Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Hudson Bay Health And Rehabilitation during CMS and state inspections, most recent first.
A resident reported that her food was usually warm but not hot. During meal service, hot dogs initially measured at a safe temperature but dropped to about 100°F by the end of service, which the Culinary Manager acknowledged was not warm enough.
A resident with a diagnosis of PTSD, who was alert, oriented, and receiving antipsychotic medication, did not have a care plan or trauma-informed care evaluation addressing PTSD. Both the Social Services Director and CNO confirmed the absence of the required care plan, despite facility expectations.
A resident with schizophrenia and mood disorders exhibited crying episodes during an interview, but these behaviors were not documented in the progress notes as required by the care plan. Staff confirmed that such behaviors should be recorded to ensure proper monitoring and intervention.
A resident who was alert and oriented was observed taking an oral medication without staff supervision after a nurse left medications at the bedside. The nurse admitted to leaving the room before ensuring all medications were ingested, and no self-administration evaluation had been completed. Facility policy required staff to observe medication ingestion and not leave medications at the bedside without proper approval.
A resident's bed rail was repeatedly observed to be loose and inadequately secured, despite the resident notifying staff multiple times. Staff confirmed that a work order had been submitted for repair, but the bed rail remained unfixed for several days, contrary to facility policy requiring proper installation and maintenance of bed rails.
A resident with COPD experienced significant medication errors due to incorrect administration of a Prednisone taper and an ADVAIR inhaler. The Prednisone taper was initiated incorrectly, starting with a lower dose than prescribed, and the ADVAIR inhaler was not administered as ordered, leading to a discrepancy in the number of doses remaining. These errors were attributed to an LPN responsible for the administration.
The facility failed to maintain clean kitchen vent covers, with lint observed trapped between the grilles and greasy stove hood filters. The Dietary Manager acknowledged the issue, noting that maintenance was responsible for cleaning the vent covers, while hood filter cleaning was contracted out every six months.
A resident with documented food dislikes continued to receive meals that did not align with her preferences, despite communicating these to the dietary staff. The dietary manager admitted that without a specific menu from nursing staff, the main meal was served by default, leading to a deficiency in accommodating the resident's food preferences.
A facility failed to develop a care plan for a resident's contracted left arm, leading to unmet care needs. The resident's care plan lacked interventions for the contracture, which had worsened over time. Both an LPN and the CNO confirmed the absence of a plan to address the issue.
The facility failed to maintain a safe environment when medication was found on the floor in a resident hallway. An unidentified resident reported a pill on the floor, which was identified as Zoloft by a Registered Nurse. Later, a partial blue pill was found near the nurse's station. Staff acknowledged the issue and expressed that the area should have been searched to ensure no other pills were present.
Failure to Maintain Safe Hot Food Temperatures
Penalty
Summary
The facility failed to ensure that hot food was served at a safe and appetizing temperature. On one occasion, a resident reported that her food was usually warm but not hot. During an observation, hot dogs were measured at over 160 degrees Fahrenheit when first placed on the service line, but by the end of the meal service, the remaining hot dogs had dropped to approximately 100 degrees Fahrenheit. The Culinary Manager confirmed that the hot dogs were not warm enough at that point. These findings were based on direct observation and resident interview.
Failure to Develop PTSD Care Plan for Resident
Penalty
Summary
The facility failed to develop a comprehensive care plan addressing the needs of a resident diagnosed with Post Traumatic Stress Disorder (PTSD). The resident was admitted with PTSD and was documented as alert, oriented, and receiving antipsychotic medication according to the most recent assessment. Upon review, the resident's care plan did not include any focus, goals, or interventions related to PTSD. Both the Social Services Director and the Chief Nursing Officer confirmed that there was no care plan or trauma-informed care evaluation in place for the resident, despite the expectation that such a plan should exist for individuals with this diagnosis.
Failure to Document and Monitor Targeted Behaviors for Resident with Behavioral Health Needs
Penalty
Summary
The facility failed to document and monitor targeted behaviors for one resident with a history of schizophrenia, depression, visual and auditory hallucinations, uncontrollable crying, delusional thoughts, and agitation. The resident was identified as moderately cognitively impaired and had a care plan in place that required monitoring for symptoms such as irritability, agitation, tearfulness, and changes in mood, with documentation of any observed changes and updates to the care plan as needed. During an interview, the resident cried several times when discussing her living situation, a fall, and activities. Although a Licensed Practical Nurse was alerted to these crying episodes, there was no documentation of the incidents in the resident's progress notes. Staff interviews confirmed that such behaviors should have been documented, regardless of who witnessed them, and that documentation is necessary for tracking and intervening in behavioral issues.
Medications Left Unattended and Not Administered per Professional Standards
Penalty
Summary
A deficiency occurred when a resident, who was alert and oriented, was observed taking an oral medication without staff supervision. The resident was found lying in bed with a white oval pill on a napkin on the overbed table. The resident picked up the pill and swallowed it without a nurse present. Upon questioning, the resident stated she had taken about 13 pills and that the nurse did not stay with her while she took the last few. The nurse involved admitted to leaving the resident unattended, assuming the medications were being taken as she walked away. A review of the resident's electronic health record revealed that no self-medication administration evaluation had been completed for this resident. Facility policy required staff to observe residents ingest medications and not to leave medications at the bedside unless the resident had approval for self-administration, which was not the case here. Both the Resident Care Manager and the Chief Nursing Officer confirmed that medications should not be left at the bedside and that staff are expected to observe residents taking all medications.
Failure to Securely Fasten Bed Rail
Penalty
Summary
The facility failed to ensure that a bed rail was securely fastened to the bed for one resident. The resident was observed on multiple occasions with a quarter length bed rail on the left side of the upper bed that was loose, with four to five inches of movement up and down and five to six inches of movement back and forth. The bracket attaching the bed rail to the bed frame was also observed to be loose, wiggling about one inch around the bolt. The resident reported to staff several times that the bed rail was loose, but it had not been fixed. Staff interviews confirmed that the process for reporting broken equipment, such as bed rails, involved submitting a work order through the TELS electronic system and verbally notifying maintenance. A CNA had submitted a TELS work order for the loose bed rail, but it remained unrepaired for several days. The Chief Nursing Officer acknowledged that the bed rail was looser than it should have been and that safety-related issues like this should be addressed immediately. The facility's policy required correct installation, use, and maintenance of bed rails, but this was not followed in this instance.
Medication Administration Errors in Resident with COPD
Penalty
Summary
The facility failed to administer medications accurately for a resident with chronic respiratory failure and COPD, leading to significant medication errors. The first error involved a Prednisone taper that was initiated incorrectly. Instead of starting with the prescribed 40 mg dose and tapering down to 10 mg, the taper was mistakenly started with the 10 mg dose. This error was identified by a registered nurse who notified the provider and received a new order to restart the taper correctly. However, the error was repeated, and the resident did not receive the proper dosages at the beginning of the taper. The second medication error involved the administration of an ADVAIR inhaler. The resident was prescribed two puffs twice daily, but a photograph of the inhaler showed a discrepancy in the number of doses remaining, indicating that the inhaler was not administered as ordered. This discrepancy was confirmed by a pharmacist, who noted that the resident could experience exacerbated symptoms of COPD if the doses were not given as prescribed. The errors were attributed to a licensed practical nurse who was responsible for the incorrect administration.
Kitchen Vent Cleanliness Deficiency
Penalty
Summary
The facility failed to maintain the cleanliness of the vent covers in the kitchen, which was observed during a survey. On June 6, 2024, at 10:05 AM, the overhead vent covers located over the food preparation areas were found to have lint trapped between the grilles. Additionally, the stove hood filters appeared greasy and also had lint between the grilles. At 2:07 PM, when questioned about the condition of the overhead vents, the Dietary Manager, identified as Staff F, acknowledged the presence of lint and noted that the slats of the hood filters were not installed correctly. Staff F indicated that maintenance was responsible for cleaning the overhead vent covers, while the cleaning of the hood filters was contracted out and performed approximately every six months.
Failure to Honor Resident Food Preferences
Penalty
Summary
The facility failed to honor the food preferences of Resident 114, who was cognitively intact and had specific cereal dislikes documented in her Diet History & Preferences. Despite having communicated her preferences to the dietician, dietary manager, and aides, Resident 114 continued to receive food she disliked, including oatmeal, which was observed during a meal service. The dietary manager acknowledged the oversight and noted that if a menu was not received from nursing staff, the main meal was served by default. This failure to accommodate Resident 114's food preferences was identified during a survey, highlighting a deficiency in the facility's food service practices.
Failure to Address Contractures in Resident's Care Plan
Penalty
Summary
The facility failed to develop and implement a person-centered care plan addressing limited mobility for a resident reviewed for comprehensive care plan related to mobility. The resident's comprehensive care plan, dated 05/20/2024, did not include a plan of care for contractures to the left arm. On 06/03/2024, the resident was observed with a contracted left arm and reported that the contracture had worsened. On 06/05/2024, a Licensed Practical Nurse confirmed that there were no interventions in place for the resident's contracted left arm. On 06/06/2024, the Chief Nursing Officer and Registered Nurse acknowledged that the care plan did not reflect a plan to address the resident's contractures.
Medication Found on Floor in Resident Hallway
Penalty
Summary
The facility failed to ensure a safe environment in one of the resident hallways, as evidenced by the presence of medication on the floor. An unidentified resident alerted an unidentified staff member to a pill on the floor, which was subsequently identified by Staff D, a Registered Nurse, as Zoloft, an antidepressant. Later, a partial blue pill was observed on the floor near the nurse's station. Staff E, a Resident Care Manager and LPN, acknowledged the presence of the pill but could not identify it due to the lack of a marker. Staff E expressed that staff should have searched the area to ensure no other pills were present. Staff B, the Chief Nursing Officer, also stated that she would expect staff to check the area thoroughly if a pill was found on the floor.
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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) |
|---|---|---|---|---|
| Vancouver Specialty And Rehab Care | 0.1 mi | — | 29 | 0 |
| Avamere Rehabilitation Of Cascade Park | 3.5 mi | — | 9 | 0 |
| The Oaks At Timberline | 4.1 mi | — | 15 | 0 |
| Bridge Crest Post Acute | 4.5 mi | — | 26 | 0 |
| Fernhill Rehabilitation And Care | 4.7 mi | — | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.