Vancouver Specialty and Rehab Care

In the surveyor’s words

From the most serious findings on record at Vancouver Specialty and Rehab Care, in the surveyor’s own words.

• Actual harm, isolatedF686Oct 13, 2023

  Based 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. […]

• Actual harm, isolatedF686Apr 6, 2023

  Based on observation, interview and record review, the facility failed to implement prevention and treatment strategies and failed to implement wound treatment orders for 1 of 3 sampled residents (64) reviewed for pressure ulcers (a skin wound caused by pressure preventing blood flow to the skin). This caused harm to Resident 64 when seven facility acquired Stage 4 (full thickness skin and tissue loss extending into muscle, tendon, ligament, cartilage or bone) pressure ulcers developed. This failure placed residents at risk for infection, wound development and worsening and a diminished quality of life. […]

• No harm, potential for more than minimal, widespreadF725Feb 24, 2026

  Based 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.Findings included.Record review of the PBJ Staffing Data Report, FY [fiscal year] Quarter 4, 2025 (July 1 - September 30), indicated the facility had excessively low weekend staffing.Record review of the facility's staff Hours Summary Report, and the Daily Staffing Form, showed the facility did not have the 3.4 hours of direct care per resident days, from 07/05/2025 through 09/21/2025. […]

• No harm, potential for more than minimal, widespreadF578Apr 6, 2023

  Based on interview and record review, the facility failed to obtain, provide, and/or assist with completing Advance Directives (ADs) for 10 of 18 sampled residents (Residents 48, 55, 68, 27, 229, 30, 35, 56, 8 & 13) reviewed for ADs. This failure place residents at risk for losing their right to have their healthcare preferences and/or decisions honored. Findings included . 1) Resident 55 was admitted to the facility on [DATE]. The admission Minimum Data Set, (MDS), an assessment tool, dated [DATE], documented the resident was cognitively intact. Review of Resident 55's Electronic Health Record (EHR) did not show documentation of an AD. 2) Resident 68 was admitted to the facility on [DATE]. […]

• No harm, potential for more than minimal, widespreadF725Feb 3, 2022

  Based on observation, interview and record review, the facility failed to ensure there was sufficient staff for residents to received prompt call light responses and assistance with activities of daily living (ADLs) in four of four hallways reviewed for sufficient nursing staff. This failure placed residents at risk for unmet care needs and negative outcomes. Findings included . The facility's policy entitled Activities of Daily Living (ADLs), Supporting, revised March 2018, documented Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. […]