Salmon Creek Post Acute & Rehabilitation

In the surveyor’s words

From the most serious findings on record at Salmon Creek Post Acute & Rehabilitation, in the surveyor’s own words.

• Actual harm, isolatedF607Mar 31, 2021

  Based on interview and record review, the facility failed to implement their written abuse prevention policies and procedures for timely identifying and investigating potential allegations of abuse/neglect when facility staff failed to recognize potential abuse for one of three sampled residents (#1) reviewed for investigations and grievances. This failure placed residents at risk for abuse, psychosocial harm and a decreased quality of life. This caused harm to Resident #1 when three unidentified and uninvestigated incidents occurred and the resident reported the incidents saying they felt embarrassed and ashamed. […]

• No harm, potential for more than minimal, patternF656Apr 9, 2026

  Based on interview and record review, the facility failed to ensure a comprehensive individualized care plan was developed with specific information for that resident for 4 of 7 sampled residents (1, 4, 5, and 6) reviewed for care plans. This failure placed residents at risk for unmet care needs and a diminished quality of life.Findings included . Resident 1Resident 1 was admitted to the facility on [DATE] with diagnoses including spinal stenosis (narrowing of the spaces within the spinal canal), osteoarthritis (a chronic, degenerative joint disease leading to pain, stiffness, and reduced mobility), and presence of an artificial knee joint. […]

• No harm, potential for more than minimal, patternF760Apr 9, 2026

  Based on interview and record review, the facility failed to ensure residents were free from significant medication errors when medications were not administered in accordance with provider orders and/or within the standard practice administration parameters for 3 of 7 sampled residents (Resident 1, 2, and 6) reviewed for significant medication errors. This failure placed residents at risk of adverse medical conditions, a change in health conditions, and a diminished quality of life.Findings included.Review of the facility policy, Medication Administration Section 7.1, General Guidelines, dated January 2023, showed, Medications are administered in accordance with written orders of the prescriber . […]

• No harm, potential for more than minimal, patternF761Jan 9, 2026

  Based on observation, interview and record review, the facility failed to ensure expired and/or BUE (beyond-use date) medications were discarded when expired from 2 of 5 medication carts (Cart B & Cart E) reviewed. The facility also failed to store medication in residents' room in a locked container for 1 of 1 resident reviewed (Resident 80). This failure placed residents at risk of not receiving the full benefits of the medication, equipment, supplies, and at risk for accessing unsecured medication. Findings included . Expired medications During an observation and review of the E Wing medication cart on 01/09/2026 at 10:22 AM, the cart had two pill packs with expired medication packs. […]

• No harm, potential for more than minimal, patternF812Jan 9, 2026

  Based on observation and interview, the facility failed to ensure staff performed hand hygiene during the lunch hallway meal pass for 1 of 5 hallways (C-Wing) reviewed for lunch meal pass. This failure to perform proper hand hygiene placed residents at risk of cross-contamination, food borne illness and a diminished quality of life. Findings included.During the lunch time dining observation on 01/06/2026 at 1:03 PM, Staff Q, Nursing Assistant (NA), took a meal tray into room [ROOM NUMBER]-B put the tray on the bedside table and pulled the table up to the resident. Staff Q left the room but did not wash or sanitize her hands.In an observation on 01/06/2026 at 1:04 PM, Staff Q grabbed another tray from the cart and took it into room [ROOM NUMBER]. […]