Above average — CMS composite of the measures below.
The next survey window likely opens around January 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 Vancouver Specialty And Rehab Care during CMS and state inspections, most recent first.
The facility failed to provide sufficient weekend staffing and did not maintain 3.4 hours of direct care per resident day during the reviewed period. PBJ staffing data, the staff hours summary, and the daily staffing form showed excessively low weekend staffing, and the Administrator acknowledged awareness of the low staffing and said agency staff and new hires were later used to make up for it.
The facility failed to document in its Voluntary Arbitration Agreement that a convenient venue for arbitration would be selected for both the facility and the resident or resident representative. Record review for three residents showed signed arbitration agreements that did not include this information, and the Administrator was unable to show supporting documentation during interview.
A resident receiving insulin injections was given an insulin shot by an LPN without gloves, despite the facility policy requiring gloves for injections involving possible contact with blood or body fluids. In a separate finding, dirty laundry bins were observed in a hallway vestibule near the smoking-area exit, with linen bags sticking out of one bin; staff said the bins contained dirty laundry and were moved there during mealtime, even though they were supposed to be bagged and taken outside before becoming overfilled.
A resident’s trust account was not conveyed promptly after discharge. The BOM stated discharged resident accounts were supposed to be closed within 30 days, but this resident’s account remained open beyond that timeframe and was closed later than expected.
Failure to complete AIMS testing and monitor adverse side effects for psychotropic and opiate medications: A resident with paranoid schizophrenia and major depressive disorder was receiving quetiapine, bupropion, and oxycodone as ordered, but the EHR did not show an AIMS test or documentation of adverse side effect monitoring. The DON stated an AIMS test was expected on admission for residents taking antipsychotics and that ASE monitoring was expected for residents taking opiate, antidepressant, and antipsychotic medications.
A resident with anxiety disorder and PTSD had an MDS that stated no antianxiety meds were being taken, even though the EHR and eMAR showed Buspirone HCL 10 mg TID. The MDS nurse acknowledged the antianxiety medication was missed, and the DON stated the MDS should be coded accurately to reflect resident meds.
A resident with severe cognitive impairment did not receive restorative ambulation and ROM services as planned. Care plans called for ambulation with a FWW and SBA, plus AROM to both UEs with an orange band, but task sheets showed repeated refusals and only limited participation. An EHR note stated the RA program was discontinued for lack of participation, and the DON said RAs should have documented refusals and offered services at least 3 times per week.
A resident’s physician orders in PCC were not updated to match the POLST. The chart still listed CPR/full treatment/avoid TF, while the POLST indicated DNR and Allow Natural Death. The RN said she often checked the POLST because PCC code status orders were sometimes not updated, and the DON and Resident Care Manager confirmed the PCC code status should have matched the POLST.
A facility failed to keep 2 of 4 mechanical lifts on one hall functional and safe. A CNA observed one lift with a broken plastic cover over the pump or motor and said another lift had legs that kept coming together and was not safe with a heavy resident. The CNA said the lifts had not worked in a long time and had only reported concerns verbally, while the maintenance director said no TELS work orders had been received and later determined both lifts were unsafe.
Resident rooms did not provide enough space for comfort and privacy for two residents. One resident was dependent for transfers, severely cognitively impaired, and required a Hoyer lift, while another resident was alert and oriented. Staff had to move the second resident’s bed to position the lift and then shift the first resident’s bed to make room for the wheelchair and lift, disrupting the other resident.
A resident with dementia sustained a new skin injury that was assessed and treated by staff, but there was no documentation that the resident's POA or physician were notified as required. Staff interviews confirmed the lack of notification documentation.
A resident dependent on staff for ADLs, including bathing, did not receive the scheduled number of baths or showers due to staffing shortages and missed assignments. Facility records and staff interviews confirmed that bathing was frequently delayed or missed, with responsibilities often passed between shifts and exacerbated by insufficient staffing.
The facility failed to implement bowel management protocols for three residents, resulting in prolonged constipation and discomfort. Despite the facility's policy requiring specific interventions and documentation, staff interviews revealed a lack of adherence, with no consistent initiation of the bowel protocol or documentation of interventions. This led to significant delays between bowel movements for the residents, impacting their well-being.
The facility failed to provide at least eight hours of RN coverage and supervision for three out of thirty days reviewed. Interviews and record reviews showed that the facility's daily nurse staff postings and the Staffing Coordinator's schedule did not reflect 24 hours of RN coverage on all reviewed days. The Administrator confirmed the lack of a waiver for RN coverage and mentioned recruitment efforts and incentives for staff retention.
The facility did not have procedures to assist a resident with completing advance directives (AD) or maintaining Power of Attorney documentation. A resident, moderately cognitively impaired, lacked an AD or documentation of AD review since March 2024. Despite having a POLST, there was no AD, Power of Attorney, or guardian documented. Staff indicated ADs were reviewed quarterly, but this was not done for the resident. The Administrator confirmed ADs should be reviewed upon admission and quarterly.
A facility failed to accurately complete the PASARR for a resident with anxiety and depression, as required by policy. The resident was admitted without a Level II evaluation, and the PASARR was not reviewed for accuracy until days later, despite the resident showing signs of distress and fear. This oversight risked unmet mental health needs.
The facility did not complete a performance evaluation for a nursing assistant hired in 2021, as required by policy. This oversight was identified through interviews and record reviews, revealing a lack of adherence to the facility's policy of conducting annual evaluations or additional training when needed. This failure posed a risk to residents by potentially exposing them to unskilled care.
The facility failed to monitor two residents on psychotropic medications for target behaviors and interventions. One resident, who was alert and oriented, had no behavior monitoring for depression symptoms in their EHR. Another resident was started on Trazadone for insomnia, but there was no monitoring for its psychotropic use. This lack of monitoring placed residents at risk for decreased mental health well-being.
A facility failed to obtain informed consent for a resident before administering Trazadone, a psychotropic medication. The resident, who was alert and oriented, was started on Trazadone for depression without documented consent. Staff interviews indicated that obtaining consent is usually the responsibility of Resident Care Managers or nurse managers, but no consent was found in the resident's records.
A facility failed to conduct quarterly care conferences for a resident, who was moderately cognitively impaired, resulting in an eight-month gap between meetings. This oversight was confirmed by staff, who acknowledged that care conferences should occur quarterly, potentially impacting the resident's involvement in their care decisions.
A facility failed to ensure a safe discharge for a resident with diabetes and moderate cognitive impairment. The discharge care conference did not address diabetic monitoring, and there was no documentation that the resident received a glucometer or training on its use. Staff acknowledged the oversight but could not provide evidence of proper discharge preparation.
The facility failed to initiate bowel interventions for a moderately cognitively impaired resident who had not had a bowel movement for over six days. The MAR did not show any interventions from 02/21/2024 until 5:52 PM on 02/27/2024, despite the bowel protocol requiring initiation after 72 hours.
The facility failed to conduct neurological checks for two residents who experienced unwitnessed falls. Both residents were moderately cognitively impaired, and staff confirmed that neurological checks should have been performed but were not documented. This lack of comprehensive investigation placed residents at risk.
Insufficient Weekend Staffing and Direct Care Hours
Penalty
Summary
The facility failed to ensure sufficient weekend staffing to meet resident needs and have a licensed nurse in charge on each shift. Review of the PBJ Staffing Data Report for FY Quarter 4, 2025 showed excessively low weekend staffing, and review of the facility’s staff Hours Summary Report and Daily Staffing Form showed the facility did not have 3.4 hours of direct care per resident day from 07/05/2025 through 09/21/2025. An interview with the Administrator on 02/24/2026 confirmed awareness of the low staffing levels during that period, and the Administrator stated the facility began using agency staff and onboarding new employees to make up for the low staffing.
Arbitration Agreement Lacked Venue Selection Documentation
Penalty
Summary
The facility failed to ensure that its binding arbitration agreement included documentation that the facility would provide for selection of a convenient venue for arbitration proceedings that was convenient to both the facility and the resident or resident representative. The deficiency was identified for 3 of 3 residents reviewed for arbitration: Resident 10, Resident 21, and Resident 50. Record review showed the facility's Voluntary Arbitration Agreement, revised on 08/23/2023, did not document that residents or their representatives were given the opportunity to select a convenient venue for arbitration. Resident 10's signed agreement dated 09/30/2024, Resident 21's signed agreement dated 02/06/2024, and Resident 50's signed agreement dated 04/13/2025 all lacked information showing that the arbitration process included an opportunity to select a convenient venue. In an interview on 02/24/2026 at 1:10 PM, the Administrator reviewed the agreement but was unable to show documentation that a convenient venue would be selected for arbitration.
Improper glove use during insulin injection and dirty laundry bins left in hallway vestibule
Penalty
Summary
The facility failed to ensure proper glove use during an insulin injection for a resident with diabetes mellitus, embolism, and thrombosis of the left lower extremity. The resident was moderately cognitively impaired and was receiving insulin injections and antiplatelet medication. During an observation, a charge nurse/LPN administered an insulin injection to the resident's upper right arm without wearing gloves. When asked about glove use, the nurse acknowledged that gloves were supposed to be worn. The facility's policy on administration of injections stated that gloves and other PPE are required for administering medications that might involve contact with blood or body fluids. The facility also failed to ensure dirty laundry bins were properly stored and/or transported for one of four bins reviewed. Four trash cans were observed in the vestibule between resident rooms and near the exit leading to the residents' smoking area, and one bin had two plastic bags of what appeared to be linen sticking out of the top. A nursing assistant placed a tied plastic bag into one of the bins, and then the bins were pushed outside the door to the outside of the building. Staff stated the bins contained dirty laundry, that they were taken to the vestibule during mealtime so they would not be in the way, and that dirty linen was supposed to be bagged and placed in a big bin outside before the bins became overfilled.
Delayed Conveyance of Resident Trust Account After Discharge
Penalty
Summary
The facility failed to convey the trust account for Resident 112 after the resident discharged from the facility on 12/09/2025. Review of the facility’s Trial Balance form dated 02/19/2026 showed that Resident 112’s trust account was closed on 01/20/2026, approximately 42 days after discharge. During interviews on 02/19/2026, the Business Office Manager stated that discharged resident accounts were supposed to be conveyed within 30 days from discharge and acknowledged that Resident 112’s account was not closed until 01/20/2026, saying it should have been closed sooner.
Failure to complete AIMS testing and monitor adverse side effects for psychotropic and opiate medications
Penalty
Summary
The facility failed to complete an AIMS test for Resident 111, who was admitted with diagnoses including paranoid schizophrenia and major depressive disorder and was documented on the 5-Day MDS as moderately cognitively impaired. Resident 111 had physician orders for Quetiapine Fumarate 25 mg by mouth three times daily, and the February 2026 EMAR showed the medication was being administered as ordered. The resident's EHR did not show documentation of an AIMS test for the antipsychotic medication. The facility also failed to document monitoring for adverse side effects of Resident 111's psychotropic and opiate medications. Resident 111 had orders for Bupropion HCl 100 mg by mouth each morning and Oxycodone HCl 5 mg by mouth every four hours, and the February 2026 EMAR showed both medications were being given as ordered. Review of the EHR did not show documentation that staff monitored for adverse medication side effects while the resident was receiving the opiate, antidepressant, and antipsychotic medications. Staff D reviewed the record and stated there was no AIMS test and no order or documentation for adverse side effect monitoring, and the DON stated she expected an AIMS test on admission for residents taking antipsychotic medications and expected adverse side effects to be monitored for residents taking opiate, antidepressant, and antipsychotic medications.
Inaccurate MDS Coding for Antianxiety Medication
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) was completed accurately for one sampled resident, Resident 6, in relation to unnecessary medications. Resident 6 was admitted with multiple diagnoses including anxiety disorder and PTSD. The quarterly MDS documented the resident as cognitively intact, with anxiety disorder and PTSD, and stated the resident was not taking antianxiety medications. Record review showed a physician’s order for Buspirone HCL 10 mg three times a day, and the February 2025 eMAR showed the resident was receiving that medication. During interview, the MDS nurse stated she gathered information from the resident and medical records when completing the MDS, and after reviewing the EHR acknowledged that Resident 6 was taking an antianxiety medication that had not been coded on the MDS, saying it had been missed. The DON stated it was her expectation that the MDS be coded accurately to reflect medications taken by residents.
Failure to Provide Restorative Aid Services
Penalty
Summary
The facility failed to ensure Resident 10 received restorative aid services for ambulation and range of motion as planned. Resident 10 was admitted to the facility and the quarterly MDS dated 01/13/2026 indicated severe cognitive impairment. The restorative ambulation care plan dated 10/10/2025 directed ambulation 3 times per week with a front-wheeled walker, stand-by assist, and verbal cues for safety up to 300 feet. The restorative range of motion care plan dated 10/02/2025 directed active range of motion to both upper extremities using an orange band and a handout, with physical therapy to complete 1 set of 10 repetitions of each exercise 3 to 5 times per week as tolerated. Task sheets for ambulation and active range of motion from 01/25/2026 through 02/23/2026 showed limited participation, with Resident 10 participating only twice on 02/20/2026 and refusing multiple scheduled sessions on several dates. An EHR progress note dated 02/18/2026 documented that the resident had refused the RA program on multiple occasions and that the RA program was discontinued at that time for lack of participation. During interview, the DON stated the resident refused often, that RAs should document refusals in the EHR, and that RAs should have been offering services at least three times per week.
Code Status Orders Not Updated to Match POLST
Penalty
Summary
The facility failed to ensure the physician’s orders were updated to accurately reflect Resident 72’s choices regarding code status. Resident 72 was admitted to the facility and the admission MDS indicated the resident was moderately cognitively impaired. The physician order in the chart documented code status as CPR, Full treatment, avoid TF, while the resident’s POLST was marked Do not attempt resuscitation and Allow Natural Death. The Order Summary Report/Active Orders also continued to list code status as CPR, Full treatment, avoid TF. During interview, Staff E, RN, stated she could find a resident’s code status in PCC and said she usually checked the resident’s POLST at the start of her shift because PCC code status orders were sometimes not updated. Staff B, DON, and Staff D, Resident Care Manager, stated the PCC code status should coincide with the resident’s POLST. After reviewing Resident 72’s POLST, both staff said the resident’s code status should have been changed to DNR in PCC.
Mechanical lifts left in unsafe and nonfunctional condition
Penalty
Summary
The facility failed to maintain resident care equipment in a functional and safe manner for 2 of 4 mechanical lifts on Hall 200. During observation, a CNA was seen moving a Reliant mechanical lift out of a resident room and pointed out a broken plastic cover, approximately six inches by three inches, that was designed to encase the hydraulic pump or motor at the center of the lift. The CNA stated that the lift appeared broken, that another lift down the hall had legs that kept coming together, and that the equipment was not safe with a heavy resident. The CNA also stated a preference to use other lifts if available. A RCM/LPN later inspected the mechanical lifts on Hall 200, observed the broken cover, removed the lift from the hall, and notified the maintenance director. Staff stated that equipment problems were expected to be reported through the TELS work order system, although some concerns were reported verbally. The CNA said the lifts had not worked in a very long time and that she had not used TELS to report the malfunctions. The maintenance director stated that no work orders had been received regarding the mechanical lifts, that he was notified by the RCM/LPN, and that both lifts were unsafe. The administrator stated staff were instructed to use TELS for work orders and was unaware of any lift malfunctioning.
Resident Room Space and Privacy
Penalty
Summary
Resident rooms did not provide enough space for comfort and privacy for 2 of 3 residents reviewed, including one resident who was dependent for transfers and severely cognitively impaired and another resident who was alert and oriented. The dependent resident’s care plan directed staff to use a Hoyer lift for transfers, and the room contained three beds with the dependent resident in the bed next to the window, the second resident in the middle bed, and another resident closest to the door. During observation, staff had to move the second resident’s bed to position the Hoyer lift near the dependent resident’s bed, and after the resident was lifted, staff pushed the dependent resident’s bed toward the window to create more room for the wheelchair and lift. The second resident stated that nursing assistants had to move his bed to get the Hoyer lift under the other resident’s bed and that this disrupted him. The administrator acknowledged that the expectation was not to create an environment where residents feel they do not have their own space for comfort.
Failure to Notify Representative and Physician of Change in Condition
Penalty
Summary
The facility failed to ensure timely notification of a resident's representative and physician following a significant change in the resident's condition. Specifically, a resident with dementia, who had a Power of Attorney (POA) responsible for health care decisions, sustained a new skin injury that was assessed and treated by staff. However, there was no documentation verifying that the resident's representative or physician were notified of the injury as required. Staff interviews confirmed that the required notifications were not documented.
Failure to Provide Scheduled Bathing Assistance Due to Staffing Shortages
Penalty
Summary
The facility failed to provide scheduled bathing assistance to a resident who was dependent on staff for activities of daily living (ADLs), specifically bathing. The resident, who had diagnoses including cerebral infarction, hemiplegia, and hemiparesis, required substantial or maximal assistance with bathing according to the Minimum Data Set and care plan, which specified bathing or showering twice per week and as necessary. However, facility records showed that the resident received only four out of eight scheduled baths or showers over a one-month period. Interviews with the resident and multiple nursing assistants revealed that staff were frequently unable to complete all assigned showers during their shifts, often passing the responsibility to the next shift. Staff cited staffing shortages, particularly on weekends, as a reason for missed showers. The Director of Nursing confirmed that the facility had experienced staffing difficulties during the relevant period due to nursing assistants quitting or not showing up for shifts.
Failure to Implement Bowel Management Protocol
Penalty
Summary
The facility failed to consistently assess and implement interventions for bowel management for three residents, leading to prolonged periods without bowel movements and associated discomfort. Resident 76 experienced no documented bowel movements for seven days, despite reporting constipation and poor appetite to the staff. Similarly, Resident 332 had no documented bowel movements for 12 shifts, with no initiation of the bowel protocol, resulting in poor eating due to constipation. Resident 72 also faced significant delays between bowel movements, with no initiation of the bowel protocol for over 105 hours, 77 hours, and 86 hours during different periods. Despite being given Senna on multiple occasions, there was no progression to the next steps of the bowel protocol. Staff interviews revealed a lack of adherence to the facility's bowel management policy, which required specific actions and documentation when residents did not have bowel movements. Staff D, a Licensed Practical Nurse, and Staff E, the Assistant Director of Nursing Services, acknowledged the failure to follow the protocol and document interventions. The Director of Nursing Services, Staff B, confirmed the expectation for the bowel program to be initiated and documented, with medical director notification if no bowel movements occurred. However, the facility was unable to provide documentation showing that the bowel protocol was consistently initiated and followed for the affected residents.
Deficiency in RN Coverage and Supervision
Penalty
Summary
The facility failed to provide at least eight hours of Registered Nurse (RN) coverage and supervision for three out of thirty days reviewed. This deficiency was identified through interviews and record reviews, which revealed that the facility's daily nurse staff postings and the Staffing Coordinator's working schedule did not show 24 hours of RN coverage on all reviewed days. The Administrator, Staff A, confirmed that the facility did not have a waiver for RN coverage and mentioned efforts to recruit RNs and offer bonuses and incentives for staff retention.
Failure to Assist with Advance Directives
Penalty
Summary
The facility failed to have procedures in place to assist with completing advance directives (AD) and obtaining and maintaining Power of Attorney documentation for one of the twelve sampled residents reviewed for ADs. Resident 13, who was moderately cognitively impaired, was admitted to the facility and did not have an AD or documentation that ADs were reviewed since March 2024. Although the resident had a POLST, there was no AD, Power of Attorney, or guardian documented. Staff I, from Social Services, stated that ADs were reviewed quarterly during care conferences, and if a resident did not have an AD, they would assist in completing one. However, this was not done for Resident 13. The Administrator confirmed that ADs should be reviewed upon admission and quarterly if not already in place.
Failure to Ensure Accurate PASARR for Resident with Mental Health Needs
Penalty
Summary
The facility failed to ensure the Preadmission Screening and Resident Review (PASARR) was completed accurately for a resident with a history of anxiety and depression. The resident was admitted with diagnoses including anxiety and depression, and the initial Level I PASARR screening conducted by the discharging hospital indicated that a Level II evaluation was not required. However, the facility did not review the PASARR for accuracy upon admission, as per their policy, which mandates coordination with the PASARR program to ensure appropriate care for individuals with mental disorders or intellectual disabilities. The deficiency was identified when the resident exhibited signs of distress, including tearfulness and anxiety, and expressed fear of retaliation by staff after an incident involving a bag of knives. The Social Services Director acknowledged that the PASARR was not reviewed for accuracy until several days after admission, and the facility administrator could not provide documentation to support that the PASARR Level I had been reviewed for accuracy at the time of admission. This oversight placed the resident at risk for unmet mental health needs and a diminished quality of life.
Failure to Conduct Annual Performance Evaluation for Nursing Assistant
Penalty
Summary
The facility failed to complete performance evaluation reviews for a nursing assistant, identified as Staff J, who was hired on May 11, 2021. Staff J's personnel records lacked a performance evaluation for the previous year. This deficiency was identified through interviews and record reviews, indicating that the facility did not adhere to its policy of conducting annual performance evaluations or additional training when necessary. This oversight placed residents at risk of receiving care from unskilled staff, potentially affecting their quality of life.
Failure to Monitor Psychotropic Medication Use
Penalty
Summary
The facility failed to monitor residents on psychotropic medications for target behaviors and interventions, which led to a deficiency in the care of two residents. Resident 36, who was admitted to the facility, was noted to be alert and oriented with no symptoms of depression according to the Quarterly Minimum Data Set (MDS) assessment. However, a review of Resident 36's Electronic Health Records (EHR) revealed a lack of behavior monitoring for symptoms and/or signs of depression. Staff D, a Licensed Practical Nurse, indicated that behaviors should be recorded each shift, and new behaviors should be documented and monitored. Despite this, Staff E, the Assistant Director of Nursing Services, was unable to locate records of target behaviors and interventions for Resident 36 in the electronic Medication Administration Record (EMAR). Similarly, Resident 332, who was also alert and oriented with no signs of depression according to the 5-day MDS assessment, was started on Trazadone for depression. The EHR for Resident 332 did not show any monitoring of target behaviors or interventions related to the use of the psychotropic medication. Staff D and Staff E both acknowledged that Resident 332 was on Trazadone for insomnia, yet the January 2025 Medication Administration Record showed no monitoring for the psychotropic use of Trazadone. This lack of monitoring placed the residents at risk for decreased mental health well-being and a decreased quality of life.
Failure to Obtain Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to ensure that Resident 332 was informed about the risks and benefits of psychotropic medication and did not obtain informed consent prior to administering Trazadone. Resident 332, who was alert and oriented with no signs of depression, was admitted to the facility and started on Trazadone for depression shortly after admission. However, the electronic health record did not contain documentation of informed consent for the medication. Interviews with staff revealed that obtaining informed consent for psychotropic medications is typically the responsibility of Resident Care Managers or nurse managers, but in this case, no consent was documented for Resident 332's Trazadone prescription.
Failure to Conduct Quarterly Care Conferences
Penalty
Summary
The facility failed to ensure that residents and/or their representatives were offered the opportunity to participate in care conferences, as evidenced by the case of Resident 13. Resident 13, who was moderately cognitively impaired, was admitted to the facility and had a care conference documented on 04/16/2024. However, the next care conference was not conducted until 12/04/2024, which is almost eight months later, instead of the required quarterly schedule. Staff I from Social Services confirmed the dates of the care conferences, and Staff A, the Administrator, acknowledged that care conferences should be completed quarterly. This lapse in scheduling care conferences placed residents at risk of not being involved in decisions about their long-term care needs and a diminished quality of life.
Failure to Ensure Safe Discharge for Diabetic Resident
Penalty
Summary
The facility failed to ensure a safe and orderly discharge for Resident 186, who was admitted with a diagnosis of diabetes and had moderate cognitive impairment. During a discharge care conference, it was noted that Resident 186 would be discharging home with their spouse, who was also a resident at the facility. However, the documentation from this meeting did not include any discussion of diabetic monitoring or management, which is crucial for the resident's health given their condition. Upon review, it was found that there was no documentation to confirm that Resident 186 received a glucometer or training on its use prior to discharge. Staff I, the Social Services Director, and Staff E, the Assistant Director of Nursing Services, both acknowledged that the resident should have been provided with a glucometer and trained on its use, but neither could provide documentation to support that this occurred. Staff B, the Director of Nursing Services, also expected that such training would have been documented in the electronic health record, but was unable to find any evidence of it.
Failure to Initiate Bowel Interventions
Penalty
Summary
The facility failed to initiate bowel interventions for a resident who was moderately cognitively impaired and had not had a bowel movement for over six days. The resident was admitted to the facility and had a documented bowel movement on 02/21/2024. However, the next documented bowel movement was not until 02/28/2024, indicating a gap of over six days. The February 2024 Medication Administration Record (MAR) did not show any interventions from 02/21/2024 until 5:52 PM on 02/27/2024. According to the Director of Quality Assurance and Registered Nurse, the bowel protocol should have been initiated if a resident did not have a bowel movement after 72 hours, which should have been started on 02/25/2024.
Failure to Conduct Neurological Checks for Unwitnessed Falls
Penalty
Summary
The facility failed to ensure falls were comprehensively investigated, including obtaining neurological checks for two residents who experienced unwitnessed falls. Resident 53, who was moderately cognitively impaired, had multiple unwitnessed falls documented on various dates, but there was no documentation of neurological checks being completed for these incidents. Staff members, including a CNA, LPN, and the Risk Management Nurse, confirmed that neurological checks should be performed for unwitnessed falls, but these were not documented in the resident's fall investigations. The Director of Quality Assurance also confirmed that neurological checks should have been completed for all unwitnessed falls. Similarly, Resident 56, also moderately cognitively impaired, had unwitnessed falls on two separate occasions, but the facility did not document the completion of neurological checks. The Resident Care Manager and the Director of Quality Assurance both acknowledged that the Neurological Assessment Flowsheet was not completed for these incidents. This lack of comprehensive investigation placed residents at risk of inadequate interventions and a diminished quality of life.
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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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Nursing homes near Vancouver
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Hudson Bay Health And Rehabilitation | 0.1 mi | ★★★★★ | 14 | 0 |
| Avamere Rehabilitation Of Cascade Park | 3.5 mi | ★★★★★ | 9 | 0 |
| The Oaks At Timberline | 4 mi | ★★★★★ | 15 | 0 |
| Bridge Crest Post Acute | 4.4 mi | ★★★★★ | 29 | 0 |
| Fernhill Rehabilitation And Care | 4.8 mi | ★★★★★ | 0 | 0 |
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