Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
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 Grays Harbor Health & Rehabilitation Center during CMS and state inspections, most recent first.
A resident with moderate cognitive impairment and ADL needs had a care plan stating that staff would provide bathing assistance, but the plan did not reflect the documented arrangement and preference for the resident’s spouse to perform showers. Progress notes indicated the spouse would be present on shower days to assist, and the resident reported that staff did not shower him while admitted. An LPN and the RN care manager confirmed the spouse insisted on providing showers and did not want staff involved, yet there was no documented orientation of the spouse to the shower room and no completed safety assessment, despite acknowledged fall risk. The Administrator later stated that the spouse-provided showers were not sanctioned and that the required safety assessment for showering had not been completed.
A resident who required assistance with ADLs and had moderate cognitive impairment was care planned for OT involvement and had physician orders for OT evaluation and treatment two times per week. The resident received only an initial OT evaluation, with no follow-up treatment sessions provided, and reported not recalling working with therapy staff. The rehab director confirmed the lack of ongoing OT services and noted reliance on part-time and PRN OT staff while therapy positions were being advertised.
A resident with severe cognitive impairment and an order for continuous oxygen therapy was observed without oxygen in use; the concentrator was off, the nasal cannula was not applied, and the oxygen tank on the wheelchair was empty. Both an LPN and the DON confirmed the resident was not receiving oxygen as ordered, and no changes to the physician's order had been made.
A resident with mild cognitive impairment had a physician-ordered UA that was not collected for three days after the order was placed. Nursing staff documented waiting for the sample, and interviews with the DON and other nurses confirmed that the delay was due to the order not being properly scheduled in the electronic medical record, resulting in the UA not being collected within the expected timeframe.
The facility failed to assist residents with completing advance directives (AD) and maintaining Durable Power of Attorney (DPOA) documentation. Several residents, including those with cognitive impairments, did not have their ADs properly documented in their electronic health records (EHRs). Staff acknowledged that ADs were not adequately addressed, and POLST forms were mistakenly used as substitutes, leading to a lack of proper AD documentation.
A facility failed to issue a Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) to a resident, who was moderately cognitively impaired, before the end of Medicare-covered services. Although a Notice of Medicare Non-Coverage (NOMNC) was provided, the SNF ABN, which details potential financial liability, was not given, as confirmed by the Social Services Director.
A facility failed to obtain consent and a physician's order for bed rails for a moderately cognitively impaired resident. Observations showed the resident with bed rails installed, but the electronic health record lacked the necessary documentation. Staff confirmed the oversight, acknowledging the failure to follow the facility's process.
A facility failed to complete a timely Level II PASRR referral for a resident with depression and anxiety. The initial Level I PASRR did not reflect the resident's diagnoses, and the necessary referral was delayed by over eight months. The Social Services Director admitted to missing the step, and the DON was aware of the oversight.
The facility failed to initiate bowel interventions for two residents who did not have bowel movements for extended periods, contrary to the facility's bowel management policy. Additionally, a resident requiring urology and vascular consultations did not have these appointments arranged, as there was no system in place to track and follow up on specialist referrals. Staff interviews confirmed the absence of documentation and a clear process for managing these referrals.
A resident with moderate cognitive impairment was found with loose bed rails, creating a gap between the mattress and rail. The resident struggled to use the rail for mobility, and staff interviews revealed a lack of timely reporting and maintenance checks. The maintenance director confirmed the need for tightening the rails.
Failure to Implement and Document ADL Care Plan for Resident Showering by Family
Penalty
Summary
The deficiency involves the facility’s failure to implement and update a complete, individualized ADL care plan and corresponding interventions for a resident whose wife was providing showers. Facility policy titled "Quality of Life" required development and implementation of care plans and interventions to maintain, improve, or prevent avoidable decline in ADLs based on assessed needs, goals, and preferences. The resident was admitted with moderate cognitive impairment and required assistance with ADLs. The 5‑day admission MDS documented these needs, and the ADL care plan initiated the day before the MDS specified that one staff member would provide bathing/showering assistance as needed. However, the care plan did not document the resident’s or wife’s preference for the wife to provide showers. Progress notes documented that the wife would do the resident’s laundry and would be present in the evenings to shower him on his shower days. The resident later stated that while he was in the facility, staff did not shower him and that his wife assisted him instead. An LPN and the Residential Care Manager/RN both reported that the wife was insistent on showering the resident and did not want staff involved, and the RN acknowledged there was no documentation of any orientation to the shower room for the wife. The RN also acknowledged a fall risk associated with family members showering residents. The Administrator stated she learned after the fact that the wife had been showering the resident, that this was not sanctioned by the facility, and that an assessment to verify safety with showering, which should have been completed, was not done for this resident.
Failure to Provide Ordered Occupational Therapy Services
Penalty
Summary
Failure to provide specialized rehabilitative services occurred when a resident with physician orders for occupational therapy (OT) evaluation and treatment did not receive ordered OT services beyond the initial evaluation. The resident was admitted with needs for assistance with activities of daily living (ADLs) and was documented as moderately cognitively impaired on the 5-day admission MDS. The resident’s fall risk care plan included an intervention to refer to OT as needed per orders, and physician orders dated 02/24/2026 specified OT evaluation and treatment as indicated. The Director of Rehabilitation Services reported that OT was ordered two times per week and confirmed that the resident was evaluated for OT on 02/25/2026 but did not receive any subsequent OT treatments. The resident also stated he did not recall working with therapy staff while admitted. Facility staff reported that there was no full-time occupational therapist on staff and that OT coverage was being provided by a part-time weekend therapist and PRN COTAs, with ongoing efforts to recruit additional therapy staff.
Failure to Provide Continuous Oxygen Therapy as Ordered
Penalty
Summary
A resident who was admitted to the facility with severe cognitive impairment had physician orders and a care plan in place for continuous oxygen therapy at 2 liters per minute via nasal cannula for dyspnea. Despite these orders, during an observation, the resident was found in bed without oxygen in use; the oxygen concentrator was turned off and the nasal cannula was not applied. Additionally, the oxygen tank attached to the resident's wheelchair was empty. Interviews with facility staff revealed a lack of awareness regarding any changes to the resident's oxygen orders, and upon review, staff confirmed that the order for continuous oxygen therapy remained in effect. Both the LPN and the DON acknowledged that the resident was not receiving oxygen as prescribed at the time of observation, and the DON confirmed that the expectation was for the resident to have oxygen applied at all times per the current orders.
Delayed Collection of Physician-Ordered Urinalysis
Penalty
Summary
The facility failed to ensure the timely completion of a physician-ordered urinalysis (UA) for one resident. The resident, who was mildly cognitively impaired, had a physician's order for a UA with culture and sensitivity if indicated. The order, dated 07/18/2025, did not specify collection instructions. Nursing documentation on the same day noted that staff were awaiting a urine sample from the resident. The UA was not collected until 07/21/2025, three days after the order was placed, and was then sent to the lab. Interviews with facility staff revealed that standard practice was to collect UAs within the same shift or within 24 hours of the order. Staff indicated that a three-day delay in collection was not considered timely. The Director of Nursing identified that the order was entered but not scheduled in the electronic medical record, which prevented the system from alerting nurses to complete the lab. This resulted in the UA not being collected in a timely manner as required.
Failure to Properly Document and Assist with Advance Directives
Penalty
Summary
The facility failed to have procedures in place to assist residents with completing advance directives (AD) and obtaining and maintaining Durable Power of Attorney (DPOA) documentation. This deficiency was identified for five residents who were part of a sample review. The facility's policy required that upon admission, residents should be informed of their right to establish advance directives and be provided assistance if needed. However, the facility did not adhere to this policy, as evidenced by the lack of documentation in the residents' electronic health records (EHR) regarding discussions or assistance offered for ADs. Several residents, including those who were moderately cognitively impaired, did not have their ADs properly documented or maintained in their EHRs. Staff members, including the Social Services Director and the Director of Nursing Services, acknowledged that ADs were not being adequately addressed and that POLST forms were mistakenly used as substitutes for ADs. This misunderstanding led to the absence of proper AD documentation for the residents, placing them at risk of not having their healthcare preferences honored.
Failure to Provide SNF ABN to Resident
Penalty
Summary
The facility failed to provide a resident with the required Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN), which is necessary to inform residents of their potential financial liability when Medicare services are ending. Resident 34, who was moderately cognitively impaired and admitted with diagnoses including abnormalities of gait and mobility, was issued a Notice of Medicare Non-Coverage (NOMNC) on 01/31/2025, indicating that skilled nursing services would end on 02/02/2025. However, the SNF ABN, which should have been provided before the last covered day to explain the financial implications of continuing care, was not issued to the resident or their representative. This oversight was confirmed by the Social Services Director during an interview on 03/19/2025.
Failure to Obtain Consent and Physician's Order for Bed Rails
Penalty
Summary
The facility failed to obtain consent and a physician's order for the use of physical restraints, specifically bed rails, for a resident identified as moderately cognitively impaired. The resident was admitted to the facility and had an assessment indicating the use of assist rails for bed mobility. However, observations on multiple occasions revealed the resident lying in bed with quarter bed rails installed, without any documented consent or physician's order in the resident's electronic health record. Staff interviews confirmed the oversight, with the Unit Manager and LPN acknowledging the absence of necessary consent and physician orders for the bed rails. The Director of Nursing also stated that it was expected for consent and physician orders to be obtained prior to the installation of bed rails, indicating a failure to follow the facility's established process for this resident.
Failure to Complete Timely PASRR Level II Referral
Penalty
Summary
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 for one of the sampled residents. This resident was admitted with diagnoses of depression and anxiety, and the initial Level I PASRR did not reflect these diagnoses. Despite being prescribed Duloxetine for depressive symptoms, the necessary Level II referral was not completed until over eight months after admission. Staff F, the Social Services Director, acknowledged missing the step of sending off the Level II referral within the required timeframe. The Director of Nursing Services was aware of the oversight and expected PASRR processes to be followed according to facility policy.
Failure to Initiate Bowel Protocol and Arrange Consultations
Penalty
Summary
The facility failed to initiate bowel interventions for two residents, identified as Resident 18 and Resident 42, who were reviewed for bowel management. According to the facility's bowel management policy, residents who do not have a bowel movement for more than three days should be assessed and the bowel protocol should be initiated. Resident 18 did not have a bowel movement for over 81 hours, and Resident 42 did not have a bowel movement for over 128 hours. Despite these extended periods without bowel movements, the bowel protocol was not initiated for either resident, as confirmed by the lack of documentation in their Medication Administration Reports (MARs). Additionally, the facility failed to arrange necessary consultations for Resident 55, who was reviewed for physician orders for urology and vascular consults. Resident 55 was admitted with an indwelling foley catheter, and a urology consult was ordered to address urinary retention. Furthermore, a vascular consult was ordered following the discovery of a full-thickness wound and moderate stenosis in the resident's lower extremities. However, there was no documentation to confirm that these consultations were scheduled, and staff members were unable to verify if the appointments had been arranged. Interviews with staff members revealed a lack of a clear process for tracking and following up on specialist referrals. Staff members, including unit managers and the Director of Nursing Services, acknowledged the absence of a system to ensure that referrals were completed and appointments were scheduled. This lack of organization and documentation contributed to the failure to provide timely and appropriate care for the residents involved.
Failure to Securely Fasten Bed Rails
Penalty
Summary
The facility failed to ensure that bed rails were securely fastened and without gaps between the mattress and bed rail for a resident reviewed for accident hazards. The resident, who was moderately cognitively impaired, was observed with loose bed rails on both sides of the bed. The right bed rail was leaning outward and had significant movement, with a noticeable gap between the mattress and the rail, where a box of tissues had fallen. The left bed rail also exhibited movement. The resident expressed difficulty using the loose rail to get in and out of bed and to move around, indicating that the rail had been loose for a long time. Staff interviews revealed that maintenance was responsible for installing and checking bed rails, with checks scheduled twice a year. However, the staff did not report any current issues with bed rails, and the maintenance director confirmed that the rails needed tightening after observing the resident's bed. The Director of Nursing stated that staff should report loose bed rails through the electronic work order system, TELS, and expected that bed rails would be maintained properly.
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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 Aberdeen
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pacific Care And Rehabilitation | 0.5 mi | — | 0 | 0 |
| Montesano Health-rehab Center | 12.3 mi | — | 1 | 0 |
| Willapa Harbor Care | 21.5 mi | — | 0 | 0 |
| Fir Lane Care | 38.9 mi | — | 7 | 0 |
| Shelton Health And Rehabilitation | 39 mi | — | 19 | 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.