Willapa Harbor Care

Inspectors wroteBased on interview and record review, the facility failed to ensure a thorough investigation was conducted for 1 of 2 sampled residents (Resident 1) reviewed for accident and incident investigations. This failure placed residents at risk for abuse and neglect, inappropriate corrective actions, and a diminished quality of life.

Inspectors wroteBased on observation and interview, the facility failed to ensure food items were labeled and dated when opened in 1 of 2 kitchen refrigerators, reviewed for food storage. This failure placed residents at risk for food borne illness, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents and/or resident representatives were informed and provided consent before administering a psychotropic medication (medications capable of affecting the mind, emotions, and/or behaviors) for 1 of 5 sampled residents (Resident 14) reviewed for unnecessary medications. This failure placed residents and/or resident representatives at risk of not being fully informed of the risks and benefits before making decisions about medications, and a diminished quality of life. Findings Included . Review of the facility's policy titled, Psychoactive [a drug affecting the mind] Medication Management, revised 08/2024, documented, .10. Complete the Psychopharmacologic [drugs used to treat mental health conditions] Medication Information Evaluation with the resident/resident representative. a. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to complete an accurate comprehensive dental/oral assessment for 1 of 1 resident (Resident 8) reviewed for dental status. This failure placed the residents at risk for unmet care needs and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to revise a resident care plan for 1 of 3 sampled residents (Resident 37) reviewed for activities of daily living (ADL). This failure placed residents at risk for unmet needs and inappropriate plans of care.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide resident centered activities that incorporated the resident's preferences for 1 of 3 residents (Resident 37) reviewed for activities. This failure placed residents at risk for a diminished quality of life.

Inspectors wroteBased on interviews and record review, the facility failed to initiate bowel interventions for 3 of 6 residents (Resident 1, 3 & 30) reviewed for quality of care. This failure placed residents at risk of unmet care needs and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure an order was in place prior to the administration of oxygen, for 1 of 2 sampled residents (Resident 30) reviewed for respiratory services. This failure placed residents at risk for complications in respiratory health and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were administered by professional standards of practice for 1 of 5 residents (Resident 20) reviewed for medication administration. This failure placed residents at risk for medication errors, negative outcomes, and a diminished quality of life. Findings Included. Review of the facility's policy titled, Medication Administration, revised 12/2024, documented, .15. Remain with the resident until all medication is taken. Resident 20 was admitted to the facility on [DATE]. The End of PPS (Prospective Payment System) Part A Stay Minimum Data Set, an assessment tool, dated 07/08/2025, documented Resident 20 was cognitively intact. In an observation and interview on 08/04/2025 at 10:47 AM, Resident 20 was observed lying in bed with no staff present in the room. [...]

Inspectors wroteBased on observation and interview, the facility failed to distribute resident meal trays in a sanitary manner in 1 of 2 hallways reviewed for infection control. This failure placed residents at risk of infection transmission and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure nursing hours were accurately posted and updated daily for 30 of 31 days reviewed for nurse staff postings. This failure placed residents, resident representatives, and visitors at risk of not being fully informed of the current staffing levels and census information.

Inspectors wroteBased on observation and interview, the facility failed to provide a safe dining environment by ensuring the floorboard heater was not hot to the touch in 1 of 1 dining room reviewed for environment. This failure had the potential to place residents at risk of burns and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain an evaluation assessment, consent, and physician order for full length bolsters on both sides of the bed for 1 of 2 sampled residents (7) reviewed for physical restraints. This failure placed residents at risk for injury, unmet care needs, and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement a comprehensive care plan addressing wounds for 1 of 5 sampled residents (20) reviewed for comprehensive care plans. This failure placed residents at risk for continued decline and decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure grooming assistance was provided for 1 of 2 sampled residents (12) reviewed for activities of daily living (ADLs). This failure placed residents at risk for unmet care needs, poor hygiene, and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide resident centered activities incorporating the resident's preferences for 1 of 1 sampled resident (285) reviewed for activities. This failure placed residents at risk for a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure restorative services were provided for 1 of 2 sampled residents (12) reviewed for range of motion (ROM) and mobility. This failure placed residents at risk for avoidable decline and diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure Registered Nurse (RN) supervision was provided at least eight hours daily for 3 of 30 days reviewed. This failure placed residents at risk for not receiving needed care and supervision of care.

Inspectors wroteBased on interview and record review, the facility failed to ensure staff received dementia training and/or abuse/neglect training for 3 of 5 sampled staff (F, G & H) reviewed for nurse aids in-service trainings. This failure placed residents at risk for receiving necessary care from unskilled staff.

Inspectors wroteBased on interview and record review, the facility failed to ensure informed consents were obtained prior to administration of psychotropic medications (medications affecting the mind) for 2 of 5 sampled residents (16 & 31) reviewed for rights to be informed about care and treatment related to unnecessary medications. This failure placed residents at risk of not knowing the effects of medications, medication side effects, and a decreased quality of life.

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 6 sampled residents (2) reviewed for participating in care planning. This failure placed residents at risk of not belong allowed to be involved in care decisions and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident preferences were honored regarding a later wake-up time in the morning for 1 of 1 sampled residents (20) reviewed for self determination. This failure placed residents at risk of depression, fatigue, and a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain and provide a safe, sanitary, and homelike environment for 2 of 5 sampled residents (Residents 15 & 28) reviewed for homelike environment. This failure placed residents at risk for a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure comprehensive care plans addressed dental and end of life for 2 of 2 sampled residents (16 & 32) reviewed for development and implementation of comprehensive care plans. 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 ensure resident care plans were reviewed, revised, and accurately reflected resident care needs for 1 of 1 sampled residents (7) reviewed for care plan timing and revisions related to hospitalization. This failure placed residents at risk for unidentified and unmet care needs and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure that provider orders were followed and/or completed for 1 of 5 sampled residents (12) reviewed for services meet professional standards related to unnecessary medications. This failure placed residents at risk for medical complications, unmet care needs and a diminished quality of care.

Inspectors wroteBased on interview and record review, the facility failed to ensure ongoing neurological assessments (assesses the nervous system and identifies any abnormalities that affect function and activities of daily living) were performed for a resident after an unwitnessed fall for 1 of 3 sampled residents (30) reviewed for quality of care related to accidents. This failure placed residents at risk of having unidentified injuries, a delay in treatment, worsening conditions, health complications and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free from unnecessary psychotropic (affecting the mind) medications by failing to monitor for medication side effects and adverse behaviors for 1 of 5 sampled residents (31) reviewed for unnecessary psychotropic medications. These failures placed residents at risk for medical complications, receiving unnecessary psychotropic medications and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure hand sanitization was being performed to prevent the transmission of a multi-drug resistant organism (MDRO), Extended Spectrum Beta-Lactamase (ESBL, an enzyme resistant to antibiotics and is spread through contaminated hands and surfaces), for 1 of 2 sampled residents (2) reviewed for infection prevention and control related to Transmission Based Precautions (TBP). This failure placed residents at risk of transmission of a MDRO and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to offer the pneumococcal vaccine to 3 of 5 sampled residents (16, 31 & 30) reviewed for immunizations. This failure placed residents at risk for developing pneumonia with potential negative outcomes.