Vancouver Specialty and Rehab Care

Inspectors wroteBased on interview and record review, the facility failed to ensure sufficient weekend staffing as identified by the PBJ (payroll-based journal) to provide necessary care and services for 24 of 26 weekend days review for excessively low weekend staffing during the fourth quarter 2025. This failure placed residents at risk for unmet care needs and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure the binding arbitration agreement (a legally enforceable contract where parties agree to resolve disputes through a private arbitrator [an impartial third party] rather than the court system) included documentation that the facility would ensure the selection of a convenient venue that was convenient to both parties (facility and resident/resident representative) in which to carry out arbitration proceedings for 3 of 3 residents (Resident 10, 21 & 50) reviewed for arbitration. This failure placed residents at risk of not being fully informed of the arbitration process.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff properly donned (putting on) gloves during administration of a medication by injection (a medical procedure that involves administering medication directly into the body using a needle which allows the medication to enter the bloodstream or tissues rapidly) for 1 of 2 sampled residents (Resident 47) reviewed for injectable medication administration; and the facility failed to ensure staff properly stored and/or transported dirty laundry bins for 1 of 4 laundry bins reviewed for infection prevention. This failure placed residents and staff at risk for the spread of communicable diseases and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to convey the trust account for 1 of 4 residents (Resident 112) reviewed for trust funds. This failure placed the residents and/or their representatives at risk for loss of funds.

Inspectors wroteBased on interview and record review, the facility failed to complete an AIMS (Abnormal Involuntary Movement Scale) test (a rating scale used to assess the severity of involuntary movements that sometimes develop as a side effect of treatment with antipsychotic medications [drugs used primarily to treat symptoms such as hallucinations and delusions]) for 1 of 5 sampled residents (Resident 111). The facility failed to monitor for adverse side effects (ASE) of psychotropic medications (any drug that alters the brain affecting mood, behavior, perception and thought processes) and Opiate medication (pain medication) for 1 of 5 sampled residents (Resident 111) reviewed for unnecessary medications. This failure placed residents at risk for adverse medication side effects and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Minimum Data Set (MDS, an assessment tool) was completed accurately to reflect a resident's health status and/or care needs for 1 of 5 sampled residents (Resident 6) reviewed for unnecessary medications. This failure placed residents at risk for unidentified and/or unmet care needs and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents received restorative aid (RA) services for 1 of 3 residents (Resident 10) reviewed for restorative services. These failures placed residents at risk for further decline and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure the physician's orders were updated to accurately reflect the resident's choices regarding code status for 1 of 2 residents (Resident 72) reviewed for Cardiopulmonary Resuscitation (CPR, an emergency lifesaving procedure that maintains blood flow and oxygenation to vital organs when the heart stops beating or breathing ceases). This failure placed the resident at risk of not having their end-of-life wishes honored and decreased quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain resident care equipment in a functional and safe manner, for 2 of 4 Mechanical Lifts (Hall 200). This failure placed residents who were dependent for transfers at risk for falls, avoidable injury, and a diminished quality of life. Findings Included. In an interview and observation on 02/19/2026 at 9:09 AM, Staff K, Certified Nursing Assistant (CNA), was observed to be pushing a Reliant Mechanical Lift (battery-powered, mobile floor lift designed to safely transfer residents from beds, chairs, toilets, or the floor) out of room [ROOM NUMBER]. Staff K said that particular lift appeared to be broken and pointed towards a broken off plastic part measuring approximately six inches by three inches in diameter, designed to encase/ cover the hydraulic pump/or motor at the center of the lift. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure resident rooms provided enough space for comfort and privacy for 2 of 3 residents (Resident 1 & 24) reviewed for resident rooms. This failure to provide enough room could lead to a disruption of comfort and a diminished quality of life.

Inspectors wroteBased on record review and interview, the facility failed to ensure timely notification of the resident's representative of a significant change in condition for 1 of 3 residents (Resident 1) reviewed for change-of-condition. This failure placed the resident at risk of the representative being uninformed of the resident's change in condition and unable to participate in care decisions.

Inspectors wroteBased on interview and record review, the facility failed to provide activities of daily living (ADLs) for resident's dependent on staff assistance related to bathing for one of three sampled residents (1) reviewed for ADLs. This failure placed residents at risk for poor hygiene and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to consistently assess and implement interventions for bowel management for 3 of 4 sampled residents (76, 332 & 72) reviewed for quality of care related to constipation. This failure placed residents at risk of increased discomfort and negative health outcomes.

Inspectors wroteBased on interview and record review, the facility failed to provide at least eight hours of Registered Nurse (RN) coverage and supervision for 3 of 30 days reviewed. This failure placed residents at risk for not receiving needed care and supervision.

Inspectors wroteBased on interviews and record review, the facility failed to ensure the resident was informed about the risk and benefits and could provide an informed consent prior to administration of psychotropic medications for 1 of 5 sampled residents (332) reviewed for informed consent of psychotropic medications. This failure placed residents as risk for not being informed prior to receiving psychotropic medication and a decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents and/or their representatives were offered the opportunity to participate in care conferences for 1 of 3 sampled residents (13) reviewed for right to participate in planning care. This failure placed residents at risk of not being involved in decisions about their long-term care needs and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to provide and/or have procedures in place to assist with completing advance directives (AD), and obtaining and maintaining Power of Attorney documentation for 1 of 12 sampled residents (13) reviewed for ADs. This failure place residents at risk for losing their right to have their healthcare preferences and/or decisions honored.

Inspectors wroteBased on interviews and record review, the facility failed to ensure preparations were made for a safe orderly discharge for 1 of 2 sampled residents (186) reviewed for discharge planning. This failure placed residents at risk for an unsafe discharge into the community and a diminished quality of life.

Inspectors wroteBased on interviews and and record review, the facility failed to ensure the Preadmission Screening and Resident Review (PASARR) was completed for 1 of 6 sampled residents (76) reviewed for Preadmission Screening for individuals with a mental disorder and individuals with intellectual disability. This failure placed residents at risk for unidentified mental health needs, unmet mental health needs and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to complete performance evaluation reviews for 1 of 2 sampled nursing assistants (Staff J) reviewed for nurse aide performance reviews. This failure placed residents at risk for receiving care from unskilled staff and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to monitor residents on psychotropic medications for target behaviors and interventions for 2 of 5 sampled residents (36 & 332) reviewed for unnecessary psychotropic medications. This failure placed residents as risk for decreased mental health well-being and a decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure falls in the facility were comprehensively investigated including obtaining neurological checks (a physical examination to identify signs of disorders affecting the nervous system) for 2 of 5 sampled residents (53 & 56) reviewed for investigation of accidents and falls. This failure placed residents at risk of inadequate interventions, abuse, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to initiate bowel interventions for 1 of 3 sampled residents (37) reviewed for constipation. This failure placed residents at risk for discomfort, experiencing health complications and diminished qualify of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure allegations of potential abuse and neglect were reported immediately, but no later than two hours, to the State Agency for 2 of 3 sampled residents (1 & 2) reviewed for reporting of alleged violations. This failure placed residents at risk for abuse, neglect, and diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure treatments were implemented for a Stage 1 pressure ulcer (red area on the skin that does not turn white when pressed) upon admission and prevent further pressure ulcer development for 1 of 4 sampled residents (Resident 1) reviewed for pressure ulcers. This caused harm to Resident 1 when admitted with a Stage 1 pressure ulcer to the coccyx (boney structure at the bottom of the spine) and did not receive treatment or preventable measures for nine days after admission and the pressure ulcer progressed to an unstageable (base of wound is covered by a layer of dead tissue and cannot be seen) wound; and the resident developed an additional unstageable pressure ulcer to the right heel. This failure placed residents at risk for worsening of skin impairment, a change in health status and a diminished quality of life.