Grays Harbor Health & Rehabilitation Center
Inspection Findings
F-Tag F0695
F 0695
Provide safe and appropriate respiratory care for a resident when needed.
Level of Harm - Minimal harm or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review, the facility failed to ensure resident oxygen administration orders were completed per physician order for 1 of 4 sampled residents (Resident 1) reviewed for oxygen administration. This failure placed residents at risk of low oxygen levels and a diminished quality of life.Findings included. Resident 1 admitted to the facility on [DATE REDACTED]. The 5-day admission Minimum Data Set, an assessment tool, documented the resident was on oxygen therapy and was severely cognitively impaired. Record review of Resident 1's oxygen care plan, initiated 07/14/2025, documented, Administer oxygen @ 2L/min [at two liters per minute] via nasal cannula; Continuous for dyspnea [trouble breathing].
Record review of a physician order, dated 07/11/2025, documented, Administer oxygen @ 2L/min via nasal cannula; Continuous for dyspnea. In an observation on 09/03/2025 at 9:30 AM, Resident 1 was observed in her room, in bed, under covers, eyes closed. Resident presented confused and asked where she was. An oxygen concentrator was near the resident bed, turned off, with the nasal cannula wrapped on top of the machine. Near the bed was the resident's wheelchair, and on the back of the wheelchair was an oxygen tank that was empty. In an interview on 09/03/2025 at 9:34 AM, Staff C, Licensed Practical Nurse, said she thought Resident 1's oxygen orders had been changed, but reviewed the orders and said Resident 1 had orders for continuous oxygen therapy. In an observation on 09/03/2025 at 9:37 AM, Staff B, Director of Nursing/Registered Nurse, observed Resident 1 in her room and confirmed the resident was not on oxygen while in the room, and the oxygen tank on the back of the wheelchair was empty. In an interview on 09/03/2025 at 9:46 AM, Staff B said Resident 1's orders state continuous oxygen therapy, and the order had not been changed since the resident admitted to the facility on [DATE REDACTED]. Staff B said with orders for continuous oxygen orders she would expect Resident 1 to have oxygen applied at all times. Reference WAC 388-97-1060 (3)(j)(vi).
Residents Affected - Few
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99) Previous Versions Obsolete
Facility ID:
If continuation sheet
Event ID:
GRAYS HARBOR HEALTH & REHABILITATION CENTER in ABERDEEN, WA inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in ABERDEEN, WA, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from GRAYS HARBOR HEALTH & REHABILITATION CENTER or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.