Grays Harbor Health & Rehabilitation Center

Inspectors wroteBased on interview and record review, the facility failed to ensure the facility's binding arbitration agreements (legal document that required the use of a third party to resolve disputes) was reviewed and explained in a form and/or manner, understood by 2 of 3 sampled residents (Resident 74 & 75) reviewed for binding arbitration agreements. This failure placed residents at risk for lacking understanding of the legal document signed and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents received information about the risk and benefits and failed to obtain informed consent prior to the administration of psychotropic medications for 1 of 5 sampled residents (Resident 52) reviewed for unnecessary medication use. These failures placed residents and/or their representatives at risk of not being fully informed about the care and treatment related to the risks and benefits associated with psychotropic medications.

Inspectors wroteBased on interview and record review, the facility failed to provide a written Bed-Hold notice to residents and/or residents' representative at the time of transfer to the hospital for 2 of 5 sampled residents (Residents 4 and 8) reviewed for hospitalization and/or discharge. This failure placed residents at risk for lack of knowledge regarding their right to hold their bed while in the hospital.

Inspectors wroteBased on observation, 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 4 sampled residents (Resident 8) reviewed for dementia (a decline in mental ability including memory, language, and problem-solving) care. This failure placed residents at risk for unidentified and/or unmet care needs and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a comprehensive care plan for 1 of 3 sampled resident (Resident 36) reviewed for skin conditions, and 1 of 4 sampled residents (Resident 61) reviewed for anticoagulant (blood thinning) unnecessary medications. This failure placed residents at risk for injury, unmet care needs, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure resident care plans were revised to accurately reflect care needs for 1 of 3 sampled residents (Resident 36) reviewed for pressure ulcer/injury (damage to the skin and underlying soft tissue caused by prolonged pressure, usually over a bony area), and for 1 of 4 sampled residents (Resident 8) reviewed for anticoagulant (blood thinner) unnecessary medications. This failure placed residents at risk for unmet care needs and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain a physician's order for oxygen use for 1 of 2 sampled residents (Resident 12) reviewed for respiratory care. This failure placed residents at risk for unmet care needs, and a diminished quality of life. Findings Included. Record review of the facility's policy, titled, Quality Of Care Respiratory Care/Tracheostomy Care & Suctioning, dated July 2018, documented . b. There will be a practitioner's order for oxygen therapy to include indication for use. The type of equipment to use, baseline SpO2 [a measurement of how much oxygen a person's blood is carrying] SpO2 levels to initiate and/or discontinue oxygen therapy. Resident 12 was admitted to the facility on [DATE]. The admission Minimum Data Set, an assessment tool, dated 04/04/2026, showed Resident 12 was cognitively intact and was on oxygen therapy. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure anticoagulant (blood thinner) medication related side effects were monitored for 1 of 4 sampled residents (Resident 61) reviewed for unnecessary medications. This failure placed residents at risk for adverse side effects from anticoagulant medication use and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff maintained proper infection control practices for storage of personal care equipment in 1 of 1 resident's room (room [ROOM NUMBER]) reviewed for infection control. This failure placed residents at risk for infection and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure nurse staffing information was posted and updated daily at the beginning of each shift for 32 of 32 days reviewed for nurse staff postings. These failures placed residents, resident representatives, and visitors at risk of not being fully informed of the current staffing levels.

Inspectors wroteBased on interview and record review, the facility failed to implement care-planned interventions for 1 of 5 sampled residents (Resident 1) reviewed for care planning. This failure placed residents at risk of fall injuries, unmet care needs, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to provide Occupational Therapy (OT) services for 1 of 5 sampled residents (Resident 1) reviewed for therapy services. This failure placed residents at risk of delayed healing, a decrease in Activity of Daily Living (ADL) participation, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident oxygen administration orders were completed per physician order for 1 of 4 sampled residents (Resident 1) reviewed for oxygen administration. This failure placed residents at risk of low oxygen levels and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure timely completion of physician-ordered Urinalysis (UA) labs for 1 of 4 sampled residents (Resident 1) reviewed for quality of care. This failure placed residents at risk for delayed care, unmet 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 Durable Power of Attorney (DPOA) documentation for 5 of 12 sampled residents (18, 161, 54, 19 & 55) reviewed for ADs. This failure place residents at risk for not having their healthcare preferences honored and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were informed in writing of their potential liability for payment related to Medicare services ending for 1 of 3 sampled residents (34) reviewed for Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN). This failure placed the residents at risk of not having adequate information to make care and financial decisions during their continued stay.

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain a consent and physician's order for 1 of 2 sampled residents (54) reviewed for physical restraints. This failure placed residents at risk for injury, unmet needs, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to accurately complete a Level I Pre-admission Screening and Resident Review (PASRR) and ensure a referral for a Level II evaluation was completed for 1 of 5 sampled residents (34) reviewed for PASRR. This failure placed residents at risk for inappropriate placement and/or not receiving timely and necessary services to meet mental health care needs.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure bowel interventions were initiated for 2 of 7 sampled residents (18 & 42) reviewed for bowel management, and failed to ensure that physicians orders for consultations were arranged for 1 of 3 (55), residents reviewed for physician orders for urology and vascular consults. These failures placed residents at risk for discomfort, health complications and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure bed rails were securely fastened to the bed and without gaps between the mattress and bed rail, for 1 of 1 sampled resident (28) reviewed for accident hazards. This failure placed residents at risk for injury and/or entrapment.

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 7 sampled residents (118) reviewed for right to participate in planning care. This failure placed residents at risk of not being involved in their long-term care needs and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure care plan nutritional interventions were updated for 1 of 2 sampled residents (21) reviewed for care plan revisions. This failure placed residents at risk of weight loss, unmet care needs, and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure hearing devices were maintained in working order for 1 of 2 sampled residents (26) reviewed for hearing. This failure placed the resident at risk for decreased hearing function and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure nurse aide staff received Dementia training for 1 of 5 sampled nursing assistant staff (F) reviewed for nurse aide staff in-service trainings. This failure placed residents at risk for receiving necessary care from unskilled staff.