Grays Harbor Health & Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Grays Harbor Health & Rehabilitation Center, in the surveyor’s own words.

• Actual harm, isolatedF760May 3, 2023

  Based on interview and record review, the facility failed to ensure residents were free of significant medication errors for 1 of 3 sampled residents (1) reviewed for medication errors. This failure caused harm to Resident 1 when medications were not administered as ordered and the resident suffered a significant change in level of consciousness requiring the administration of Narcan (a medication used for known or suspected signs and symptoms of narcotic overdose) and hospitalization . This failure placed residents at risk for medication overdose, medical complications, and a diminished quality of life. […]

• No harm, potential for more than minimal, widespreadF812Mar 24, 2023

  Based on observation, interview and record review, the facility failed to ensure the kitchen's walk-in freezer was in good working condition for one of one facility kitchen and failed to ensure proper temperature logs were maintained for 3 of 3 facility nourishment freezers. These failures placed residents at risk of food-borne illness, and a diminished quality of life. Findings included . <Kitchen Freezer> On 03/20/2023 at 9:18 AM, the kitchen's walk-in freezer door was observed to have ice and snow buildup at the bottom right corner, preventing the door from closing completely. The opening measured approximately one inch. […]

• No harm, potential for more than minimal, patternF847May 7, 2026

  Based on interview and record review, the facility failed to ensure the facility's binding arbitration agreements (legal document that required the use of a third party to resolve disputes) was reviewed and explained in a form and/or manner, understood by 2 of 3 sampled residents (Resident 74 & 75) reviewed for binding arbitration agreements. This failure placed residents at risk for lacking understanding of the legal document signed and a diminished quality of life.Findings included.Resident 74 was admitted to the facility on [DATE]. The admission Minimum Data Set, (MDS, assessment tool), dated 04/30/2026, showed Resident 74 was cognitively intact. […]

• No harm, potential for more than minimal, patternF578Nov 19, 2021

  Based on interview and record review, the facility failed to provide and/or have procedures in places to assist with development of Advanced Directives (AD) for four of six sampled residents (7, 14, 39, & 40) reviewed for ADs. This failure placed residents and/or legal representative not having the opportunity to make desired choices regarding end-of-life care. Findings included . 1) Resident 7 was admitted to the facility on [DATE]. Record review for Resident 7 showed a progress note, dated 09/09/2021, where Staff D, Social Services Director, documented, Information/literature and verbal explanation on Advanced Directives provided to resident. […]

• No harm, potential for more than minimal, patternF600Nov 19, 2021

  Based on interview and record review, the facility failed to ensure residents were free from neglect when a staff member was reported to have not changed assigned residents for six hours on 10/25/2021 for seven of 11 sampled residents (#43, 49, 23, 37, 16, 45 & 13) reviewed for abuse and neglect. This failure placed residents at risk for skin conditions, urinary tract infections, and a decreased quality of life. Findings included . A facility investigation, initiated 10/25/2021, documented on 10/25/2021 Staff O, Certified Nursing Assistant (CNA), was assigned 11 residents in the dementia unit, a locked unit that housed residents with cognitive impairments. Staff P, CNA, was working on the locked dementia unit with Staff O and had her own assigned residents. […]