Above average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of August 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.
Binding Arbitration Agreement Not Adequately Explained: Two cognitively intact residents signed a Patient and Facility Arbitration Agreement, but neither recalled being informed about the right to rescind within 30 days. The BOM said the agreement was reviewed with both residents, while the ADM stated the agreement was voluntary and could be rescinded within 30 days after signing.
The facility failed to ensure informed consent was obtained before giving a psychotropic medication to a resident who was severely cognitively impaired. The resident had an order for Duloxetine for depression, but the EHR did not show consent for the medication. An RCM/LPN stated that risk and benefits were reviewed with residents and/or their representatives and consent was obtained, but he could not find a consent for Duloxetine.
Failure to provide bed-hold notice at hospital transfer: The facility did not give written bed-hold information to two residents or their representatives when they were transferred to the hospital. One resident was alert and oriented and transferred for SOB related to bronchitis/pneumonia; the other was moderately cognitively impaired and said she was not told whether her bed would be held. Staff notes and EHR review showed no documentation of the required notice or contact.
A resident with moderate cognitive impairment and Non-Alzheimer's Dementia had a Wander Guard on the left ankle, with orders and a care plan directing its use for wandering. However, the Quarterly MDS stated the resident did not use a wander/elopement alarm. The DON said the alarm should have been captured on the MDS.
A facility failed to develop comprehensive care plans for two residents. One resident had a scabbed area on the bottom of the left second toe with orders for betadine, monitoring, and skin prep, but the care plan did not include skin risk or the toe wound. Another resident had a right arm DVT and was receiving Eliquis, but the EHR did not include a care plan for the DVT or anticoagulant use; staff confirmed both care plans were missing.
Care plans were not kept current for two residents. One resident’s care plan still listed a sacral pressure ulcer even though the MDS and staff indicated the wound had resolved, and another resident’s anticoagulant care plan still stated the resident was on anticoagulant therapy even though apixaban had been discontinued and the MDS showed no anticoagulant use. The DON acknowledged both care plans needed updating.
A resident was observed receiving oxygen via NC at 2 lpm, and stated she used oxygen intermittently for SOB. Although the care plan noted altered respiratory status, recent COVID-19, acute hypoxic respiratory failure, and asthma with oxygen per order, the EHR did not contain a physician order for oxygen. The DON stated residents using oxygen were expected to have a physician order before oxygen was administered.
Failure to Monitor Anticoagulant Side Effects: A resident with a right arm DVT was prescribed Eliquis and received it twice daily, but the EHR did not show documentation of monitoring for anticoagulant side effects such as bleeding or bruising. An LPN and the DON stated the resident should have had anticoagulant side effect monitoring and a care plan addressing the anticoagulant and DVT.
Improper Storage of Specimen Hat in Resident Room: Staff left a specimen hat used for emptying a resident’s colostomy bag on the floor near the sink in a resident room without a protective covering. A CNA identified its use, and an RN and the DON confirmed the expectation was that the item be cleaned and kept in a plastic bag off the floor after use.
Nurse staffing information was not posted and updated daily at the beginning of each shift. The staffing posting on the main floor was observed to be a day behind, and the Staffing Coordinator said she routinely posted the previous day’s information and updated changes the next day instead of throughout the day when call-outs or other staffing changes occurred. The DON stated the expectation was for the posting to show the current date and reflect staffing changes every shift.
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.
Binding Arbitration Agreement Not Adequately Explained
Penalty
Summary
The facility failed to ensure its binding arbitration agreement was reviewed and explained in a form and/or manner understood by 2 of 3 sampled residents, Resident 74 and Resident 75. Resident 74 was admitted to the facility and the admission MDS dated 04/30/2026 showed the resident was cognitively intact. The EHR showed Resident 74 signed a Patient and Facility Arbitration Agreement on 04/27/2026, but in an interview on 05/07/2026 at 12:30 PM, Resident 74 said they did not recall signing the agreement or being informed about the right to rescind it within 30 days. Resident 75 was admitted to the facility and the admission MDS showed the resident was cognitively intact. The EHR showed Resident 75 signed a Patient and Facility Arbitration Agreement on 04/30/2026, but in an interview on 05/07/2026 at 11:36 AM, Resident 75 said they signed the agreement but did not recall being informed about the right to rescind it within 30 days. Staff E, Business Office Manager, stated they reviewed the agreement with both residents, but when asked how understanding of the right to rescind was ensured, Staff E said residents can rescind it at any time and confirmed they could rescind it 30 days after signing. Staff A, Administrator, stated the arbitration agreement was voluntary and residents had 30 days to rescind after signing.
Failure to Obtain Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to ensure that Resident 52 was fully informed and that informed consent was obtained before administration of a psychotropic medication. Resident 52 was admitted to the facility and the quarterly MDS dated 04/08/2026 indicated the resident was severely cognitively impaired. Physician orders dated 04/08/2026 directed staff to give Duloxetine, a prescription medication used to treat depression, one capsule by mouth daily for depression. Review of Resident 52's EHR did not show consent for Duloxetine. During an interview on 05/07/2026 at 9:08 AM, the RCM/LPN stated that risk and benefits of psychotropic medications were covered with residents and/or their representatives and then consent was obtained, but he could not find a consent for Duloxetine.
Failure to Provide Bed-Hold Notice at Hospital Transfer
Penalty
Summary
The facility failed to provide a written bed-hold notice to residents and/or their representatives at the time of transfer to the hospital for 2 of 5 sampled residents, Residents 4 and 8. The facility policy titled, ADMISSION, TRANSFER AND DISCHARGE Notice of Bed Hold Policy Before / Upon Transfer, stated that written information specifying the duration of the state bed-hold policy would be provided to the resident or resident representative, with two notifications given, including one at the time of transfer or within 24 hours if the transfer was an emergency. Resident 4 was admitted to the facility and was documented as alert and oriented on the Admission/5-day MDS. On 04/30/2026, Resident 4 was transferred to an acute hospital for shortness of breath related to bronchitis and pneumonia. The EHR did not show documentation that the bed hold was reviewed with Resident 4 or the representative, although Staff D stated he spoke with Resident 4 at the hospital the following day and did not think it was documented. Resident 8 was documented as moderately cognitively impaired on the Quarterly MDS and was transferred to the hospital on [DATE]. The EHR did not show documentation of a written bed-hold notice or contact with the resident and/or representative regarding bed-hold information. Resident 8 stated the facility did not mention whether her bed would be held, and Staff F stated the resident would be given a copy of the bed hold policy and it would be reviewed with them; Staff B stated Resident 8 was not given bed-hold information or offered a bed-hold and should have been.
MDS Did Not Reflect Wander Guard Use
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) was completed accurately for Resident 8, who was admitted to the facility and was documented as moderately cognitively impaired with Non-Alzheimer's Dementia. The Quarterly MDS documented that the resident did not use a wander/elopement alarm, even though the resident had a physician order for a Wander Guard to the left ankle with checks for placement and functioning every shift and replacement as needed for wandering. The resident's elopement risk/wanderer care plan also documented that a Wander Guard was placed on the left ankle and was to be checked for placement and functioning and changed as needed. During observation, the resident was sitting in a wheelchair in her room with a Wander Guard alarm bracelet attached to her left ankle, and the resident stated that it stayed on her ankle 24/7 to keep an eye on things. The DON stated in interview that the Wander Guard alarm should have been captured on the MDS and would need to be fixed.
Failure to Develop Comprehensive Care Plans for Skin Condition and Anticoagulant Use
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident with a skin condition involving the bottom of the left second toe. The resident was admitted with moderate cognitive impairment, and records showed physician orders for betadine to the left foot toe area, monitoring of an abrasion to the bottom of the left second toe, and later skin prep applied twice daily to a scab on the bottom side of the left second toe. A joint observation found a scabbed area on the bottom of the left foot second toe, but the comprehensive care plan initiated and revised in April did not include a focus area or goal for skin at risk care or for the scabbed area. Staff confirmed that a care plan should have been developed for the skin issue and that it was not. The facility also failed to develop a comprehensive care plan for a resident receiving anticoagulant medication for a DVT. The resident was cognitively intact and reported having a blood clot in the right arm and believing he was on a blood thinner. Records showed an ultrasound result indicating an occlusive, likely acute to subacute DVT within the right brachial vein, followed by a physician order for Eliquis, which was then administered twice daily in April and May. The resident’s EHR did not contain a comprehensive care plan for the DVT or for anticoagulant medication use, and staff stated that anticoagulant use and DVT monitoring should have been included in the care plan.
Care plans not updated for wound status and anticoagulant use
Penalty
Summary
The facility failed to ensure care plans were revised to accurately reflect the care needs of 2 residents. Resident 36 was admitted with moderate cognitive impairment, and the admission MDS dated 04/15/2026 documented no pressure ulcer/injury. However, the record showed physician orders dated 04/12/2026 through 04/21/2026 for daily and as-needed sacral wound treatment, and the comprehensive care plan dated 04/11/2026 still listed a focus area stating the resident had a pressure ulcer of the sacrum. Staff F stated the resident had a pressure area on her bottom when first admitted and it had been resolved, and the DON stated the resident did not have a pressure ulcer and that the care plan needed to be fixed. Resident 8 was admitted to the facility and had a quarterly MDS documenting moderate cognitive impairment and no anticoagulant use. The electronic health record showed the resident had been taking apixaban twice daily, but it was discontinued on 02/09/2026. Despite this, the anticoagulant care plan dated 11/03/2023 still stated the resident was on anticoagulant therapy and included interventions to administer anticoagulant medications as ordered by the physician. The DON stated the care plan should have been updated to reflect that the resident was no longer taking anticoagulant medication.
Missing Physician Order for Oxygen Therapy
Penalty
Summary
The facility failed to obtain a physician's order for oxygen use for one resident who was receiving oxygen via nasal cannula at 2 lpm through an oxygen concentrator. The resident was admitted to the facility, was cognitively intact, and the admission MDS showed oxygen therapy. During observation, the resident stated she used oxygen at 2 lpm intermittently for shortness of breath. The care plan documented altered respiratory status/difficulty breathing related to recent COVID-19, acute hypoxic respiratory failure with oxygen use, and asthma, with oxygen per order. However, record review of the resident's electronic health record did not show a physician's order for oxygen, despite the facility policy stating there must be a practitioner's order for oxygen therapy including the indication for use and related parameters. The DON stated it was her expectation that residents using oxygen had physician's orders in place before oxygen was administered.
Failure to Monitor Anticoagulant Side Effects
Penalty
Summary
The facility failed to ensure anticoagulant medication side effects were monitored for one resident who was receiving Eliquis for a right arm deep venous thrombosis. The resident was admitted to the facility and was documented as cognitively intact on the Quarterly MDS dated 04/11/2026. During an interview on 05/04/2026, the resident stated he had a blood clot in his right arm and believed he was taking a blood thinner medication. Record review showed that on 04/20/2026 an ultrasound identified an occlusive, likely acute to subacute DVT within the right brachial vein, and the MD was notified and ordered Eliquis. Physician orders and the April and May 2026 MARs confirmed Eliquis was administered twice daily for DVT. The resident’s EHR did not contain documentation of monitoring for anticoagulant side effects. Staff D stated that residents on anticoagulants should be monitored for side effects such as bleeding and bruising and that this should be included in the care plan; after reviewing the record, Staff D said monitoring should have been ordered every shift and was not. Staff B stated the resident should have had anticoagulant side effect monitoring and a care plan addressing both anticoagulant use and DVT.
Improper Storage of Specimen Hat in Resident Room
Penalty
Summary
The facility failed to ensure staff maintained proper infection control practices for storage of personal care equipment in one resident room, room [ROOM NUMBER]. During an observation on 05/04/2026 at 12:20 PM, a specimen hat used to collect urine or stool was seen on the floor near the sink with no protective covering. Later that day, Staff H, a CNA, stated the specimen hat was used for emptying the colostomy bag belonging to the resident in bed 107-3. During a subsequent observation and interview, Staff I, an RN, also observed the specimen hat on the floor and stated the expectation was that the specimen hat would be cleaned and kept in a plastic bag off the floor after use. In a joint interview on 05/06/2026, Staff B, DON/RN, and Staff G, Infection Control/Staff Development/RN, stated it was the expectation that staff cleaned the specimen hat and bagged it after use.
Nurse Staffing Postings Not Updated Daily
Penalty
Summary
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. On observation, the nurse staffing posting on the first floor was dated 04/30/2026 on 05/04/2026, and on 05/06/2026 it was dated 05/05/2026. During interview and record review, the Staffing Coordinator stated she usually posted the previous day’s nurse staffing information and did not update staffing numbers and hours for each shift throughout the day when changes occurred; instead, she posted the updated information the next day. She said this was the process used for postings reviewed from 04/04/2026 through 05/04/2026, and that if a staff member called out, the staffing postings were updated the next day. The DON stated the expectation was that posted nursing staff information showed the current date and that staffing changes were adjusted every shift.
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.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 1 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
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 | ★★★★★ | 9 | 0 |
| Shelton Health And Rehabilitation | 39 mi | ★★★★★ | 20 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Grays Harbor Health & Rehabilitation Center.
100% money-back within 48 hours.
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.