Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around November 2026
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 Willapa Harbor Care during CMS and state inspections, most recent first.
A resident exhibiting aggressive and threatening behaviors, including verbal threats and physical actions with a butterknife, was not properly investigated according to facility policy. Staff provided witness statements, but no residents were interviewed, no incident report was filed, and there was no documented assessment of the affected resident's safety or well-being.
Surveyors observed that several opened food items in a kitchen refrigerator were not discarded by their labeled use by dates. The Dietary Manager and DON both confirmed that expired food should have been removed, but these items remained past their expiration.
A resident with severe cognitive impairment was administered psychotropic medications without timely or appropriate informed consent from their representative. Consent for one medication was obtained late, and dose changes for another were not communicated to or consented by the representative, contrary to facility policy and staff expectations.
A resident was admitted and assessed as alert and oriented, but the MDS assessment failed to document the presence of broken or loose teeth. Observations and an LPN assessment later confirmed the resident had broken and loose teeth, and the RN Infection Preventionist acknowledged the MDS was inaccurate.
A resident who was assessed as dependent for oral care and requiring substantial assistance with personal hygiene did not have their care plan updated to reflect these needs. The care plan continued to indicate only set-up assistance was required, despite staff and assessment documentation showing a higher level of dependence. Staff interviews confirmed the care plan was not revised in accordance with the resident's current condition.
A resident with moderate cognitive impairment and a documented preference for listening to country music was not provided with opportunities to engage in this preferred activity. Despite assessments and care plans highlighting the importance of music, activity records showed minimal engagement, and the resident confirmed she had not been offered suitable options such as a radio. Staff interviews revealed that refusals to participate in offered activities were not documented, contrary to facility expectations.
Three residents experienced prolonged periods without a bowel movement, and nursing staff did not initiate the prescribed bowel protocol as required by facility policy and physician orders. Documentation in the EMAR did not show that interventions such as Milk of Magnesia, Bisacodyl suppository, or Fleet Enema were administered after the specified timeframes, and staff interviews confirmed the protocol was not followed.
A resident with COPD and pulmonary fibrosis received continuous oxygen therapy without a physician's order, contrary to facility policy. Staff confirmed the resident had been on oxygen since admission, but the required order was not entered until several days later.
A nurse left a medication cup with multiple pills at the bedside of a cognitively intact resident who was not on a self-medication program, contrary to facility policy requiring staff to remain until medications are taken. The resident was found alone with the medications and reported not knowing what all the pills were for. No self-administration evaluation was documented, and the DON confirmed this was not permitted practice.
A CNA delivered a meal tray to a room under enhanced barrier precautions, and after the resident declined the tray, the CNA returned it to the meal cart with other trays due to be served. The Infection Preventionist/RN confirmed that staff were expected to leave refused trays in the room to prevent cross-contamination, but this protocol was not followed.
Nursing hours were not accurately posted or updated daily for nearly all days reviewed. The staffing coordinator, new to the role, did not update staffing numbers for each shift and was unaware of the requirement to reflect real-time changes. The DON confirmed there was no process in place for updating postings with shift changes, resulting in posted staffing information that did not accurately reflect current staffing levels.
The facility failed to ensure a safe dining environment as the floorboard heater in the dining room was excessively hot. During an observation, the heater was found to be radiating heat, causing an observer to quickly withdraw their hand upon contact. The Maintenance Director confirmed the heater's excessive heat, with a thermometer reading of 100 degrees.
A facility failed to obtain an evaluation assessment, consent, and physician order for a resident's use of full-length bolsters on both sides of the bed. The resident, who was moderately cognitively impaired, was observed multiple times with the bolstered air mattress, but their health record lacked the necessary documentation. Staff acknowledged the oversight, which placed the resident at risk.
A facility failed to develop a comprehensive care plan for a resident at risk of skin breakdown. The resident was observed with a darkened skin impairment on the left great toe, but the care plan did not address this issue. Staff confirmed the absence of a specific care plan for the impairment, despite expectations for such plans to be implemented.
A resident with cognitive intactness and an upper extremity impairment did not receive adequate grooming assistance, specifically nail care, as per their care plan. Despite the resident's preference for shorter nails, they were observed with long, unkempt fingernails. Staff indicated that nail care should occur on shower days, but there was no documentation of nail care being offered or refused, highlighting a deficiency in care provision.
A facility failed to provide a resident-centered activity for a moderately cognitively impaired resident who preferred going outside for fresh air. Despite the resident's expressed preference, there was no documentation of the resident being offered or participating in outdoor activities over several months. Staff interviews revealed uncertainty about whether the resident had been outside, and the facility's documentation of refusals was noted as weak.
A facility failed to provide restorative services for a resident with limited mobility due to a stroke. The resident's care plan lacked interventions for maintaining range of motion (ROM), and staff were unaware of any contractures or restorative programs in place. The resident demonstrated limited hand mobility and reported no ROM exercises were performed by staff.
The facility did not ensure RN supervision for at least eight hours daily on three occasions, risking inadequate care for residents. Despite efforts to hire RNs, the facility primarily received LPN applicants. In response to RN shortages, management or staff from other facilities were used to cover shifts, violating WAC 388-97-1080 (3).
Failure to Conduct Thorough Investigation After Resident Behavioral Incident
Penalty
Summary
The facility failed to conduct a thorough investigation following an incident involving a resident who exhibited heightened behaviors, including refusing medication, throwing objects, attempting to pull the fire alarm, making verbal threats, and having physical contact with aides. The resident, who was cognitively intact, also obtained a butterknife from a meal tray, threatened staff and another resident, and struck a window with the utensil. Despite these actions and the facility's policy requiring a comprehensive investigation of all allegations of abuse, neglect, or mistreatment—including resident and staff interviews and documentation in the electronic incident report system—no incident report was filed, and the event was not documented in the Accident and Injury log. The administrator acknowledged that while staff were asked to provide witness statements, no residents were interviewed or asked for statements, and there was no documented evaluation to determine if the other resident involved felt safe. Additionally, monitoring of the potentially affected resident for harm did not occur. The administrator admitted that a full investigation, as outlined in facility policy and regulatory requirements, was not completed.
Expired Food Items Not Discarded as Required
Penalty
Summary
The facility failed to ensure that food items stored in one of the kitchen refrigerators were properly managed according to professional standards. During an observation, multiple opened food items, including butter pasta, meatballs, diced carrots, bulk ham, deli ham, and parmesan cheese, were found in the refrigerator past their labeled use by dates. The Dietary Manager confirmed that these items should have been discarded by their use by dates but had not been removed. The Director of Nursing also stated that her expectation was for expired food items to be discarded from refrigerators and freezers.
Failure to Obtain Informed Consent for Psychotropic Medication Administration
Penalty
Summary
The facility failed to ensure that residents and/or their representatives were informed and provided consent prior to the administration of psychotropic medications for one of five sampled residents. Specifically, a resident with diagnoses including depression and dementia, and who was assessed as severely cognitively impaired, was started on Sertraline without documented consent from the resident's representative until 18 days after the medication was initiated. Additionally, while consent for Bupropion was obtained on the day it was started, it was signed by the resident despite their low cognitive status, and there was no documentation that the representative was notified or provided consent for subsequent dose reductions of Bupropion. Staff interviews confirmed that the expectation was for consent to be obtained from the resident or their power of attorney prior to starting psychotropic medications, and that any dosage changes should be communicated and documented with the resident or representative. However, documentation in the electronic health record did not show that these procedures were followed for the resident in question, particularly given the resident's cognitive impairment and the need for representative involvement in consent decisions.
Inaccurate Dental Assessment Documented in MDS
Penalty
Summary
The facility failed to complete an accurate comprehensive dental and oral assessment for a resident. Upon admission, the resident was documented as alert and oriented. The Medicare 5-day Minimum Data Set (MDS) assessment indicated that the resident did not have broken or loose natural teeth. However, during an observation, the resident was seen with broken and loose teeth, and was able to move his front teeth with his tongue. A subsequent assessment by an LPN confirmed the presence of loose and broken teeth. The Infection Preventionist/Registered Nurse later reviewed the MDS assessment and acknowledged that it was incorrect, as the resident did have broken teeth. The expectation was that an accurate physical assessment would be completed and documented in the MDS assessment.
Failure to Update Care Plan for Dependent Resident's ADL Needs
Penalty
Summary
The facility failed to revise the care plan for a resident who was dependent with activities of daily living (ADL), specifically oral care and personal hygiene. According to the facility's policy, care plans must be reviewed and revised at a minimum upon admission, quarterly, and with any significant change in condition. Record review showed that the resident's most recent comprehensive assessment documented a need for full staff assistance with oral care and substantial/maximal assistance with personal hygiene. However, the resident's care plan, last revised nearly a year prior, only indicated the need for set-up assistance by one staff member for these tasks. Interviews with facility staff, including a CNA, Infection Preventionist/RN, and the DON, confirmed that the resident's care needs had changed and that the care plan should have been updated to reflect the increased level of assistance required. Staff described the difference between set-up assistance and full dependence, and acknowledged that the care plan did not match the resident's current needs as documented in the assessment. This discrepancy placed the resident at risk for unmet needs and inappropriate care planning.
Failure to Provide Resident-Centered Activities Based on Preferences
Penalty
Summary
The facility failed to provide resident-centered activities that incorporated the preferences of a resident who was moderately cognitively impaired and had expressed a strong interest in listening to music, particularly country music. The resident's care plan and assessments documented the importance of music and specific television channel preferences, as well as occasional participation in religious meetings via Zoom. Despite these documented preferences, activity records showed that the resident only received five one-on-one visits over a 27-day period, with no other activities documented. Observations revealed the resident lying in bed with the television on, unresponsive to external stimuli, and not engaged in preferred activities. Interviews with the resident confirmed that she had not been provided opportunities to listen to her preferred music, stating she would listen to music television but preferred a radio, which was not available. The Life Enrichment Director acknowledged the availability of CD players and country music CDs but noted the resident had declined their use a few times, and refusals were not documented. The Administrator confirmed that refusals should be documented, but this was not done. These actions and omissions resulted in the facility not meeting the resident's individualized activity needs as required.
Failure to Initiate Bowel Protocol per Policy and Physician Orders
Penalty
Summary
The facility failed to initiate bowel interventions in accordance with physician orders and facility policy for three residents who experienced extended periods without a bowel movement. The facility's policy required licensed nurses to assess residents and begin a bowel protocol if no or minimal bowel movement was documented for 64 hours. This protocol included administering Milk of Magnesia, followed by Bisacodyl suppository, and then a Fleet Enema if previous interventions were ineffective, as outlined in the residents' physician orders. For one resident, documentation showed a gap of approximately 118 hours between bowel movements, with no evidence in the Electronic Medication Administration Record (EMAR) that the prescribed interventions were administered after the 64-hour threshold. Another resident experienced a 121-hour interval between bowel movements, and again, the EMAR did not reflect any medication intervention as required by the protocol. A third resident had a 130-hour gap between bowel movements, with no documentation of bowel protocol interventions during this period. Interviews with nursing staff and the Director of Nursing confirmed that the bowel protocol was not initiated as expected and that there were issues with documentation. Staff acknowledged that there should have been records of interventions during the periods of no bowel movement, but none were found. The failure to follow the established bowel management protocol resulted in unmet care needs for the affected residents.
Oxygen Therapy Administered Without Physician Order
Penalty
Summary
A deficiency occurred when a resident with chronic obstructive pulmonary disease (COPD) and pulmonary fibrosis was administered continuous oxygen therapy without a physician's order in place, as required by the facility's Oxygen Management Policy. The resident was observed receiving oxygen on two separate occasions, and review of the electronic health record confirmed that no physician's order for oxygen existed prior to a specific date. Staff interviews further confirmed that the resident had been using oxygen since admission, but the order was not entered until several days later. The facility's policy, revised in December 2022, mandates that a physician's order must be obtained before administering oxygen. Despite this, staff acknowledged that the resident was admitted with oxygen and continued to receive it without the necessary order. The Director of Nursing Services also confirmed that oxygen administration should follow facility policy, which was not adhered to in this instance.
Medications Left Unattended at Bedside Without Self-Administration Assessment
Penalty
Summary
A deficiency occurred when a nurse failed to remain with a resident during medication administration, contrary to the facility's policy requiring staff to stay with residents until all medications are taken. During an observation, a resident was found alone in bed with a medication cup containing nine pills left on the bedside table. The resident reported that the nurse left the medications at the bedside because she was not ready to take them, and the nurse did not remain to ensure the medications were ingested. The resident was cognitively intact but stated she did not know what all the medications were for, mentioning some were for nausea, dizziness, and high blood pressure. A review of the resident's electronic health record showed no evaluation for self-administration of medication had been completed, and the DON confirmed that the resident was not on a self-medication program. The DON also stated that medications should not be left at the bedside unless a resident is on such a program. The nurse involved reported that she assumed the resident would take the medications and left the room. This failure to follow professional standards and facility policy was identified through observation, interview, and record review.
Improper Handling of Meal Trays Under Enhanced Barrier Precautions
Penalty
Summary
Staff F, a Certified Nurse Assistant, was observed carrying a meal tray from the food cart into a resident's room that was under enhanced barrier precautions, as indicated by an orange-colored sign at the entrance. When the resident declined the meal tray, Staff F picked up the tray from the bedside table and returned it to the meal cart in the hallway, which contained other meal trays yet to be served. During an interview, Staff F confirmed that it was typical practice to return refused trays to the meal cart. However, the Infection Preventionist/Registered Nurse stated that the expectation was for staff to leave the tray in the room to prevent contamination of other trays, highlighting a failure to follow proper infection control procedures during meal distribution.
Failure to Accurately Post and Update Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that nursing hours were accurately posted and updated daily for 30 out of 31 days reviewed. Record review showed that the Daily Nursing Staffing Report postings were not provided for review prior to being edited, and the reports that were provided showed changes to key columns such as Hours Scheduled, Staffing Total, and Actual Hours Worked for every day except one. Interviews revealed that the staffing coordinator, who had only recently taken on the role, was not updating the staffing numbers for each shift on the posted reports and was unaware that updates were required throughout the day. The coordinator admitted to only posting scheduled numbers and not reflecting actual changes as they occurred. Further interviews with the DON confirmed that the staffing coordinator did not have a process in place to update the postings with shift changes and was unaware of the requirement to do so. The coordinator also stated that she would review and correct the postings the day after they were taken down, rather than updating them in real time. As a result, the posted staffing information did not accurately reflect current staffing levels and census information throughout the day, as required.
Unsafe Dining Environment Due to Hot Floorboard Heater
Penalty
Summary
The facility failed to provide a safe dining environment by not ensuring that the floorboard heater in the dining room was not excessively hot. During an observation, the heater was found to be radiating heat, and when touched, it was hot enough to cause an observer to quickly withdraw their hand. The Maintenance Director, identified as Staff D, confirmed that the heater had to be manually turned on and acknowledged its excessive heat after touching it and quickly removing his hand. A thermometer reading taken by Staff D showed the heater's temperature at 100 degrees, confirming the heater's excessive heat.
Failure to Obtain Required Documentation for Use of Bed Bolsters
Penalty
Summary
The facility failed to obtain an evaluation assessment, consent, and physician order for the use of full-length bolsters on both sides of the bed for a resident who was moderately cognitively impaired. The resident was observed multiple times lying in bed with an air mattress equipped with bolsters on both the upper and lower full-length sides of the bed. Despite these observations, the resident's electronic health record did not contain any documentation of an evaluation assessment, consent, or physician's order for the use of the bolstered air mattress. Staff members, including the Resident Care Manager and the Director of Nursing Services, acknowledged the necessity of having an assessment, physician's order, and consent for the use of such safety devices. However, they confirmed that these documents were not present for the resident in question. This oversight placed the resident at risk for injury, unmet care needs, and a diminished quality of life, as the necessary procedural steps for the use of physical restraints were not followed.
Failure to Address Skin Impairment in Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a resident, identified as Resident 20, who was at risk for skin breakdown. Resident 20 was admitted to the facility and was documented as cognitively intact with a risk of developing skin breakdown according to the quarterly Minimum Data Set assessment. On a specific date, Resident 20 was observed with a darkened skin impairment on the left great toe, but the comprehensive care plan did not address this new skin impairment. Staff E, an Infection Preventionist and LPN, confirmed that Resident 20's electronic health record lacked a specific care plan for the left great toe skin impairment. Additionally, Staff B, the Director of Nursing Services and RN, acknowledged that it was expected for a care plan to be implemented for new skin impairments, but confirmed that no such care plan was in place for Resident 20's condition.
Failure to Provide Adequate Grooming Assistance
Penalty
Summary
The facility failed to provide adequate grooming assistance for a resident, identified as Resident 12, who was reviewed for activities of daily living (ADLs). Resident 12, who was cognitively intact and had an impairment on the left side of the upper extremity, required extensive assistance with personal hygiene according to their care plan. However, the care plan did not include specific interventions for nail care. On observation, Resident 12 was found to have long, unkempt fingernails, which was against their preference for shorter nails. The electronic medical record showed no documentation of nail care being offered or refused from late June to late July. Staff interviews revealed that nail care was supposed to be provided on shower days, which occurred twice weekly, and any refusals should be documented. However, there was no record of such documentation. The Director of Nursing Services confirmed the observation of Resident 12's long and unkempt nails, indicating a lapse in the expected care routine.
Failure to Provide Resident-Centered Activities
Penalty
Summary
The facility failed to provide resident-centered activities that incorporated the preferences of a resident, identified as Resident 285, who was moderately cognitively impaired. The resident expressed a preference for going outside to get fresh air when the weather was good, as noted in the admission Minimum Data Set assessment. However, the Activity Participation reports for May, June, and July 2024 did not document any instances where the resident was offered, refused, or had gone outside. During interviews, the resident expressed a desire to go outside, and the Life Enrichment Director acknowledged inviting residents outside but was unsure if Resident 285 had participated. The Director of Nursing Services confirmed that resident preferences should be offered, and the Administrator noted that documentation of refusals was weak.
Failure to Provide Restorative Services for Resident with Limited Mobility
Penalty
Summary
The facility failed to provide restorative services for a resident who was reviewed for range of motion (ROM) and mobility. The resident, who was cognitively intact and had impairment on one side of the body due to a stroke, was not included in a restorative therapy program as per the quarterly Minimum Data Set (MDS) assessment. The care plan, dated several months prior, indicated the resident had limited physical mobility related to stroke and weakness but did not include interventions for maintaining ROM or function. The resident required extensive assistance for bed mobility, repositioning, and transfers with a mechanical lift. During interviews, the resident expressed that her hand did not open and demonstrated limited mobility, indicating that staff had not performed ROM exercises on her left hand. Staff members, including the Resident Care Manager and the Director of Nursing Services, acknowledged the absence of a restorative program and were unaware of any residents with contractures. Upon observation, the Director of Nursing Services noted that the resident's left hand appeared contracted, confirming the lack of a restorative program in place.
Failure to Provide RN Supervision for Required Hours
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was on duty for at least eight hours daily on three specific days within a 30-day review period. This deficiency was identified through interviews and record reviews, which revealed that on 06/30/2024, 07/07/2024, and 07/14/2024, there was no RN coverage for any of the three shifts (day, evening, and night). The absence of RN supervision on these days placed residents at risk of not receiving the necessary care and supervision. During an interview on 07/24/2024, the facility's administrator, Staff A, acknowledged the difficulty in hiring RNs, noting that their hiring efforts primarily attracted Licensed Practical Nurse (LPN) applicants. Staff A mentioned that in cases of RN shortages, they would utilize their management team or staff from another facility to cover the shifts. This situation was in violation of WAC 388-97-1080 (3), which mandates RN supervision for a minimum of eight hours daily.
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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 Raymond
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pacific Care And Rehabilitation | 21.4 mi | — | 0 | 0 |
| Grays Harbor Health & Rehabilitation Center | 21.5 mi | — | 2 | 0 |
| Montesano Health-rehab Center | 22.9 mi | — | 1 | 0 |
| Clatsop Care Center | 34 mi | — | 6 | 0 |
| South Creek Post Acute | 36.1 mi | — | 21 | 0 |
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