Above average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Hudson Bay Health And Rehabilitation during CMS and state inspections, most recent first.
Advance Directive and POA Documentation Not Maintained: The facility failed to consistently address advance directives and maintain POA documentation for two residents. One resident was listed as having a son as POA in the EHR, but no POA paperwork was available, and the resident had no AD documented. Another resident was alert and oriented, had declined an AD on admission, but subsequent care conferences and quarterly reviews did not show that ADs were readdressed or that the resident was offered another opportunity to complete them.
Failure to offer a resident and/or representative the opportunity to participate in care conferences. The resident was alert and oriented, but no care conferences were completed over the past 14 months. Staff documented calls to the son/POA about CC scheduling, but he was unavailable due to work and asked to be contacted later. The Social Services Manager confirmed no CCs had been done over the past year, despite the facility policy calling for resident and representative involvement and allowing participation by phone or video.
Failure to Refer Residents for Level II PASARR Evaluation: The facility failed to refer two residents for Level II PASARR evaluations after Level I screens identified SMI. One resident had bipolar disorder and major depressive disorder with moderate cognitive impairment, and the other had bipolar disorder and anxiety disorder with intact cognition. PASARR records showed conflicting results over time, but EHR review did not show Level II evaluations for either resident, and the SS Director stated the evaluations were not completed correctly.
A resident’s care plan was not revised to match changing code status orders. The record showed conflicting POLST and physician orders, including DNR and FULL CODE entries, while the care plan still reflected a DNR POLST and a goal that CPR would not be initiated. The DON stated the care plan was not updated after the resident was changed back to full code.
Undated opened medications were found in the East med storage room and on Medication Cart 4. An opened multi-dose vial of TB protein derivative in the med refrigerator and three opened insulin pens in the cart drawer were not labeled with open dates, despite facility policy requiring dating when opened.
PPE was not properly used for residents on Contact Precautions and EBP in two rooms. A CNA entered one room without gown or gloves while assisting a resident, and later assisted another resident in the bathroom with gloves but no gown amid confusion about which resident was on precautions because the wrong sign was posted. In another room, a CNA changed linens without a gown despite a Contact Precautions sign at the entrance; the IP and DON stated staff should have worn gown and gloves for Contact Precautions and high-contact EBP care.
A resident reported that her food was usually warm but not hot. During meal service, hot dogs initially measured at a safe temperature but dropped to about 100°F by the end of service, which the Culinary Manager acknowledged was not warm enough.
A resident with a diagnosis of PTSD, who was alert, oriented, and receiving antipsychotic medication, did not have a care plan or trauma-informed care evaluation addressing PTSD. Both the Social Services Director and CNO confirmed the absence of the required care plan, despite facility expectations.
A resident with schizophrenia and mood disorders exhibited crying episodes during an interview, but these behaviors were not documented in the progress notes as required by the care plan. Staff confirmed that such behaviors should be recorded to ensure proper monitoring and intervention.
A resident who was alert and oriented was observed taking an oral medication without staff supervision after a nurse left medications at the bedside. The nurse admitted to leaving the room before ensuring all medications were ingested, and no self-administration evaluation had been completed. Facility policy required staff to observe medication ingestion and not leave medications at the bedside without proper approval.
A resident's bed rail was repeatedly observed to be loose and inadequately secured, despite the resident notifying staff multiple times. Staff confirmed that a work order had been submitted for repair, but the bed rail remained unfixed for several days, contrary to facility policy requiring proper installation and maintenance of bed rails.
A resident with COPD experienced significant medication errors due to incorrect administration of a Prednisone taper and an ADVAIR inhaler. The Prednisone taper was initiated incorrectly, starting with a lower dose than prescribed, and the ADVAIR inhaler was not administered as ordered, leading to a discrepancy in the number of doses remaining. These errors were attributed to an LPN responsible for the administration.
The facility failed to maintain clean kitchen vent covers, with lint observed trapped between the grilles and greasy stove hood filters. The Dietary Manager acknowledged the issue, noting that maintenance was responsible for cleaning the vent covers, while hood filter cleaning was contracted out every six months.
A resident with documented food dislikes continued to receive meals that did not align with her preferences, despite communicating these to the dietary staff. The dietary manager admitted that without a specific menu from nursing staff, the main meal was served by default, leading to a deficiency in accommodating the resident's food preferences.
A facility failed to develop a care plan for a resident's contracted left arm, leading to unmet care needs. The resident's care plan lacked interventions for the contracture, which had worsened over time. Both an LPN and the CNO confirmed the absence of a plan to address the issue.
The facility failed to maintain a safe environment when medication was found on the floor in a resident hallway. An unidentified resident reported a pill on the floor, which was identified as Zoloft by a Registered Nurse. Later, a partial blue pill was found near the nurse's station. Staff acknowledged the issue and expressed that the area should have been searched to ensure no other pills were present.
Advance Directive and POA Documentation Not Maintained
Penalty
Summary
The facility failed to provide and/or have procedures in place to assist with completing advance directives and to obtain and maintain Durable Power of Attorney documentation for 2 of 7 sampled residents. The facility policy stated residents have the right to self-determination regarding medical care, including the right to execute or refuse advance directives, and that advance directive and advance care planning information should be reviewed at admission, quarterly, and when a change in condition is noted. The policy also stated the social services director or designee should document the conversation in the medical record and assist as needed with updating documents. Resident 10 was admitted to the facility and was documented as alert and oriented on the annual MDS. The EHR profile section listed the resident's son as POA, but no POA paperwork was available in the EHR. The resident's multidisciplinary care conference documented that the resident did not have an advance directive, and Staff C, Social Services Manager, stated the facility was behind on advance directives and that this was the only information found for the resident. Resident 6 was admitted to the facility and was documented as alert and oriented on the quarterly MDS. The EHR showed the resident declined to formulate an advance directive on admission and did not have one on file, but the resident's comprehensive care conferences and quarterly clinical evaluations did not indicate that advance directives were addressed or that the resident was offered another chance to formulate them. Staff J, Social Services Assistant, stated advance directives were typically addressed during care conferences, but the resident refused care conferences and she could not provide documentation of readdressing advance directives, describing it as verbal only.
Failure to Offer Care Conference Participation
Penalty
Summary
The facility failed to ensure residents and/or their representatives were offered the opportunity to participate in care conferences for 1 of 3 residents reviewed for care conferences, Resident 10. The facility policy titled, Comprehensive Care Plans & Conference, stated the interdisciplinary team would include the resident and, when appropriate, the resident's representative, and that the facility would actively support resident engagement by explaining the process, scheduling meetings when the resident was most alert, allowing adequate time for discussion, and encouraging the representative to attend. The policy also stated participation could occur in person, by phone, or by video conferencing depending on availability and preference. Resident 10 was admitted to the facility and the annual MDS dated 01/18/2026 indicated the resident was alert and oriented. The last multidisciplinary care conference for Resident 10 was dated 01/27/2025 and showed the resident attended with two family members, but there were no care conferences over the past 14 months. Progress notes documented staff called Resident 10's son/POA about care conference scheduling on 08/08/2025 and 01/19/2026; on both occasions the son said he was unavailable due to work and asked to be contacted later, and the second note stated care conference scheduling was refused at that time. During interview, the Social Services Manager stated care conferences were done quarterly, with a significant change, and annually, and said none had been done for Resident 10 over the past year. The DON stated care conferences should be done quarterly, with a change of condition, or at the resident's request.
Failure to Refer Residents for Level II PASARR Evaluation
Penalty
Summary
The facility failed to refer 2 of 7 residents, Resident 7 and Resident 13, to the state-designated authority for a Level II PASARR evaluation after positive Level I PASARR findings indicated a serious mental illness. Facility policy titled "Pre-admission Screening & Resident Review (PASRR) Process" stated that a positive Level I PASARR screen requires an in-depth evaluation by the state-designated authority, known as a Level II PASARR, prior to admission unless otherwise authorized. Resident 7 was admitted with diagnoses including bipolar disorder and major depressive disorder, and the Quarterly MDS dated 01/14/2026 showed moderate cognitive impairment. PASARR records showed a 05/21/2024 screen with no SMI indicator and no Level II evaluation indicated, a 11/19/2024 screen documenting SMI with anxiety disorder and requiring a Level II referral, and a 12/16/2024 screen again documenting no SMI indicator and no Level II evaluation indicated. Resident 13 was admitted with diagnoses including bipolar disorder and anxiety disorder, and the Quarterly MDS showed cognitive intactness. PASARR records showed a 07/19/2023 screen with no SMI indicator and no Level II evaluation indicated, a 11/21/2023 screen documenting SMI with bipolar disorder and requiring a Level II referral, and a 07/12/2025 screen documenting SMI with mood disorder and no Level II evaluation indicated. Review of both residents' EHRs did not show a Level II evaluation, and the Social Services Director stated on 03/18/2026 that the evaluations were not completed correctly and both residents needed Level II PASARR evaluations completed.
Care Plan Not Updated to Match Code Status
Penalty
Summary
The facility failed to ensure Resident 101’s care plan was revised to accurately reflect the resident’s care needs after the resident’s code status changed. Record review showed the resident was admitted on [DATE], and the Admission/5 day MDS dated [DATE] documented severe cognitive impairment. The record also included a POLST dated [DATE] indicating YES - Attempt Resuscitation/CPR, physician orders dated [DATE] and discontinued [DATE] documenting FULL CODE, physician orders dated [DATE] and discontinued [DATE] documenting DNR, and a physician order dated [DATE] documenting FULL CODE. The Care Plan Report, initiated [DATE], documented a focus that the resident had a DNR POLST in place and a goal that CPR would not be initiated if the resident’s heart stopped or they stopped breathing in honor of the resident’s code status wishes. During an interview on [DATE] at 8:04 AM, the DON/RN stated that after Resident 101 was changed back to full code on [DATE], the care plan was not updated and should have been. The deficiency was cited under WAC 388-97-1020 (2)(a).
Undated Opened Medications Found in Storage Areas
Penalty
Summary
The facility failed to ensure medications were properly labeled with an open date in the East Medication Storage Room and on Medication Cart 4. During observation and interview in the East Medication Storage Room, the medication refrigerator contained an undated, opened multi-dose vial of TB protein derivative. Staff D stated the vial should have been dated when it was opened and it was not. During a separate observation and interview, Medication Cart 4 contained three undated, opened insulin pens in the top drawer. Staff E stated the insulin pens were supposed to be dated when opened and they were not. The facility policy titled Medication Storage & Labeling required multi-dose vials to be dated when first opened and discarded within 28 days unless otherwise specified, and insulin pens to be dated when opened and discarded per the manufacturer’s timeframe, usually 28 days after opening.
PPE Not Properly Worn for Residents on Precautions
Penalty
Summary
The facility failed to ensure staff properly donned PPE for residents on Contact Precautions and Enhanced Barrier Precautions in two sampled rooms. The facility policy for Contact Precautions required staff to put on appropriate PPE before or upon entry into the resident’s environment, and the Transmission-Based Precautions policy described EBP as targeted gown and glove use during high-contact resident care activities. In one room, two resident name tags were posted on the wall by the entrance, with a Contact Precautions sign placed below one resident’s name. A CNA entered and adjusted one resident’s legs on wheelchair foot rests without a gown or gloves, and later assisted the other resident in the bathroom with gloves on but no gown. Staff stated there was confusion about which resident in the room was on Contact Precautions, and the wrong sign had been posted for the room. In another room, a Contact Precautions sign was posted by the entrance, and a CNA changed linens on the bed without a gown. The CNA said she had been told the resident was on precautions related to wounds and believed a gown was not needed unless she was doing wound care. The Infection Preventionist and DON stated staff should have worn a gown and gloves for residents on Contact Precautions and during high-contact activities for residents on EBP.
Failure to Maintain Safe Hot Food Temperatures
Penalty
Summary
The facility failed to ensure that hot food was served at a safe and appetizing temperature. On one occasion, a resident reported that her food was usually warm but not hot. During an observation, hot dogs were measured at over 160 degrees Fahrenheit when first placed on the service line, but by the end of the meal service, the remaining hot dogs had dropped to approximately 100 degrees Fahrenheit. The Culinary Manager confirmed that the hot dogs were not warm enough at that point. These findings were based on direct observation and resident interview.
Failure to Develop PTSD Care Plan for Resident
Penalty
Summary
The facility failed to develop a comprehensive care plan addressing the needs of a resident diagnosed with Post Traumatic Stress Disorder (PTSD). The resident was admitted with PTSD and was documented as alert, oriented, and receiving antipsychotic medication according to the most recent assessment. Upon review, the resident's care plan did not include any focus, goals, or interventions related to PTSD. Both the Social Services Director and the Chief Nursing Officer confirmed that there was no care plan or trauma-informed care evaluation in place for the resident, despite the expectation that such a plan should exist for individuals with this diagnosis.
Failure to Document and Monitor Targeted Behaviors for Resident with Behavioral Health Needs
Penalty
Summary
The facility failed to document and monitor targeted behaviors for one resident with a history of schizophrenia, depression, visual and auditory hallucinations, uncontrollable crying, delusional thoughts, and agitation. The resident was identified as moderately cognitively impaired and had a care plan in place that required monitoring for symptoms such as irritability, agitation, tearfulness, and changes in mood, with documentation of any observed changes and updates to the care plan as needed. During an interview, the resident cried several times when discussing her living situation, a fall, and activities. Although a Licensed Practical Nurse was alerted to these crying episodes, there was no documentation of the incidents in the resident's progress notes. Staff interviews confirmed that such behaviors should have been documented, regardless of who witnessed them, and that documentation is necessary for tracking and intervening in behavioral issues.
Medications Left Unattended and Not Administered per Professional Standards
Penalty
Summary
A deficiency occurred when a resident, who was alert and oriented, was observed taking an oral medication without staff supervision. The resident was found lying in bed with a white oval pill on a napkin on the overbed table. The resident picked up the pill and swallowed it without a nurse present. Upon questioning, the resident stated she had taken about 13 pills and that the nurse did not stay with her while she took the last few. The nurse involved admitted to leaving the resident unattended, assuming the medications were being taken as she walked away. A review of the resident's electronic health record revealed that no self-medication administration evaluation had been completed for this resident. Facility policy required staff to observe residents ingest medications and not to leave medications at the bedside unless the resident had approval for self-administration, which was not the case here. Both the Resident Care Manager and the Chief Nursing Officer confirmed that medications should not be left at the bedside and that staff are expected to observe residents taking all medications.
Failure to Securely Fasten Bed Rail
Penalty
Summary
The facility failed to ensure that a bed rail was securely fastened to the bed for one resident. The resident was observed on multiple occasions with a quarter length bed rail on the left side of the upper bed that was loose, with four to five inches of movement up and down and five to six inches of movement back and forth. The bracket attaching the bed rail to the bed frame was also observed to be loose, wiggling about one inch around the bolt. The resident reported to staff several times that the bed rail was loose, but it had not been fixed. Staff interviews confirmed that the process for reporting broken equipment, such as bed rails, involved submitting a work order through the TELS electronic system and verbally notifying maintenance. A CNA had submitted a TELS work order for the loose bed rail, but it remained unrepaired for several days. The Chief Nursing Officer acknowledged that the bed rail was looser than it should have been and that safety-related issues like this should be addressed immediately. The facility's policy required correct installation, use, and maintenance of bed rails, but this was not followed in this instance.
Medication Administration Errors in Resident with COPD
Penalty
Summary
The facility failed to administer medications accurately for a resident with chronic respiratory failure and COPD, leading to significant medication errors. The first error involved a Prednisone taper that was initiated incorrectly. Instead of starting with the prescribed 40 mg dose and tapering down to 10 mg, the taper was mistakenly started with the 10 mg dose. This error was identified by a registered nurse who notified the provider and received a new order to restart the taper correctly. However, the error was repeated, and the resident did not receive the proper dosages at the beginning of the taper. The second medication error involved the administration of an ADVAIR inhaler. The resident was prescribed two puffs twice daily, but a photograph of the inhaler showed a discrepancy in the number of doses remaining, indicating that the inhaler was not administered as ordered. This discrepancy was confirmed by a pharmacist, who noted that the resident could experience exacerbated symptoms of COPD if the doses were not given as prescribed. The errors were attributed to a licensed practical nurse who was responsible for the incorrect administration.
Kitchen Vent Cleanliness Deficiency
Penalty
Summary
The facility failed to maintain the cleanliness of the vent covers in the kitchen, which was observed during a survey. On June 6, 2024, at 10:05 AM, the overhead vent covers located over the food preparation areas were found to have lint trapped between the grilles. Additionally, the stove hood filters appeared greasy and also had lint between the grilles. At 2:07 PM, when questioned about the condition of the overhead vents, the Dietary Manager, identified as Staff F, acknowledged the presence of lint and noted that the slats of the hood filters were not installed correctly. Staff F indicated that maintenance was responsible for cleaning the overhead vent covers, while the cleaning of the hood filters was contracted out and performed approximately every six months.
Failure to Honor Resident Food Preferences
Penalty
Summary
The facility failed to honor the food preferences of Resident 114, who was cognitively intact and had specific cereal dislikes documented in her Diet History & Preferences. Despite having communicated her preferences to the dietician, dietary manager, and aides, Resident 114 continued to receive food she disliked, including oatmeal, which was observed during a meal service. The dietary manager acknowledged the oversight and noted that if a menu was not received from nursing staff, the main meal was served by default. This failure to accommodate Resident 114's food preferences was identified during a survey, highlighting a deficiency in the facility's food service practices.
Failure to Address Contractures in Resident's Care Plan
Penalty
Summary
The facility failed to develop and implement a person-centered care plan addressing limited mobility for a resident reviewed for comprehensive care plan related to mobility. The resident's comprehensive care plan, dated 05/20/2024, did not include a plan of care for contractures to the left arm. On 06/03/2024, the resident was observed with a contracted left arm and reported that the contracture had worsened. On 06/05/2024, a Licensed Practical Nurse confirmed that there were no interventions in place for the resident's contracted left arm. On 06/06/2024, the Chief Nursing Officer and Registered Nurse acknowledged that the care plan did not reflect a plan to address the resident's contractures.
Medication Found on Floor in Resident Hallway
Penalty
Summary
The facility failed to ensure a safe environment in one of the resident hallways, as evidenced by the presence of medication on the floor. An unidentified resident alerted an unidentified staff member to a pill on the floor, which was subsequently identified by Staff D, a Registered Nurse, as Zoloft, an antidepressant. Later, a partial blue pill was observed on the floor near the nurse's station. Staff E, a Resident Care Manager and LPN, acknowledged the presence of the pill but could not identify it due to the lack of a marker. Staff E expressed that staff should have searched the area to ensure no other pills were present. Staff B, the Chief Nursing Officer, also stated that she would expect staff to check the area thoroughly if a pill was found on the floor.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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How nearby facilities compare on the same public inspection record.
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| Vancouver Specialty And Rehab Care | 0.1 mi | ★★★★★ | 29 | 0 |
| Avamere Rehabilitation Of Cascade Park | 3.5 mi | ★★★★★ | 9 | 0 |
| The Oaks At Timberline | 4.1 mi | ★★★★★ | 15 | 0 |
| Bridge Crest Post Acute | 4.5 mi | ★★★★★ | 29 | 0 |
| Fernhill Rehabilitation And Care | 4.7 mi | ★★★★★ | 0 | 0 |
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