Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around January 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 Vancouver Specialty And Rehab Care during CMS and state inspections, most recent first.
A resident with dementia sustained a new skin injury that was assessed and treated by staff, but there was no documentation that the resident's POA or physician were notified as required. Staff interviews confirmed the lack of notification documentation.
A resident dependent on staff for ADLs, including bathing, did not receive the scheduled number of baths or showers due to staffing shortages and missed assignments. Facility records and staff interviews confirmed that bathing was frequently delayed or missed, with responsibilities often passed between shifts and exacerbated by insufficient staffing.
The facility failed to implement bowel management protocols for three residents, resulting in prolonged constipation and discomfort. Despite the facility's policy requiring specific interventions and documentation, staff interviews revealed a lack of adherence, with no consistent initiation of the bowel protocol or documentation of interventions. This led to significant delays between bowel movements for the residents, impacting their well-being.
The facility failed to provide at least eight hours of RN coverage and supervision for three out of thirty days reviewed. Interviews and record reviews showed that the facility's daily nurse staff postings and the Staffing Coordinator's schedule did not reflect 24 hours of RN coverage on all reviewed days. The Administrator confirmed the lack of a waiver for RN coverage and mentioned recruitment efforts and incentives for staff retention.
The facility did not have procedures to assist a resident with completing advance directives (AD) or maintaining Power of Attorney documentation. A resident, moderately cognitively impaired, lacked an AD or documentation of AD review since March 2024. Despite having a POLST, there was no AD, Power of Attorney, or guardian documented. Staff indicated ADs were reviewed quarterly, but this was not done for the resident. The Administrator confirmed ADs should be reviewed upon admission and quarterly.
A facility failed to accurately complete the PASARR for a resident with anxiety and depression, as required by policy. The resident was admitted without a Level II evaluation, and the PASARR was not reviewed for accuracy until days later, despite the resident showing signs of distress and fear. This oversight risked unmet mental health needs.
The facility did not complete a performance evaluation for a nursing assistant hired in 2021, as required by policy. This oversight was identified through interviews and record reviews, revealing a lack of adherence to the facility's policy of conducting annual evaluations or additional training when needed. This failure posed a risk to residents by potentially exposing them to unskilled care.
The facility failed to monitor two residents on psychotropic medications for target behaviors and interventions. One resident, who was alert and oriented, had no behavior monitoring for depression symptoms in their EHR. Another resident was started on Trazadone for insomnia, but there was no monitoring for its psychotropic use. This lack of monitoring placed residents at risk for decreased mental health well-being.
A facility failed to obtain informed consent for a resident before administering Trazadone, a psychotropic medication. The resident, who was alert and oriented, was started on Trazadone for depression without documented consent. Staff interviews indicated that obtaining consent is usually the responsibility of Resident Care Managers or nurse managers, but no consent was found in the resident's records.
A facility failed to conduct quarterly care conferences for a resident, who was moderately cognitively impaired, resulting in an eight-month gap between meetings. This oversight was confirmed by staff, who acknowledged that care conferences should occur quarterly, potentially impacting the resident's involvement in their care decisions.
A facility failed to ensure a safe discharge for a resident with diabetes and moderate cognitive impairment. The discharge care conference did not address diabetic monitoring, and there was no documentation that the resident received a glucometer or training on its use. Staff acknowledged the oversight but could not provide evidence of proper discharge preparation.
The facility failed to initiate bowel interventions for a moderately cognitively impaired resident who had not had a bowel movement for over six days. The MAR did not show any interventions from 02/21/2024 until 5:52 PM on 02/27/2024, despite the bowel protocol requiring initiation after 72 hours.
The facility failed to conduct neurological checks for two residents who experienced unwitnessed falls. Both residents were moderately cognitively impaired, and staff confirmed that neurological checks should have been performed but were not documented. This lack of comprehensive investigation placed residents at risk.
Failure to Notify Representative and Physician of Change in Condition
Penalty
Summary
The facility failed to ensure timely notification of a resident's representative and physician following a significant change in the resident's condition. Specifically, a resident with dementia, who had a Power of Attorney (POA) responsible for health care decisions, sustained a new skin injury that was assessed and treated by staff. However, there was no documentation verifying that the resident's representative or physician were notified of the injury as required. Staff interviews confirmed that the required notifications were not documented.
Failure to Provide Scheduled Bathing Assistance Due to Staffing Shortages
Penalty
Summary
The facility failed to provide scheduled bathing assistance to a resident who was dependent on staff for activities of daily living (ADLs), specifically bathing. The resident, who had diagnoses including cerebral infarction, hemiplegia, and hemiparesis, required substantial or maximal assistance with bathing according to the Minimum Data Set and care plan, which specified bathing or showering twice per week and as necessary. However, facility records showed that the resident received only four out of eight scheduled baths or showers over a one-month period. Interviews with the resident and multiple nursing assistants revealed that staff were frequently unable to complete all assigned showers during their shifts, often passing the responsibility to the next shift. Staff cited staffing shortages, particularly on weekends, as a reason for missed showers. The Director of Nursing confirmed that the facility had experienced staffing difficulties during the relevant period due to nursing assistants quitting or not showing up for shifts.
Failure to Implement Bowel Management Protocol
Penalty
Summary
The facility failed to consistently assess and implement interventions for bowel management for three residents, leading to prolonged periods without bowel movements and associated discomfort. Resident 76 experienced no documented bowel movements for seven days, despite reporting constipation and poor appetite to the staff. Similarly, Resident 332 had no documented bowel movements for 12 shifts, with no initiation of the bowel protocol, resulting in poor eating due to constipation. Resident 72 also faced significant delays between bowel movements, with no initiation of the bowel protocol for over 105 hours, 77 hours, and 86 hours during different periods. Despite being given Senna on multiple occasions, there was no progression to the next steps of the bowel protocol. Staff interviews revealed a lack of adherence to the facility's bowel management policy, which required specific actions and documentation when residents did not have bowel movements. Staff D, a Licensed Practical Nurse, and Staff E, the Assistant Director of Nursing Services, acknowledged the failure to follow the protocol and document interventions. The Director of Nursing Services, Staff B, confirmed the expectation for the bowel program to be initiated and documented, with medical director notification if no bowel movements occurred. However, the facility was unable to provide documentation showing that the bowel protocol was consistently initiated and followed for the affected residents.
Deficiency in RN Coverage and Supervision
Penalty
Summary
The facility failed to provide at least eight hours of Registered Nurse (RN) coverage and supervision for three out of thirty days reviewed. This deficiency was identified through interviews and record reviews, which revealed that the facility's daily nurse staff postings and the Staffing Coordinator's working schedule did not show 24 hours of RN coverage on all reviewed days. The Administrator, Staff A, confirmed that the facility did not have a waiver for RN coverage and mentioned efforts to recruit RNs and offer bonuses and incentives for staff retention.
Failure to Assist with Advance Directives
Penalty
Summary
The facility failed to have procedures in place to assist with completing advance directives (AD) and obtaining and maintaining Power of Attorney documentation for one of the twelve sampled residents reviewed for ADs. Resident 13, who was moderately cognitively impaired, was admitted to the facility and did not have an AD or documentation that ADs were reviewed since March 2024. Although the resident had a POLST, there was no AD, Power of Attorney, or guardian documented. Staff I, from Social Services, stated that ADs were reviewed quarterly during care conferences, and if a resident did not have an AD, they would assist in completing one. However, this was not done for Resident 13. The Administrator confirmed that ADs should be reviewed upon admission and quarterly if not already in place.
Failure to Ensure Accurate PASARR for Resident with Mental Health Needs
Penalty
Summary
The facility failed to ensure the Preadmission Screening and Resident Review (PASARR) was completed accurately for a resident with a history of anxiety and depression. The resident was admitted with diagnoses including anxiety and depression, and the initial Level I PASARR screening conducted by the discharging hospital indicated that a Level II evaluation was not required. However, the facility did not review the PASARR for accuracy upon admission, as per their policy, which mandates coordination with the PASARR program to ensure appropriate care for individuals with mental disorders or intellectual disabilities. The deficiency was identified when the resident exhibited signs of distress, including tearfulness and anxiety, and expressed fear of retaliation by staff after an incident involving a bag of knives. The Social Services Director acknowledged that the PASARR was not reviewed for accuracy until several days after admission, and the facility administrator could not provide documentation to support that the PASARR Level I had been reviewed for accuracy at the time of admission. This oversight placed the resident at risk for unmet mental health needs and a diminished quality of life.
Failure to Conduct Annual Performance Evaluation for Nursing Assistant
Penalty
Summary
The facility failed to complete performance evaluation reviews for a nursing assistant, identified as Staff J, who was hired on May 11, 2021. Staff J's personnel records lacked a performance evaluation for the previous year. This deficiency was identified through interviews and record reviews, indicating that the facility did not adhere to its policy of conducting annual performance evaluations or additional training when necessary. This oversight placed residents at risk of receiving care from unskilled staff, potentially affecting their quality of life.
Failure to Monitor Psychotropic Medication Use
Penalty
Summary
The facility failed to monitor residents on psychotropic medications for target behaviors and interventions, which led to a deficiency in the care of two residents. Resident 36, who was admitted to the facility, was noted to be alert and oriented with no symptoms of depression according to the Quarterly Minimum Data Set (MDS) assessment. However, a review of Resident 36's Electronic Health Records (EHR) revealed a lack of behavior monitoring for symptoms and/or signs of depression. Staff D, a Licensed Practical Nurse, indicated that behaviors should be recorded each shift, and new behaviors should be documented and monitored. Despite this, Staff E, the Assistant Director of Nursing Services, was unable to locate records of target behaviors and interventions for Resident 36 in the electronic Medication Administration Record (EMAR). Similarly, Resident 332, who was also alert and oriented with no signs of depression according to the 5-day MDS assessment, was started on Trazadone for depression. The EHR for Resident 332 did not show any monitoring of target behaviors or interventions related to the use of the psychotropic medication. Staff D and Staff E both acknowledged that Resident 332 was on Trazadone for insomnia, yet the January 2025 Medication Administration Record showed no monitoring for the psychotropic use of Trazadone. This lack of monitoring placed the residents at risk for decreased mental health well-being and a decreased quality of life.
Failure to Obtain Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to ensure that Resident 332 was informed about the risks and benefits of psychotropic medication and did not obtain informed consent prior to administering Trazadone. Resident 332, who was alert and oriented with no signs of depression, was admitted to the facility and started on Trazadone for depression shortly after admission. However, the electronic health record did not contain documentation of informed consent for the medication. Interviews with staff revealed that obtaining informed consent for psychotropic medications is typically the responsibility of Resident Care Managers or nurse managers, but in this case, no consent was documented for Resident 332's Trazadone prescription.
Failure to Conduct Quarterly Care Conferences
Penalty
Summary
The facility failed to ensure that residents and/or their representatives were offered the opportunity to participate in care conferences, as evidenced by the case of Resident 13. Resident 13, who was moderately cognitively impaired, was admitted to the facility and had a care conference documented on 04/16/2024. However, the next care conference was not conducted until 12/04/2024, which is almost eight months later, instead of the required quarterly schedule. Staff I from Social Services confirmed the dates of the care conferences, and Staff A, the Administrator, acknowledged that care conferences should be completed quarterly. This lapse in scheduling care conferences placed residents at risk of not being involved in decisions about their long-term care needs and a diminished quality of life.
Failure to Ensure Safe Discharge for Diabetic Resident
Penalty
Summary
The facility failed to ensure a safe and orderly discharge for Resident 186, who was admitted with a diagnosis of diabetes and had moderate cognitive impairment. During a discharge care conference, it was noted that Resident 186 would be discharging home with their spouse, who was also a resident at the facility. However, the documentation from this meeting did not include any discussion of diabetic monitoring or management, which is crucial for the resident's health given their condition. Upon review, it was found that there was no documentation to confirm that Resident 186 received a glucometer or training on its use prior to discharge. Staff I, the Social Services Director, and Staff E, the Assistant Director of Nursing Services, both acknowledged that the resident should have been provided with a glucometer and trained on its use, but neither could provide documentation to support that this occurred. Staff B, the Director of Nursing Services, also expected that such training would have been documented in the electronic health record, but was unable to find any evidence of it.
Failure to Initiate Bowel Interventions
Penalty
Summary
The facility failed to initiate bowel interventions for a resident who was moderately cognitively impaired and had not had a bowel movement for over six days. The resident was admitted to the facility and had a documented bowel movement on 02/21/2024. However, the next documented bowel movement was not until 02/28/2024, indicating a gap of over six days. The February 2024 Medication Administration Record (MAR) did not show any interventions from 02/21/2024 until 5:52 PM on 02/27/2024. According to the Director of Quality Assurance and Registered Nurse, the bowel protocol should have been initiated if a resident did not have a bowel movement after 72 hours, which should have been started on 02/25/2024.
Failure to Conduct Neurological Checks for Unwitnessed Falls
Penalty
Summary
The facility failed to ensure falls were comprehensively investigated, including obtaining neurological checks for two residents who experienced unwitnessed falls. Resident 53, who was moderately cognitively impaired, had multiple unwitnessed falls documented on various dates, but there was no documentation of neurological checks being completed for these incidents. Staff members, including a CNA, LPN, and the Risk Management Nurse, confirmed that neurological checks should be performed for unwitnessed falls, but these were not documented in the resident's fall investigations. The Director of Quality Assurance also confirmed that neurological checks should have been completed for all unwitnessed falls. Similarly, Resident 56, also moderately cognitively impaired, had unwitnessed falls on two separate occasions, but the facility did not document the completion of neurological checks. The Resident Care Manager and the Director of Quality Assurance both acknowledged that the Neurological Assessment Flowsheet was not completed for these incidents. This lack of comprehensive investigation placed residents at risk of inadequate interventions and a diminished quality of life.
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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) |
|---|---|---|---|---|
| Hudson Bay Health And Rehabilitation | 0.1 mi | — | 14 | 0 |
| Avamere Rehabilitation Of Cascade Park | 3.5 mi | — | 9 | 0 |
| The Oaks At Timberline | 4 mi | — | 15 | 0 |
| Bridge Crest Post Acute | 4.4 mi | — | 26 | 0 |
| Fernhill Rehabilitation And Care | 4.8 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.