Above average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Montesano Health-rehab Center during CMS and state inspections, most recent first.
Dirty Beverage Cups Served to Resident: A resident reported being served milk and other fluids in cups that appeared dirty, and provided a photo of a clear cup with brown staining on the inside. Dietary staff were later observed filling similarly stained cups with milk, and the Dietary Chef stated the cups were used for tea and other beverages and needed soaking and hand washing because the standard wash process did not remove the film. Fourteen stained cups were found on the tray line ready for use, and the DON stated she was unaware of dirty cups being used for residents.
Infection Surveillance Program Not Completed in Real Time: The facility failed to complete real-time infection surveillance analysis, including monthly line listings and map summaries, for multiple months reviewed. The President of Clinical Services stated documentation could not be found showing the IPCP was maintained, and reported gaps in the program due to personnel issues; retrospective surveillance reports were later provided instead of monthly real-time reports.
A CNA stood next to and over a resident while providing feeding assistance instead of sitting with him during the meal. The resident had paraplegia, was severely cognitively impaired, and required extensive help with eating. The DON stated staff should be seated while assisting residents with meals.
Failure to include a resident’s representative in the care conference for a resident with moderate cognitive impairment. The resident had a low BIMS score and the MDS documented cognitive impairment, but the representative said they were never involved in a care meeting to discuss the resident’s POC or discharge. The SS Director acknowledged the facility did not hold the conference with the representative despite the resident’s low BIMS score.
A resident did not receive scheduled ADL bathing support for an extended period. The bathing record showed no bed bath or shower for eight days, despite a shower schedule of twice weekly. A CNA described how shower assignments were handled, and the DON confirmed showers were to be documented in the EHR or on paper, but no further documentation was found.
A resident had no documented BM for more than 153 hours, yet the MAR showed no bowel intervention was started despite standing orders for MOM and MiraLax when no BM occurred within 3 days/72 hours. The bowel care policy called for escalation from MOM to suppository to enema, but staff could not find documentation of treatment or refusal, and the DON confirmed the record lacked evidence that the ordered bowel protocol was carried out.
A resident with pressure ulcers who was moderately cognitively impaired and dependent on staff for bed mobility did not receive documented consistent repositioning or pressure-reducing measures. The EHR included a wound report calling for aggressive offloading and a repositioning schedule, but there was no documentation of repositioning, and staff could not produce records to verify it. The resident was observed lying on his back during multiple checks, and the DON stated repositioning should have been documented in the resident care record but was not.
A resident with an order for PRN oxycodone for severe pain rated 7-10 received the medication multiple times when pain was documented below the ordered threshold. The MAR showed doses given for pain scores of 5 and 6, and the RN and DON both acknowledged the medication should not have been administered as charted.
Failure to document and monitor a resident’s targeted behaviors. A resident with dementia, MDD, and GAD had severe cognitive impairment, reported nighttime wandering and repeated bed shaking, and had a neuro status note stating behavior warranted further evaluation and elopement monitoring. However, the EHR lacked a mental health consult, behavior evaluation, or elopement documentation, and the care plan did not include behavior monitoring. Staff could not produce additional behavior documentation beyond one episode, and the DON stated the behavior should have been monitored and documented.
A resident who was not approved to self-administer meds was observed with a pill cup on the bedside tray after an NA moved it from the bedside table. An LPN later found the cup contained oxybutynin, baclofen, and oxycodone and asked the resident to take the meds before leaving the room; the LPN and DON stated nurses should witness residents taking medications before leaving the room.
Unlabeled and expired food items were found in a resident food refrigerator, including an unsealed pancake, soup, cottage cheese, spoiled apples, yogurts, hardboiled eggs, and chocolate strawberries. The facility policy required foods to be stored separately, kept in sealed containers, and labeled with the resident's name, current date, and use-by date. Nursing staff were responsible for maintaining the refrigerator, and the DON stated items should be labeled accurately and discarded by the use-by date.
A resident with moderate cognitive impairment signed an arbitration agreement, but the facility did not ensure it was explained in a form and manner understood by the resident and/or representative. The resident’s representative did not recall signing the agreement, and the Admissions Coordinator said residents with BIMS scores of 12 or lower were not given the agreement but it was offered to representatives. No documentation was available to support the representative’s directive for the resident to sign.
Failure to Provide SNF ABN Forms: The facility did not provide SNF ABN forms for two residents reviewed for beneficiary notification. One resident had moderate cognitive impairment and the other was alert and oriented; both had Medicare Part A skilled service episodes that ended when the facility initiated discharge from Part A services before benefit days were exhausted. The Administrator stated the forms were not provided due to confusion between departments about responsibility for SNF ABN issuance and signature collection.
The facility failed to notify the state mental health authority coordinator of a significant change in condition for a resident with depression and severe cognitive impairment. The resident was coded as a significant change after a 7.5% weight loss, but a new Level I PASRR was not completed because staff said there was no new MH diagnosis.
A resident with severe cognitive impairment experienced a distressful choking episode during breakfast, requiring suctioning of food from the mouth and administration of O2 after an SpO2 reading of 86% was recorded. Facility policy required immediate physician notification for clinical problems, including low pulse oximetry readings, yet the RN did not notify the provider or the resident’s family, and no such notifications were documented in the EMR. In interviews, the RN acknowledged no notifications were made and the DON stated that any change in condition should be reported immediately to the provider, and that this choking event met the criteria for a reportable change in condition.
A resident with vascular dementia and moderate cognitive impairment signed a voluntary binding arbitration agreement, but the admissions coordinator and administrator gave conflicting explanations about revocation that did not match the written terms. The resident later did not recall signing the agreement, and the facility had already initiated guardianship proceedings.
Dirty Beverage Cups Served to Resident
Penalty
Summary
The facility failed to ensure beverage cups were thoroughly cleaned for 1 of 6 sampled residents reviewed for dietary services. Record review showed the facility policy titled, Warewashing, dated 01/2024, required all cookware, dishware, and serviceware not processed through the dish machine to be manually washed and sanitized. During an interview and observation on 07/27/2026 at 4:17 PM, Resident 1 stated she had been served milk and other fluids in cups that appeared dirty and provided a photo of a clear plastic cup with brown staining on the inner side; she said this had happened on at least four occasions. Later that day, dietary staff were observed filling clear cups with milk that had brown staining on the inner side, and Staff B, Dietary Chef, stated the cups were used for tea and other beverages. Staff B said the tea film did not come off with the standard washing process and needed to be soaked and hand washed. Fourteen cups with brown staining were on the tray line area ready to be filled with beverages, and Staff B stated they should not have been on the clean side of the kitchen and should have been set aside to soak and be hand washed. The Administrator stated she was not aware of dirty cups being used to serve residents and expected dishware to be thoroughly cleaned before use.
Infection Surveillance Program Not Completed in Real Time
Penalty
Summary
The facility failed to conduct real-time analysis of its infection prevention and control program for 10 of 10 months reviewed, including monthly line listings and monthly map summaries for the surveillance program. The deficiency was identified during interview and record review and involved the facility’s inability to maintain documentation showing that it was preventing, identifying, reporting, investigating, and controlling infections during the reviewed period. The facility’s policy for the Infection Prevention and Control Program, dated 09/18/2023, stated that surveillance and data analysis were part of the program and that surveillance data should be used to spot trends and compare infection information over time. During interview, the President of Clinical Services stated the facility could not find documentation from August 2025 through December 2026 showing the surveillance program was maintained, and said there were gaps in the program due to personnel issues. In a later interview, the same staff member said there were gaps identified from February 2026 through June 2026, and provided surveillance reports that were generated retrospectively rather than completed monthly in real time.
Failure to Maintain Dignity During Meal Assistance
Penalty
Summary
The facility failed to provide care and services in a manner that maintained and promoted dignity when staff stood next to a resident while assisting with meals. Resident 3 was admitted with multiple diagnoses, including paraplegia, and the quarterly MDS dated 03/11/2026 indicated the resident was severely cognitively impaired and required extensive assistance with eating. During an observation on 06/15/2026 at 12:50 PM, Staff N, CNA, was seen standing on the resident’s right side while providing feeding assistance, and at 12:54 PM Staff N continued feeding assistance while standing over the resident on his left side. Staff N stated that staff typically sat with residents during meals but said she stood to assist Resident 3 because there were three feeders present and she needed to be available for the others. The DON stated that staff should be seated while providing feeding assistance.
Failure to Include Resident Representative in Care Conference
Penalty
Summary
The facility failed to include Resident 51’s representative in the care planning conference for a resident who was moderately cognitively impaired. Resident 51 was admitted to the facility, and the admission MDS dated 04/28/2026 documented moderate cognitive impairment. The BIMS completed on 04/23/2026 showed a score of 9, also indicating moderate cognitive impairment. During a telephone interview on 06/16/2026, Resident 51’s representative stated they had not participated in any care conference with facility staff to discuss the resident’s plan of care or discharge and said no one had talked to them at all, including about financial matters. Staff H, Social Services Director, stated care conferences were held on admission and quarterly and that resident representatives were included if the resident had a low BIMS score, then later acknowledged the facility failed to have a care conference with Resident 51’s representative despite the resident’s low BIMS score.
Missed Scheduled Bathing for a Dependent Resident
Penalty
Summary
Failure to provide ADL assistance occurred for Resident 36, who was admitted to the facility and was documented on the 5-day MDS as alert and oriented. Review of the bathing task record showed that from 05/21/2026 through 06/17/2026, Resident 36 had not received a bed bath and/or shower since 06/09/2026, leaving eight days since the last documented bath or shower. The shower log showed the resident was scheduled for showers on Mondays and Thursdays. During interview, a CNA stated shower assignments were based on room assignments and that if a resident refused during the week, the shower would be made up on Sunday. The DON stated showers were given twice weekly based on a schedule and that nursing assistants documented in the EHR and/or on paper, but after reviewing the resident’s EHR, no further documentation was located for the resident’s showers.
Failure to Initiate Ordered Bowel Interventions
Penalty
Summary
The facility failed to initiate bowel interventions for one resident who had not had a bowel movement for more than 153 hours. The resident was admitted to the facility, was alert and oriented per the Quarterly MDS dated 07/06/2026, and the EHR bowel task sheet documented a bowel movement on 06/01/2026 at 1:59 PM, with the next documented bowel movement not until 06/07/2026 at 10:59 PM. The facility policy titled Bowel Care stated that bowel care protocol should begin when a resident had not had a bowel movement in the past three days, with Milk of Magnesia, then Dulcolax suppository, then fleet enema if needed. The resident’s physician’s orders dated 9/29/2025 included Milk of Magnesia 30 ml by mouth as needed for constipation at bedtime if no bowel movement in 3 days, and MiraLax 17 grams by mouth as needed if the resident had not had a bowel movement in the past 72 hours. The June 2026 MAR did not show that a bowel intervention was initiated. Staff D stated the bowel protocol was typically initiated after 72 hours of no bowel movement and that an alert was received after three days. Staff E stated no bowel intervention was started for the resident and could not provide documentation of treatment or refusal. Staff B stated bowel interventions were expected to be initiated per physician’s orders but could not find documentation showing administration or refusal.
Failure to Document and Provide Consistent Repositioning for a Resident With Pressure Ulcers
Penalty
Summary
Provide appropriate pressure ulcer care and prevent new ulcers from developing was cited after the facility failed to ensure that one sampled resident with pressure ulcers received appropriate pressure-reducing measures and consistent repositioning. Resident 42 was admitted to the facility, was moderately cognitively impaired, and was dependent on staff for bed mobility on the 5-Day MDS dated 04/08/2026. The resident’s EHR included a Wound Healing Report dated 06/03/2026 that recommended aggressive offloading, including a repositioning schedule, and directed the facility to document offloading compliance and any barriers at each nursing assessment. However, the record contained no documentation of repositioning taking place. During observations on 06/15/2026 and 06/17/2026, Resident 42 was seen lying in bed on his back, including being observed in the same position during repeated checks. In interview, the resident stated staff said they should reposition him but never did. Staff O, RN, stated repositioning was documented on the TAR but could not produce documentation, and the DON stated the resident was repositioned every two hours during care tasks but that repositioning should have been documented in the resident care record and was not.
Improper Administration of PRN Oxycodone
Penalty
Summary
The facility failed to follow the physician’s order for pain medication for one resident who was alert and oriented. The resident had an order dated 05/22/2026 for oxycodone, 2 tablets by mouth every 4 hours as needed for severe pain rated 7-10. Review of the MAR showed the resident received two oxycodone tablets on multiple occasions when pain was documented below 7, including two doses in May 2026 for pain rated 6 and eight doses in June 2026, seven for pain rated 6 and one for pain rated 5. During interview, the Unit Manager/RN stated nursing should attempt non-pharmacological interventions before giving oxycodone, and the DON/RN, after reviewing the MAR, stated the oxycodone should not have been given when pain scores were six.
Failure to Document and Monitor Resident Behaviors
Penalty
Summary
The facility failed to document and monitor targeted behaviors for one resident who was admitted with dementia with mood disturbance, major depressive disorder, and generalized anxiety disorder. The resident’s quarterly MDS dated 05/18/2026 indicated severe cognitive impairment. A neurological status evaluation dated 06/06/2026 documented that the resident’s behavior warranted further evaluation and that elopement behavior warranted a wander guard placed to the back Velcro fold of the wheelchair, but the electronic health record contained no documentation of a mental health consult, behavior evaluation, or elopement documentation. The resident’s care plan dated 03/24/2026 did not include a focus area for dementia behavior monitoring. During interview, the roommate reported the resident was getting up in the middle of the night and repeatedly shaking the roommate’s bed daily, and said nurses had been told several times. Staff reported the resident had been looking for her husband and walking around, and that behaviors had increased due to a UTI but later subsided. Aside from one behavioral episode documented on 06/06/2026, staff were unable to produce additional documentation of the resident’s behaviors, and the DON stated the behavior should have been monitored and documented.
Medication Administration Not Witnessed Before Staff Left Room
Penalty
Summary
The facility failed to ensure medications were administered according to professional standards of practice for one resident who was reviewed for medication administration. Resident 36 was admitted to the facility, was documented on the 5-day MDS and assessment tool as alert and oriented, and had a Medication Self-Administration Evaluation dated 05/24/2026 indicating the resident was not approved to self-administer medications. During observation, an unidentified NA brought the resident’s lunch tray into the room and moved a small pill cup from the bedside table onto the tray. After the NA left, the pill cup was observed to contain three pills. When Staff L, an LPN, was asked about the resident self-administering medications, Staff L stated the resident was not approved. Staff L then observed the pill cup on the tray containing oxybutynin, baclofen, and oxycodone, and asked the resident to take the medication before leaving the room. Staff L stated she was supposed to observe residents taking their medications before leaving the room, and the DON later stated nurses should witness residents taking medications before leaving the room.
Unlabeled and Expired Food Items in Resident Refrigerator
Penalty
Summary
Food items in the resident food refrigerator were not labeled and dated in accordance with facility policy. The facility policy for safe handling of foods from visitors required foods intended for later consumption to be stored separately, kept in a sealed container, and labeled with the resident's name, current date, and use-by date. During an observation, the refrigerator contained an unsealed pancake without a use-by date, a cup of clam chowder with a use-by date of 06/15/2026, cottage cheese with a use-by date of 6/11/2026, apples with some spoiled and mushy and a use-by date of 06/04/2026, yogurts with a use-by date of 06/07/2026, hardboiled eggs with a use-by date of 06/14/2026, and TruFru chocolate strawberries with a use-by date of 01/25/2026. Staff interviews identified that the resident food refrigerator was maintained by nursing staff rather than the kitchen. The Resident Care Manager/LPN stated it was the responsibility of nursing staff to maintain the refrigerator, label all items, and discard expired items. After the contents were reviewed, the expired and unlabeled food items were thrown out. The DON stated she expected food items in the refrigerators to be labeled accurately per policy and discarded by the use-by date.
Arbitration Agreement Not Explained in an Understandable Manner
Penalty
Summary
The facility failed to ensure an arbitration agreement was explained in a form and manner understood by the resident and/or the resident’s representative for Resident 51. Resident 51 was admitted to the facility and was documented as moderately cognitively impaired on the admission MDS dated 04/28/2026. The record showed Resident 51 signed an arbitration agreement on 04/22/2026, and the BIMS completed on 04/23/2026 documented a score of 9, indicating moderate cognitive impairment. During interview, the resident’s representative said she signed many admission documents but did not recall signing an arbitration agreement. Staff I, the Admissions Coordinator, stated that residents with BIMS scores of 12 or lower were not given the arbitration agreement but it was offered to their representatives. Staff I also stated that the resident’s representative asked Staff I to have Resident 51 sign the agreement, but no documentation of that directive was provided.
Failure to Provide SNF ABN Forms
Penalty
Summary
The facility failed to provide a Medicare Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) for 2 of 3 sampled residents reviewed for beneficiary notification. Resident 39 was re-admitted to the facility and had a Quarterly MDS dated 04/24/2026 that documented moderate cognitive impairment. The record showed a Medicare Part A skilled services episode that began on 04/14/2026, with the last covered day of Part A service on 05/18/2026, and the facility initiated discharge from Medicare Part A services when benefit days were not exhausted. The SNF Beneficiary Notification Review Form received on 06/17/2026 indicated that no SNF ABN form was provided to the resident. Resident 40 was also re-admitted to the facility and had a Quarterly MDS documenting that the resident was alert and oriented. The record showed a Medicare Part A skilled services episode that began on 12/01/2025, with the last covered day of Part A service on 02/15/2026, and the facility initiated discharge from Medicare Part A services when benefit days were not exhausted. The SNF Beneficiary Notification Review Form received on 06/17/2026 indicated that no SNF ABN form was provided to the resident. In an interview on 06/17/2026 at 11:40 am, the Administrator stated the facility did not provide the residents with SNF ABN forms and that there had been confusion between departments regarding responsibility for SNF ABN issuance and signature collection.
Failure to Complete PASRR After Significant Change
Penalty
Summary
The facility failed to notify the state mental health authority coordinator of a significant change in physical condition for one resident reviewed for the PASRR process. The resident was admitted with multiple diagnoses, including depression, and the Significant Change MDS dated 05/27/2026 documented that the resident was severely cognitively impaired and had a significant change in condition. Record review showed that a new Level I PASRR was not completed when the resident was determined to have had a significant change in condition on 05/27/2026. During interview, the MDS Coordinator/RN stated the resident was coded as a significant change after a 7.5% weight loss, and the Social Services Director stated a new PASRR was completed only when a resident had a new diagnosis of serious mental illness or dementia; when asked about this resident, the Social Services Director confirmed it was not completed because there was no new mental health diagnosis.
Failure to Notify Physician and Family After Resident Choking Event
Penalty
Summary
The deficiency involves the facility’s failure to notify a physician and the resident’s family of a significant change in condition following a choking event. Facility policy titled “Guidelines for Notifying Physicians of Clinical Problems,” revised February 2014, states that the charge nurse or supervisor should contact the attending physician any time a clinical situation requires immediate discussion and management, and specifically identifies tachypnea and dyspnea with a pulse oximetry below 90% as requiring immediate notification. Resident 1, who was documented on a recent Quarterly MDS as severely cognitively impaired, experienced a distressful choking episode while eating breakfast in the room. A CNA had the resident sitting upright and repositioned the resident more upright prior to notifying the licensed nurse. The licensed nurse responded, suctioned small amounts of breakfast food from the resident’s mouth, and documented an initial oxygen saturation of 86%, after which oxygen at 2 L was applied, improving saturation to above 90% with improved color and clear lungs without evidence of aspiration at that time. Record review of the resident’s electronic medical record showed no documentation that the physician was notified of the choking incident or the low oxygen saturation, and there was also no documentation of family notification. In interview, the assigned RN (Staff C) confirmed she was informed the resident was choking, went to the room, performed suctioning, and applied oxygen after noting an SpO2 of 86%, but acknowledged that no notification was made to the resident’s physician or family and stated she did not recall when notifications should be made. The DON/RN (Staff B) stated that any change in condition required immediate provider notification via phone call and that staff were trained during orientation to report changes of condition to providers. Staff B further stated that, based on the documentation of the breakfast choking event, it would be considered a change in condition and the physician should have been notified. The survey report states that this failure placed residents at risk of unmet care needs, lack of physician oversight and interventions, and diminished quality of life.
Arbitration Agreement Not Explained Clearly to Cognitively Impaired Resident
Penalty
Summary
The facility failed to explain the voluntary binding arbitration agreement in a manner that the resident and/or representative understood for Resident 3. The agreement stated that it could be revoked only by written notice sent by certified mail within 30 calendar days of signing, but Staff E, the Business Development/Admissions Coordinator, told the resident that the agreement could be revoked at any time and that if it was within 30 days the resident could just tell the facility. Staff A, the Administrator, also stated that the agreement could be revoked at any time in writing, even after 30 days, which did not match the written agreement. Resident 3 was admitted with multiple diagnoses including vascular dementia. The Admission/Medicare 5-day MDS dated 07/29/2025 documented moderate cognitive impairment, and a Social Services progress note on 07/25/2025 documented a BIMS score of 9, also indicating moderate cognitive impairment. The record also documented that the facility initiated guardianship through Harbor County. Despite this, the arbitration agreement was signed by Resident 3 and Staff E on 07/25/2025, and Resident 3 later stated she did not remember signing anything like an arbitration agreement.
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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 Montesano
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 | 12.3 mi | ★★★★★ | 14 | 0 |
| Pacific Care And Rehabilitation | 12.8 mi | ★★★★★ | 6 | 0 |
| Willapa Harbor Care | 22.9 mi | ★★★★★ | 0 | 0 |
| Fir Lane Care | 28.1 mi | ★★★★★ | 21 | 0 |
| Shelton Health And Rehabilitation | 28.3 mi | ★★★★★ | 21 | 0 |
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