Graceville Rehabilitation by Harborview

In the surveyor’s words

From the most serious findings on record at Graceville Rehabilitation by Harborview, in the surveyor’s own words.

• No harm, potential for more than minimal, isolatedF806Feb 26, 2026

  Based on interviews, observations, record review, and facility policy review, the facility failed to honor resident's food preferences by failing to provide an alternate food for 2 of 3 residents sampled for food choices. (Resident #12 and #159)The findings include:Resident # 12On 2/23/2026 at 1:56 PM, an interview was conducted with Resident #12. She stated she had allergy to red dye and because of that she did not receive tomato sauce when they were served spaghetti. She stated she had told the staff she would prefer some other kind of topping but she kept getting dry pasta without any sauce and she could not eat the pasta like that. On 2/25/2026 at 12:40 PM, the resident received her lunch tray inside the room. She was served spaghetti again without any kind of sauce. […]

• No harm, potential for more than minimal, isolatedF842Feb 26, 2026

  Based on interviews and record review, the facility failed to maintain a complete medical record for 1 of 3 residents sampled for wound care. (Resident #159)The findings include:On 2/24/2026 at 2:24 PM, an interview was conducted with Resident #159. She stated wound care was scheduled daily but the facility was not providing wound care on the weekends.A review of Resident #159's medical record was conducted. The resident was admitted on [DATE] with diagnoses including type 2 diabetes mellitus with foot ulcers. […]

• No harm, potential for more than minimal, isolatedF908Feb 26, 2026

  Based on observations and interviews, the facility failed to maintain all mechanical, electrical, equipment in good operating condition during 2 of 2 observations of the kitchen. The findings include:On 02/23/2026 at 11:17 AM, an observation of the kitchen revealed several areas of disrepair. There were multiple doorjambs, windowsills, and walls in need of repair. The sheet metal covering the outside of the walk in cooler entrance was rusted and deteriorating at the base where the walls meet the floor. On 02/25/2026 at 1:37 PM a second observation of the kitchen revealed the same several areas of disrepair. […]

• No harm, potential for more than minimal, isolatedF693Apr 1, 2021

  Based on observations, policy reviews and interviews, the facility failed to provide appropriate treatment and services to prevent complications for 1 of 1 residents receiving tube feedings (#92). The findings include: On 3/29/21 at approximately 1:43 PM, an observation was made of resident #92, a resident receiving nutrition via a tube surgically implanted in the stomach. The tube feeding solution was observed to be hanging in a bag treaded through an electronic pump at the bedside. The Pump was off and the date on the bag with the solution was dated 3/29/21 at 8:00 AM (photographic evidence obtained). On 3/30/21 at approximately 2:40 PM, the resident was observed with the tube feeding infusing. […]

• No harm, potential for more than minimal, isolatedF755Apr 1, 2021

  Based on interviews and record reviews, the facility failed to develop a process to ensure that Resident medications were ordered and received in a timely manner for 2 of 5 residents sampled for unnecessary medications (#36 and #123) and failed to acquire pain medications from the pharmacy and/or emergency drug kit timely for a resident whose medication had ran out for 1 of 1 residents sampled for pain (Resident #123). The findings include: Resident #123 A review was conducted of the, Medication Administration Record, for Resident #123. It was noted that the order for [MEDICATION(S)] on [DATE] at 8:23 AM, was charted as, Not administered drug item unavailable: comment called to reorder, the note further stated, Will fax Doctor for a new script. […]