safe and appropriate respiratory care for a resident when needed.
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Provide enough food/fluids to maintain a resident's health.
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Ensure each resident receives an accurate assessment.
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Provide or obtain dental services for each resident.
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Provide safe, appropriate pain management for a resident who requires such services.
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Respond appropriately to all alleged violations.
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Provide enough food/fluids to maintain a resident's health.
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Respond appropriately to all alleged violations.
32 citations from earlier inspection cycles — historical, not current (expand)
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Implement a program that monitors antibiotic use.
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
PASARR screening for Mental disorders or Intellectual Disabilities
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Ensure services provided by the nursing facility meet professional standards of quality.
Provide care and assistance to perform activities of daily living for any resident who is unable.
Ensure that residents are fully informed and understand their health status, care and treatments.
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Provide enough food/fluids to maintain a resident's health.
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Provide safe and appropriate respiratory care for a resident when needed.
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Respond appropriately to all alleged violations.
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Document what happened
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