Birch Creek Post Acute & Rehabilitation
5601 S Orchard Street, Tacoma, WA 98409
Birch Creek Post Acute & Rehabilitation is a nursing home in Tacoma, Washington. This page lists the citations, fines and star ratings that CMS publishes for it. Each one has a date and a link to CMS.
At a glance
- CMS overall star rating1 of 5
- Last standard health inspectionMarch 13, 2026 (7 months ago)
- Health citations since March 22, 202478 (Washington average 50)
- Fines in the past three years1, $19,656 in total
- CMS flagsNone listed by CMS
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CMS flags
CMS does not list this home as a Special Focus Facility or a candidate. CMS does not show an abuse icon for it. CMS lists no change of ownership in the past 12 months.
Inspections, fines and changes
This list shows every citation and fine in CMS's current data, which covers about the last three years. It also shows changes CMS made to this home's ratings and records.
CMS update of October 8, 2026
Fine
CMS changed the fine from March 13, 2026 from $30,240 to $19,656.
CMS update of July 29, 2026
Star rating
The CMS overall star rating changed from 2 of 5 to 1 of 5.
Star rating
The CMS health inspection star rating changed from 2 of 5 to 1 of 5.
Star rating
The CMS quality measures star rating changed from 4 of 5 to 3 of 5.
Health inspection on June 18, 2026
3 citationsCMS lists this as a complaint inspection.
Show the 3 citations
Citation F0571. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Limit the charges against residents' personal funds for items or services for which payment is made under Medicare or Medicaid.
CMS lists it as corrected on July 23, 2026.
Citation F0684. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS lists it as corrected on July 23, 2026.
CMS has cited this home for F0684 6 times since 2024.
Citation F0689. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on July 23, 2026.
CMS has cited this home for F0689 5 times since 2025.
Health inspection on May 6, 2026
1 citationCMS lists this as a complaint inspection.
Show the 1 citation
Citation F0552. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that residents are fully informed and understand their health status, care and treatments.
CMS lists it as corrected on July 17, 2026.
CMS has cited this home for F0552 2 times since 2025.
Health inspection on March 26, 2026
3 citationsCMS lists this as a complaint inspection.
Severity G is the second-highest of CMS's four levels. It means a resident was harmed.
36 of 193 Washington homes (19%) got a citation at the actual harm level in 2026.
Show the 3 citations
Citation F0689. Severity G: actual harm, isolated.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on April 21, 2026.
Citation F0690. Severity G: actual harm, isolated.
The rule CMS cited:
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
CMS lists it as corrected on April 21, 2026.
Citation F0726. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
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.
CMS lists it as corrected on April 21, 2026.
Health inspection on March 13, 2026
19 citationsCMS lists this as a standard inspection.
CMS fine of $19,656 on March 13, 2026.
Show the 19 citations
Citation F0803. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
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.
CMS lists it as corrected on April 21, 2026.
Citation F0812. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS lists it as corrected on April 21, 2026.
CMS has cited this home for F0812 2 times since 2025.
Citation F0605. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
CMS lists it as corrected on April 21, 2026.
Citation F0610. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Respond appropriately to all alleged violations.
CMS lists it as corrected on April 5, 2026.
CMS has cited this home for F0610 5 times since 2024.
Citation F0645. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
PASARR screening for Mental disorders or Intellectual Disabilities
CMS lists it as corrected on April 21, 2026.
CMS has cited this home for F0645 2 times since 2025.
Citation F0656. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
CMS lists it as corrected on April 21, 2026.
CMS has cited this home for F0656 2 times since 2025.
Citation F0695. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide safe and appropriate respiratory care for a resident when needed.
CMS lists it as corrected on April 21, 2026.
CMS has cited this home for F0695 3 times since 2024.
Citation F0578. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on April 21, 2026.
CMS has cited this home for F0578 2 times since 2025.
Citation F0582. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
CMS lists it as corrected on April 21, 2026.
Citation F0584. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on April 21, 2026.
CMS has cited this home for F0584 2 times since 2025.
Citation F0641. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure each resident receives an accurate assessment.
CMS lists it as corrected on April 21, 2026.
Citation F0657. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
CMS lists it as corrected on April 21, 2026.
CMS has cited this home for F0657 3 times since 2024.
Citation F0684. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS lists it as corrected on April 21, 2026.
Citation F0686. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
CMS lists it as corrected on April 21, 2026.
CMS has cited this home for F0686 2 times since 2024.
Citation F0689. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on April 21, 2026.
Citation F0692. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide enough food/fluids to maintain a resident's health.
CMS lists it as corrected on April 21, 2026.
CMS has cited this home for F0692 3 times since 2025.
Citation F0693. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on April 21, 2026.
CMS has cited this home for F0693 2 times since 2025.
Citation F0697. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide safe, appropriate pain management for a resident who requires such services.
CMS lists it as corrected on April 21, 2026.
Citation F0791. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide or obtain dental services for each resident.
CMS lists it as corrected on April 21, 2026.
Fire safety inspection on March 13, 2026
9 citationsCMS lists this as a standard inspection.
Show the 9 citations
Citation E0004. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Develop and maintain an Emergency Preparedness Program (EP).
CMS lists it as corrected on April 7, 2026.
CMS has cited this home for E0004 2 times since 2024.
Citation E0030. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
List the names and contact information of those in the facility.
CMS lists it as corrected on April 7, 2026.
CMS has cited this home for E0030 2 times since 2024.
Citation K0222. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
CMS lists it as corrected on April 7, 2026.
Citation K0761. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
CMS lists it as corrected on April 7, 2026.
Citation K0915. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have proper power supply for life support equipment.
CMS lists it as corrected on April 7, 2026.
Citation K0921. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Ensure that testing and maintenance of electrical equipment is performed.
CMS lists it as corrected on April 7, 2026.
CMS has cited this home for K0921 2 times since 2025.
Citation K0321. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
CMS lists it as corrected on April 7, 2026.
Citation K0353. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Inspect, test, and maintain automatic sprinkler systems.
CMS lists it as corrected on April 7, 2026.
CMS has cited this home for K0353 2 times since 2024.
Citation K0355. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Properly select, install, inspect, or maintain portable fire extinguishes.
CMS lists it as corrected on April 7, 2026.
CMS update of February 25, 2026
Star rating
The CMS overall star rating changed from 3 of 5 to 2 of 5.
Star rating
The CMS quality measures star rating changed from 5 of 5 to 4 of 5.
Health inspection on November 19, 2025
2 citationsCMS lists this as a complaint inspection.
Show the 2 citations
Citation F0744. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
CMS lists it as corrected on December 22, 2025.
Citation F0610. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Respond appropriately to all alleged violations.
CMS lists it as corrected on December 22, 2025.
Health inspection on August 11, 2025
1 citationCMS lists this as a complaint inspection.
Show the 1 citation
Citation F0689. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on August 25, 2025.
CMS update of July 30, 2025
Star rating
The CMS staffing star rating changed from 4 of 5 to 3 of 5.
Health inspection on July 10, 2025
1 citationCMS lists this as a complaint inspection.
Show the 1 citation
Citation F0692. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide enough food/fluids to maintain a resident's health.
CMS lists it as corrected on August 29, 2025.
Health inspection on June 30, 2025
2 citationsCMS lists this as a complaint inspection.
Show the 2 citations
Citation F0609. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
CMS lists it as corrected on August 12, 2025.
CMS has cited this home for F0609 3 times since 2024.
Citation F0610. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Respond appropriately to all alleged violations.
CMS lists it as corrected on August 12, 2025.
CMS update of June 25, 2025
Health citation
CMS removed citation F0623 from the health inspection on May 23, 2024.
Health citation
CMS removed citation F0625 from the health inspection on May 23, 2024.
Health inspection on March 14, 2025
24 citationsCMS lists this as a standard inspection.
Show the 24 citations
Citation F0812. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS lists it as corrected on April 21, 2025.
Citation F0578. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
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.
CMS lists it as corrected on April 21, 2025.
Citation F0645. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
PASARR screening for Mental disorders or Intellectual Disabilities
CMS lists it as corrected on April 21, 2025.
Citation F0655. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
CMS lists it as corrected on April 21, 2025.
Citation F0656. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
CMS lists it as corrected on April 21, 2025.
Citation F0657. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
CMS lists it as corrected on April 21, 2025.
Citation F0689. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on April 21, 2025.
Citation F0881. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Implement a program that monitors antibiotic use.
CMS lists it as corrected on April 21, 2025.
Citation F0883. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Develop and implement policies and procedures for flu and pneumonia vaccinations.
CMS lists it as corrected on April 21, 2025.
Citation F0887. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
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.
CMS lists it as corrected on April 21, 2025.
Citation F0552. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that residents are fully informed and understand their health status, care and treatments.
CMS lists it as corrected on April 21, 2025.
Citation F0561. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
CMS lists it as corrected on April 21, 2025.
Citation F0584. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on April 21, 2025.
Citation F0607. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
CMS lists it as corrected on April 21, 2025.
Citation F0609. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
CMS lists it as corrected on April 21, 2025.
Citation F0658. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure services provided by the nursing facility meet professional standards of quality.
CMS lists it as corrected on April 21, 2025.
CMS has cited this home for F0658 2 times since 2024.
Citation F0677. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide care and assistance to perform activities of daily living for any resident who is unable.
CMS lists it as corrected on April 21, 2025.
CMS has cited this home for F0677 2 times since 2024.
Citation F0684. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS lists it as corrected on April 21, 2025.
Citation F0688. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on April 21, 2025.
Citation F0692. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide enough food/fluids to maintain a resident's health.
CMS lists it as corrected on April 21, 2025.
Citation F0693. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on April 21, 2025.
Citation F0695. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide safe and appropriate respiratory care for a resident when needed.
CMS lists it as corrected on April 21, 2025.
Citation F0757. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure each resident’s drug regimen must be free from unnecessary drugs.
CMS lists it as corrected on April 21, 2025.
CMS has cited this home for F0757 2 times since 2024.
Citation F0758. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on April 21, 2025.
Fire safety inspection on March 14, 2025
7 citationsCMS lists this as a standard inspection.
Show the 7 citations
Citation K0363. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Install corridor and hallway doors that block smoke.
CMS lists it as corrected on April 8, 2025.
Citation K0511. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have properly installed electrical wiring and gas equipment.
CMS lists it as corrected on April 8, 2025.
CMS has cited this home for K0511 2 times since 2024.
Citation K0521. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
CMS lists it as corrected on April 8, 2025.
Citation K0741. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
CMS lists it as corrected on April 8, 2025.
Citation K0921. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure that testing and maintenance of electrical equipment is performed.
CMS lists it as corrected on May 23, 2025.
Citation K0324. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide properly protected cooking facilities.
CMS lists it as corrected on April 8, 2025.
Citation K0374. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Install smoke barrier doors that can resist smoke for at least 20 minutes.
CMS lists it as corrected on May 23, 2025.
CMS has cited this home for K0374 2 times since 2024.
Health inspection on November 1, 2024
1 citationCMS lists this as a complaint inspection.
Show the 1 citation
Citation F0684. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS lists it as corrected on December 10, 2024.
CMS update of October 30, 2024
Star rating
The CMS staffing star rating changed from 3 of 5 to 4 of 5.
Health inspection on October 28, 2024
1 citationCMS lists this as a complaint inspection.
Show the 1 citation
Citation F0851. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
CMS lists it as corrected on November 6, 2024.
CMS update of September 26, 2024
Star rating
The CMS overall star rating changed from 4 of 5 to 3 of 5.
Star rating
The CMS health inspection star rating changed from 3 of 5 to 2 of 5.
CMS update of July 31, 2024
Star rating
The CMS overall star rating changed from 3 of 5 to 4 of 5.
Star rating
The CMS health inspection star rating changed from 2 of 5 to 3 of 5.
Health inspection on July 15, 2024
1 citationCMS lists this as a complaint inspection.
Show the 1 citation
Citation F0686. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
CMS lists it as corrected on August 6, 2024.
Health inspection on July 10, 2024
3 citationsCMS lists this as a complaint inspection.
Show the 3 citations
Citation F0684. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS lists it as corrected on August 6, 2024.
Citation F0610. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Respond appropriately to all alleged violations.
CMS lists it as corrected on August 6, 2024.
Citation F0657. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
CMS lists it as corrected on August 6, 2024.
CMS update of May 29, 2024
Changed ownership in the last 12 months
CMS no longer shows a change of ownership in the past 12 months.
Health inspection on May 23, 2024
14 citationsCMS lists this as a standard inspection.
Show the 14 citations
Citation F0677. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide care and assistance to perform activities of daily living for any resident who is unable.
CMS lists it as corrected on July 2, 2024.
Citation F0695. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide safe and appropriate respiratory care for a resident when needed.
CMS lists it as corrected on July 2, 2024.
Citation F0756. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
CMS lists it as corrected on July 2, 2024.
Citation F0757. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure each resident’s drug regimen must be free from unnecessary drugs.
CMS lists it as corrected on July 2, 2024.
Citation F0790. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide routine and 24-hour emergency dental care for each resident.
CMS lists it as corrected on July 2, 2024.
Citation F0806. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
CMS lists it as corrected on July 2, 2024.
Citation F0880. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on July 2, 2024.
Citation F0565. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Honor the resident's right to organize and participate in resident/family groups in the facility.
CMS lists it as corrected on July 2, 2024.
Citation F0609. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
CMS lists it as corrected on July 2, 2024.
Citation F0658. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure services provided by the nursing facility meet professional standards of quality.
CMS lists it as corrected on July 2, 2024.
Citation F0676. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
CMS lists it as corrected on July 2, 2024.
Citation F0755. Severity C: potential for minimal harm, widespread.
The rule CMS cited:
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
CMS lists it as corrected on July 2, 2024.
Citation F0623. Severity B: potential for minimal harm, pattern.
The rule CMS cited:
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
CMS lists it as corrected on July 2, 2024.
Citation F0625. Severity B: potential for minimal harm, pattern.
The rule CMS cited:
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
CMS lists it as corrected on July 2, 2024.
Fire safety inspection on May 23, 2024
15 citationsCMS lists this as a standard inspection.
Show the 15 citations
Citation E0004. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Develop and maintain an Emergency Preparedness Program (EP).
CMS lists it as corrected on June 24, 2024.
Citation E0015. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Address subsistence needs for staff and patients.
CMS lists it as corrected on June 24, 2024.
Citation E0039. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Conduct testing and exercise requirements.
CMS lists it as corrected on June 24, 2024.
Citation K0211. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Keep aisles, corridors, and exits free of obstruction in case of emergency.
CMS lists it as corrected on June 24, 2024.
Citation K0291. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Install emergency lighting that can last at least 1 1/2 hours.
CMS lists it as corrected on June 24, 2024.
Citation K0293. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have properly located and lighted "Exit" signs.
CMS lists it as corrected on June 24, 2024.
Citation K0345. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have approved installation, maintenance and testing program for fire alarm systems.
CMS lists it as corrected on June 24, 2024.
Citation K0362. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
CMS lists it as corrected on June 24, 2024.
Citation K0511. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have properly installed electrical wiring and gas equipment.
CMS lists it as corrected on June 24, 2024.
Citation E0030. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
List the names and contact information of those in the facility.
CMS lists it as corrected on June 24, 2024.
Citation K0100. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Meet other general requirements.
CMS lists it as corrected on June 24, 2024.
Citation K0232. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
CMS lists it as corrected on June 24, 2024.
Citation K0353. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Inspect, test, and maintain automatic sprinkler systems.
CMS lists it as corrected on June 24, 2024.
Citation K0374. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Install smoke barrier doors that can resist smoke for at least 20 minutes.
CMS lists it as corrected on June 24, 2024.
Citation K0918. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Have generator or other power source capable of supplying service within 10 seconds.
CMS lists it as corrected on June 24, 2024.
Health inspection on March 22, 2024
2 citationsCMS lists this as a complaint inspection.
Severity G is the second-highest of CMS's four levels. It means a resident was harmed.
81 of 193 Washington homes (42%) got a citation at the actual harm level in 2024.
Show the 2 citations
Citation F0684. Severity G: actual harm, isolated.
The rule CMS cited:
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS lists it as corrected on April 30, 2024.
Citation F0610. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Respond appropriately to all alleged violations.
CMS lists it as corrected on April 30, 2024.
CMS update of January 31, 2024
Star rating
The CMS staffing star rating changed from 2 of 5 to 3 of 5.
CMS update of December 21, 2023
Name
CMS lists a new legal business name for this home.
Ownership
CMS lists this home under a new chain.
CMS star ratings
- 1 of 5CMS overall star rating
- 1 of 5CMS health inspection star rating
- 3 of 5CMS staffing star rating
- 3 of 5CMS quality measures star rating
Facts from CMS
- Phone
- (253) 474-8421
- Last standard health inspection
- March 13, 2026 (7 months ago)
- Certified beds
- 124
- Residents per day, on average
- 115.1
- Ownership type
- For profit - Limited Liability company
- Legal business name
- Tacoma SNF Operations LLC
- Chain
- Hill Valley Healthcare
- Takes part in
- Medicare and Medicaid
More health citations than the Washington average (78 vs 50).
Owners and managers
CMS lists these owners and managers for this home. Names are as CMS writes them.
- WASH 6 SNF OPERATIONS HOLDINGS LLC5% or greater direct ownership interest · 100% · since 02/08/2023
- GIG HARBOR SNF OPERATIONS MANAGER LLCOperational/managerial control · not applicable · since 04/01/2023
- IDELS, SHIMONOperational/managerial control · not applicable · since 04/01/2023
- SCHWARTZ, STEVENOperational/managerial control · not applicable · since 04/01/2023
Questions
When was Birch Creek Post Acute & Rehabilitation last inspected?
CMS lists March 13, 2026 as the date of its most recent standard health inspection.
How many citations (violations) does Birch Creek Post Acute & Rehabilitation have?
CMS lists 78 health citations since March 22, 2024. CMS also calls these deficiencies.
Has Birch Creek Post Acute & Rehabilitation been fined?
CMS lists 1 fine in the past three years, $19,656 in total.
What is the CMS star rating of Birch Creek Post Acute & Rehabilitation?
Its CMS overall star rating is 1 of 5.
Is Birch Creek Post Acute & Rehabilitation a Special Focus Facility?
No. CMS does not list it as a Special Focus Facility or a candidate.