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 Pacific Care And Rehabilitation during CMS and state inspections, most recent first.
A resident with severe cognitive impairment was assisted with eating by a nursing assistant who stood next to her instead of sitting at eye level, as required for maintaining dignity. The NA reported a lack of available chairs as the reason for standing, and the DON confirmed that staff should be at eye level when assisting residents.
A resident's MDS assessment was inaccurately coded to indicate use of an antipsychotic medication, despite no such medication being prescribed or administered, as confirmed by the MDS nurse and DON after reviewing the resident's health records.
A resident who was alert, oriented, and assessed as appropriate for self-administering Parkinson's medications was observed using a pill organizer, but there was no documentation in the care plan addressing medication self-administration. Staff confirmed that a care plan had not been created at the time of assessment, contrary to facility policy.
A resident with COPD and respiratory failure did not have oxygen and nebulizer tubing changed weekly or stored in a bag as required by facility policy and physician orders. Observations showed the tubing was not dated or bagged, and staff interviews revealed inconsistent practices regarding tubing changes and storage.
A resident with moderate cognitive impairment was not documented as transferred to the hospital despite agreement from family and a nurse, and instructions from an on-call provider. The facility failed to ensure proper documentation and facilitation of the resident's healthcare decision.
A resident with moderate hearing difficulty did not receive timely hearing services, resulting in a 163-day delay from the initial note indicating the need for a hearing appointment. The social services department failed to schedule the necessary appointment promptly, despite documented needs and facility policies.
A facility failed to provide respiratory care according to physician's orders for a resident with COPD, Pneumonia, and Respiratory Failure. The resident's oxygen tubing was found out of place, and the concentrator was turned off, leading to low oxygen saturation levels. Investigation revealed a home care aide had removed the oxygen at the resident's request.
The facility failed to maintain a medication error rate below five percent, resulting in a 12% error rate. Medications for two residents were administered at incorrect times, potentially reducing the effectiveness of Levothyroxine.
A resident with ill-fitting bottom partials did not receive timely dental care due to a lack of communication between nursing staff and the Social Services Assistant. The resident was observed with missing teeth and a loose bridge, and was unsure if a dental appointment was being arranged.
Failure to Maintain Resident Dignity During Meal Assistance
Penalty
Summary
Staff failed to provide care in a manner that maintained and promoted dignity for one resident who was severely cognitively impaired. During a meal, a nursing assistant (NA) was observed standing next to the resident while assisting her with eating, rather than sitting at eye level as required. The NA later explained that there were not enough chairs available in the dining room at the time and that she attempted to get assistance to bring a chair. The Director of Nursing confirmed that staff should ideally be at eye level when assisting residents with meals.
Inaccurate MDS Assessment Coding for Medication Use
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) assessment was completed accurately for one resident. Specifically, the Annual MDS assessment documented that the resident, who was severely cognitively impaired, was taking an antipsychotic medication. However, a review of the resident's electronic health record, including physician orders and the medication administration record, showed that the resident was not prescribed nor taking any antipsychotic medication. The MDS nurse acknowledged that the MDS was miscoded after reviewing the records, and the Director of Nursing confirmed the expectation that the MDS should accurately reflect the medications taken by residents.
Failure to Develop Care Plan for Medication Self-Administration
Penalty
Summary
The facility failed to develop a person-centered care plan addressing medication self-administration for a resident who was reviewed for medication administration. The facility's policy required that determinations regarding self-administration of medications be documented in the resident's care plan. The resident, who was alert and oriented and had been evaluated and deemed appropriate to self-administer Parkinson's medications, was observed with a pill organizer containing his medications. However, review of the resident's care plan showed no documentation of a focus or interventions related to self-administration of medications. Staff confirmed that a care plan for medication self-administration had not been in place at the time of the assessment and only a new care plan was recently initiated after the deficiency was identified.
Failure to Change and Store Respiratory Tubing per Policy and Orders
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for a resident by not ensuring that oxygen and nebulizer tubing was changed and stored according to policy and physician orders. The facility's policy required oxygen tubing to be replaced every seven days or when visibly soiled, and physician orders specified weekly changes for both oxygen and nebulizer tubing, with all tubing to be dated and stored in a bag when not in use. However, observations over several days revealed that the resident's oxygen tubing was dated more than a week prior and had not been changed as required. Additionally, the nebulizer tubing and mouthpiece were found undated and uncovered, not stored in a bag as directed by both care plan and physician order. The resident involved had a history of chronic obstructive pulmonary disease (COPD) and both acute and chronic respiratory failure with hypoxia, and was alert, oriented, and receiving oxygen therapy. Interviews with staff confirmed inconsistent practices regarding the frequency of tubing changes and proper storage, with some staff stating changes occurred monthly rather than weekly. The Director of Nursing and Resident Care Manager both acknowledged that the tubing should have been changed, dated, and stored in a bag, but these actions were not carried out as required.
Failure to Document and Facilitate Resident's Hospital Transfer
Penalty
Summary
The facility failed to ensure that residents could exercise self-determination regarding significant aspects of their life, including healthcare decisions and accessing outside healthcare providers. This deficiency was identified for one resident who was moderately cognitively impaired. On a specific date, a family member and a nurse from an assisted living facility agreed that the resident needed to go to the emergency room due to symptoms of vomiting and diarrhea. However, despite the resident's and family member's agreement, there was no documentation in the resident's electronic medical record indicating that the resident was transferred to the hospital. The report details that the facility staff, including a registered nurse and the social services director, were informed of the resident's condition and the recommendation for hospital transfer. Despite this, the electronic medical record lacked documentation of the transfer, and the on-call provider service staff confirmed that a call was made to the provider, who instructed the nurse to send the resident to the hospital. The facility's infection preventionist and registered nurse, who was the manager of the day, confirmed that there should have been a progress note if a resident was transferred out of the facility, indicating a lapse in documentation and follow-through on the resident's healthcare decision.
Failure to Provide Timely Hearing Services
Penalty
Summary
The facility failed to ensure timely hearing services for Resident 5, who was cognitively intact and had moderate difficulty hearing. Despite being admitted on an earlier date and having documented needs for hearing services in both October 2023 and January 2024, no hearing aids or appointments were provided until April 2024. The social services department, responsible for scheduling these appointments, did not follow through in a timely manner, leading to a significant delay of 163 days from the initial note indicating the need for a hearing appointment. Interviews with staff revealed that the Social Services Assistant was responsible for scheduling hearing appointments but failed to do so promptly. The Social Services Director and the Administrator both acknowledged that the hearing appointment for Resident 5 was not made in a timely manner, despite the facility's policy of assessing hearing needs upon admission and quarterly. This delay in providing necessary hearing services placed Resident 5 at risk for communication difficulties and a diminished quality of life.
Failure to Provide Appropriate Respiratory Care
Penalty
Summary
The facility failed to ensure respiratory care and interventions were provided according to physician's orders for a resident diagnosed with Chronic Obstructive Pulmonary Disease, Pneumonia, and Respiratory Failure. The resident was admitted with a physician's order to maintain 2 liters of oxygen via nasal cannula. During an observation, a registered nurse found the resident's oxygen tubing not in place, the oxygen concentrator turned off, and the resident's oxygen saturation level at 87%, which is below the normal range. The nurse had to turn on the concentrator and place the tubing back in the resident's nose to address the issue. Further investigation revealed that a home care aide had removed the resident's oxygen and turned off the concentrator at the resident's request. This action was not in compliance with the physician's orders and led to the resident experiencing low oxygen saturation levels. The deficiency was identified during a review of the resident's care and the facility's adherence to respiratory care protocols.
Medication Administration Errors
Penalty
Summary
The facility failed to ensure a medication error rate of less than five percent, resulting in a 12% error rate. Specifically, the facility did not administer 3 out of 25 medications at the correct time. For Resident 12, Levothyroxine, Papaya, and Protonix were administered after breakfast, contrary to the guidelines that Levothyroxine should be taken on an empty stomach at least 30 to 60 minutes before a meal. Additionally, Papaya was supposed to be given before meals to prevent nausea and vomiting, but it was administered after the resident had already consumed her morning meal. Similarly, for Resident 56, Metformin, Omeprazole, and Levothyroxine were administered after breakfast instead of at the scheduled time of 7:00 AM. This improper timing potentially reduced the absorption rate of Levothyroxine. Staff C, the RN responsible for administering these medications, did not follow the correct administration guidelines. The Director of Nursing Services confirmed that Levothyroxine should be scheduled at 5:00 AM to ensure proper absorption.
Failure to Provide Prompt Dental Services
Penalty
Summary
The facility failed to provide prompt dental services for a resident who was cognitively intact and had ill-fitting bottom partials. The resident's dental assessment indicated a need to see a dentist, but this information was not communicated to the Social Services Assistant. As a result, the resident did not receive timely dental care, leading to continued dental issues. The resident was observed with missing teeth and a loose bridge, and was unsure if the facility was arranging a dental appointment.
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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 Hoquiam
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Grays Harbor Health & Rehabilitation Center | 0.5 mi | — | 2 | 0 |
| Montesano Health-rehab Center | 12.8 mi | — | 1 | 0 |
| Willapa Harbor Care | 21.4 mi | — | 0 | 0 |
| Fir Lane Care | 39.4 mi | — | 7 | 0 |
| Shelton Health And Rehabilitation | 39.5 mi | — | 19 | 0 |
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