Every finding on record at Graceville Rehabilitation by Harborview

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. The meal ticket stated, Consistent carbohydrate diet, regular texture and thin liquids, allergy red No.40. There were no notes on dislikes or preferences on the meal ticket. (Photographic evidence was obtained)On 2/25/2026 at 1:22 PM the resident was on interviewed. She stated she did not eat lunch because they served spaghetti and she could not eat it. She further stated staff did not listen to her and she was not offered any alternatives. A record review of the resident was conducted. Resident #12 was admitted to facility on 8/28/25 with diagnoses including anxiety, schizophrenia, fibromyalgia, major depressive disorder schizoaffective bipolar type, and chronic pain syndrome. A dietary communication form dated 8/28/25 stated diet CCD (consistent carbohydrate diet), regular texture, allergy to red dye #40 and fortified foods with breakfasts. The most recent nutrition assessment was dated 2/3/26 and stated that the resident was receiving NAS (no added salt) diet. The assessment did not include any food restrictions due to red dye allergy.On 2/25/2026 at 1:33 PM, an interview was conducted with the Dietary Manager (DM). She stated Resident #12 had told her she did not want anything red on her food. She was asked if the meal ticket reflected her preferences and food dislikes. She stated the facility got a new system to print the meal tickets in October 2025, but they were having difficulty including the likes or dislikes on the meal tickets. She was asked if a resident had a red dye allergy that would lead to not being served tomato sauce. She stated that should not happen and that she would have to train the staff about it. She stated that if Resident #12 wanted tomato sauce, she will ensure she gets it. A review of tomato sauce that facility provided to resident was conducted, ingredients included tomato paste and citric acid as the ingredients, no red dye included. Resident #159On 2/25/2026 8:30 AM, Resident #159 was interviewed and stated she had issues with the lunch tray. She stated she was served a salad and she kept having to tell them she did not eat salads. The meal ticket had no menu items, preferences, or dislikes. The meal ticket stated, diet consistent carbohydrate, regular texture, thin liquids, double portions, likes: beverage of choice. She further stated she did not know what foods she was going to get for that day. A record review was conducted. Resident #159 was admitted on [DATE] with diagnosis including pseudonomas aeruginosa mallei, chronic kidney disease, heart failure, non-pressure ulcer heel and mid foot and midfoot with necrosis of muscle, and type 2 diabetes mellitus with foot ulcers. Physician's orders include CCD (consistent carbohydrate diet), diet Regular texture, Regular/Thin consistency, NAS (no added salt), fortified foods with breakfast dated 1/30/26. A dietary communications form dated 1/30/26 has the diet as CCD regular texture, no added salt, regular liquids and fortified food with breakfast. A nutrition assessment dated [DATE] stated the resident was at risk of malnutrition related to obesity and increased needs or wound healing.On 2/26/2026 at 9:10 AM, a follow-up interview was conducted with the DM. She was asked how she was made aware of the resident's food likes and dislikes. She stated that, upon admission, she obtained a list. She further stated she would write it on a piece of paper and then would be entered in the computer so it will reflect in the meal ticket. She was asked how the residents know the menu for the day. She stated the menus were posted on all the halls. She further stated the Certified Nurse Assistants (CNAs) were supposed to tell the residents the menu of the day. If the residents did not want a specific food item on the menu, the CNAs will tell them the alternative, and the CNAs will fill out a form. She further stated when the CNAs bring in the tray, if the residents did not want something, they were supposed to replace it with one of the alternates. On 2/26/2026 at 9:23 AM, an interview was conducted with Staff A, CNA. She was assigned to work with both Resident #12 and Resident #159. She was asked to explain the process to communicate the daily menus to residents. She stated the menus were printed in the dining area, there were flyers there that they bring to the residents. She was asked if there was a specific time of the day that the flyers were distributed and filled up. She stated she was unsure and she did not have the chance to do it today yet.On 2/26/2026 at 9:31 AM, an interview was conducted with Staff B, CNA. She stated the facility protocol was to read the printed menu located at main dining area and go room to room and verbally tell the residents what they were going to have for lunch for the day. If the resident did not want something from the menu, they were able to get an alternate. Staff will bring an alternate menu form and fill out the form. She stated forms were supposed to be done before 9:30 AM every day. She stated she had not gotten around to it yet. The facility policy Food Preferences (dated [DATE]) states, A written record shall be maintained of the resident's likes and dislikes. This will also include diet order, which indicates any dietary restrictions. The food likes and dislikes of each resident are determined through a dietary food preference sheet. It will be noted in the record when a food preference have been updated, changed or reviewed.

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. Physician's orders included Acetic Acid irrigation solution 0.25% apply to bilateral heels topically every day shift related to foot ulcer, apply acetic acid moistened gauze to wound bed, and cover with BD (a basic sterile gauze dressing) pad and wrap with kerlix and secure with tape daily and as needed. A review of the February 2026 Treatment Administration Record (TAR) revealed no documentation of wound care on Saturday, February 7th and Friday, February 20th.On 2/25/2026 at 2:25 PM, an interview was conducted with the Director of Nursing (DON). She reviewed Resident #159's the missing wound care documentation on February 7th and February 20th. She stated she was going to look into it because sometimes Resident #159 would go out of the facility for the day with a family member. She clarified that expectation was to have documentation completed and if refused or treatment was not performed, to document the reason. On 2/25/2026 at 3:38 PM, a follow-up interview was conducted with DON. She stated she spoke with the staff that performed wound care on the 7th and stated she did the wound care that day but did not document it but she documented it as a late entry today. The DON further stated that the wound care orders changed on the 20th, so the old order was discontinued and the new order placed later so the nurse had no way to see the order because the order was discontinued when it was performed. The DON stated the staff member was going to write a late entry progress note to reflect the wound care was done on the 20th.

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. Upon entering the kitchen, there is a steam table that is wrapped around the lower section of the outside with a plastic skirting that appears to be falling apart at the bottom with several pieces broken off. Observation of the door entering the room where the dishwasher is located is rusted around the doorjamb and the wall adjacent to the door is covered over with the same plastic skirting used under the steam table. The wall is separating from the structure and is bowing out exposing the inner structure behind the walls. Additionally, there is only one functioning overhead light in this room, with two others not functioning. The second door leading from the dishwasher room has the same plastic covering adjacent to the door that is bowing out and cold air is blowing from the gap. The Dietary Manager (CDM) confirmed at this time that this air is coming from the walk in freezer and cooler that sits behind the wall. There is a windowsill just over the first sink of the 3 compartment sink that contains rust that is flaking off. The Registered Dietician (RD) confirmed the need for repair and had covered over the flaking rust with duct tape. The metal walls around the walk in cooler/freezer are rusting where the wall meets the floor. There are doorjambs in the dry storage closet that are rusted and completely disintegrated. These observations were shown to the RD, CDM and Regional Nurse Consultant, who all confirmed this these areas are in need of repair/replacement. (Photographic evidence obtained)

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. The bag of solution was the same one from the prior day as evidenced by the date of 3/29/21 at 8:00 AM (photographic evidence obtained). On 3/30/21 at approximately 2:45 PM, an interview was conducted with staff G, a Licensed Practical Nurse (LPN) caring for resident #92. The LPN stated the tube feeding bags have to be changed every 24 hours and is usually done by night shift. On 3/30/21 at approximately 2:47 PM, an interview was conducted with the Unit Manager (UM). The UM escorted this surveyor to resident #92's room and was shown the tube feeding bag infusing. The UM verbally agreed the tube feeding bag was labeled with the date of 3/29/21 at 8:00 AM, and stated the tube feeding bag should have been changed 24 hours after hanging. On 4/1/21 at approximately 10:33 AM, an interview was conducted with the Director of Nursing (DON). The DON stated her expectation is for the nurses to follow the facility policy and change the tube feeding bag every 24 hours and the bag for resident #92 should have come down on 3/30/21 at 8:00 AM. A review of the facility policy Gastrostomy Feeding , last reviewed 6/5/18 was conducted. On page 2 item 15 stated Rinse bag and tubing with warm water feedings are interrupted. Use new administration set every 24 hours.

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. On [DATE] at 9:35 PM, the following was documented, late administration: charted late. On [DATE] at 8:49 AM, the following was documented, not administered drug item unavailable comment: medication not at facility, called pharmacy script expired, doctor faxed on Friday. On [DATE] at 7:36 PM, the following was documented, not administered drug item unavailable comment: pharmacy awaiting signed script from Doctor. A review was conducted of the physician orders for Resident #123. On [DATE], an open-ended order for [MEDICATION(S)] ,d+[DATE] milligrams (mg) by mouth twice per day was placed. An interview was conducted with Nurse D, an Licensed Practical Nurse (LPN), on [DATE] at 2:31 PM. When asked what you do if you run out of a narcotic medication, she replied, If we are low on a medication, we can reorder in the computer 3 days before we run out so we can get the medication. Nurse D also stated, If we run out, we call the Doctor for a one time dose of the medication to fax to pharmacy and pull it from the Emergency Drug Kit (EDK) after getting code for the narcotic from pharmacy. An interview was conducted with Nurse E, the Assistant Director of Nursing (ADON) on [DATE] at 4:11 PM. When questioned, What do you do if you run out of a narcotic? Nurse E replied, We call the pharmacy and they contact the physician for a new prescription, and we assess for pain until it arrives. If Resident #123 would have complained of pain prior to receiving a new stock of the narcotic we would have contacted the physician. When Nurse E was asked if the facility had a policy on what the nurse should do if the resident runs out of a narcotic she stated, No. An interview was conducted with Nurse F, LPN, on [DATE] at 8:46 AM. When questioned what one would do if you ran out of a medication, Nurse F stated, We would call pharmacy. They would tell us if it is on the way or if we can pull it form the EDK. If the medication is not in the EDK, the pharmacy will do a stat (immediate) run. When question if the facility had a backup pharmacy, she stated, We do have a backup pharmacy. If our primary pharmacy cannot get the medication here in time, we can get it from there. For narcotics, we call the Doctor to get a one-time order, or an as needed order. The nursing staff are not able to get it out of EDK without a code from the pharmacy. Sometimes the doctor will call the pharmacy and give them a verbal order over the phone. If we cannot get a hold of the resident's doctor, we would keep calling. I have never had a problem getting in touch with the doctor. The doctors do sometimes give as needed orders like Tylenol if we are unable to get a code from pharmacy until we receive the medication. An interview was conducted with the Director of Nursing (DON) and Corporate Nurse on [DATE] at approximately 11:26 AM. When questioned why back up pharmacy or the EDK was not used to provide Resident #123 with the narcotic pain medication, the Corporate Nurse responded, We could not transfer the prescription due to there being no refills left on the prescription. The Pharmacy told them that there would need to be a new prescription. For the nursing staff to call the Doctor, it would have had to meet criteria for an emergency. When questioned about pain management until the narcotic medication arrived the Corporate Nurse responded, We continued with pain assessments. We did not have anything to show that her pain was uncontrolled. This new prescription was initiated by the pharmacy to the physician. And she did not meet criteria for change of condition. The Corporate Nurse left and the interview was continued with the DON. When shown the order for the narcotic in Resident #123's electronic record the DON agreed that this was a routine narcotic order with no stop date and that the resident should have had a continuous supply of the medication. When asked how the staff should respond when the supply of a routine medication is getting low she stated, If they see that a medication is running low or out, they should reorder the medication. She further stated that if the staff were concerned that it may take some time to get the order, they should pick up the phone and speak to the pharmacy to get an update on the status of the order. When asked what the typical process was for a nurse on the floor to reorder a medication, she stated that there is a button in the electronic orders system to reorder. She stated that sometimes there were issues with the program actually getting the reorder notification to the pharmacy. This was another reason she felt staff should pick up the phone and verify that the request was received and to check on the status of reorders. She also stated that for routine medications you would want to make sure that there was a steady supply coming so the resident did not miss a dose. The DON agreed that the order for [MEDICATION(S)] ,d+[DATE]mg was a routine medication and that the facility should have had the medication on hand for Resident #123. After numerous requests for a policy regarding the refill of routine narcotic orders to assure a continuous supply, the facility was unable to produce one. Resident #36 A record review conducted for resident #36 revealed a physician order dated [DATE] for [MEDICATION(S)] (an antidepressant) 15 mg; 1 tablet; by mouth 1 time per day. The [MEDICATION(S)] was scheduled on the medication administration record to be administered each evening at 8:00 PM. A review of the Medication Administration Record (MAR) for the administration of [MEDICATION(S)] for the dates [DATE] through [DATE] noted that 3 consecutive doses ([DATE], [DATE], [DATE]) were not administered. The reason documented for not administering the medication on those 3 dates was not administered: drug/item unavailable. Further review of resident #36's record revealed a physician order dated [DATE], for [MEDICATION(S)] (an antipsychotic)100 mg; 1 Tablet; by mouth once a day. The [MEDICATION(S)] was scheduled on the MAR to be administered each evening at 8:00 PM. A review of the MAR for the administration of [MEDICATION(S)] for the dates [DATE] through [DATE] noted that 4 consecutive doses ([DATE], [DATE], [DATE], [DATE]) were not administered. The reason documented for not administering the medication on those 4 consecutive dates was not administered: drug/item unavailable. On [DATE] at approximately 11:30 AM, an interview was conducted with the Director of Nursing during which she was shown the gaps in the MAR for resident #36. She responded that she is going to look at it but stated that they should not run out of regularly rescheduled medications.

Based on observation, interview and record review, the facility failed to maintain a complete and accurate medical record for 1 of 2 (#77) residents sampled for falls. The findings include: On 3/30/21 at 8:25 AM, an interview was conducted with Resident #77 during which he reported that he had fallen twice in the facility and that after one fall he had to get stitches in the back of his head. A review of the, Events, section of the Electronic Medical Record, revealed a Safety Event - Fall, note dated 3/2/21, which stated, fall/laceration noted to back of head states he was coming from bathroom and slid and landed on his backside sent to .ER for evaluation. Received staples to back of head. Patient was walking to bathroom at the time. The evaluation stated that neurological checks were initiated. A review of the, Neurological Evaluation Flow Sheet, starting on 3/2/21 at 3:00 PM, revealed the resident was at the hospital until 6:00 PM. The area of the form for neurological assessments on 3/3/21 for the 3 PM to - 11 PM shift was blank. The 3/4/21 for 11 PM to 7 AM, was also blank. The vital signs section was missing documentation for all vital signs from 3/3/21 at 9:00 AM, until the 3/4/21 entry for the 3PM to 11 PM shift. On 4/01/21 at 11:45 AM, an interview was conducted with the Director of Nursing. She was asked to review the, Neurological Evaluation Flow Sheet. She immediately said, Oh, all the holes? She was asked to explain the expectation for completing the form. She stated that, This does not meet expectation. There should not be the holes in the documentation. A review was conducted of the policy, Falls, last reviewed 11/6/2019, last revised 11/6/2019. The policy statement read, It is the intent of this facility to provide residents with assistance and supervision in an effort to minimize the risk of falls related injuries. Under the, Guideline, section, subsection number, 3, it stated, If a fall occurs the following actions will be taken, subsection ,C, continued, Neuro checks will be completed on residents that experience an unwitnessed fall or a fall that results in head trauma.

Based on observations, interviews and facility document review, the facility failed to ensure that resident wheelchairs were maintained in a clean and sanitary manner for 7 of 15 residents with wheelchairs observed (Resident #4, #5, #6, #7, #8 and #9, #10); and failed to ensure that respiratory supplies maintained at the resident's bedside were labeled and/or stored in a sanitary manner for 3 of 3 residents. (Resident #1, #2 and #3) The findings include: On 11/12/2019 at approximately 10:26 AM, Resident #1 was observed in bed with oxygen on via nasal cannula. There was no distilled water humidification and the oxygen tubing failed to be labeled. The resident also had a nebulizer machine and mask at his bedside, the mask was laying on the resident's nightstand without being properly stored or covered. This observation was confirmed by Staff Member A, a Licensed Practical Nurse (LPN), she stated it should be stored in a bag after use. She also confirmed that the oxygen tubing failed to be labeled with the date changed. (Photographic evidence obtained) On 11/12/2019 at approximately 10:40 AM, observed in the room for Resident #2 was the resident's nebulizer machine with a mask not covered on the resident's bedside table and the oxygen tubing was not labeled with the date changed. There was also no distilled water humidification. This was confirmed with Staff Member B, a Certified Nursing Assistant (CAN) . (Photographic evidence obtained) On 11/12/2019 at 10:57 AM, an observation was made of Resident #3 in which the resident was receiving oxygen via nasal cannula, the oxygen tubing was not labeled and there was no distilled water humidification. (Photographic evidence obtained) On 11/12/2019 11:02 AM, an interview was conducted with Resident #4, during which he stated that he has been here since (MONTH) and they have never cleaned my wheelchair. His wheelchair was noted to have a large tear along the arm of the chair. On 11/12/2019 at approximately 11:07 AM, an interview was conducted with Resident #5, during which she stated she doesn't think her wheelchair has ever been cleaned. When asked about how they store her nebulizer mask, she states Oh you're from the State, that's why they just put my mask in a plastic bag. On 11/12/2019 at approximately 11:15 AM, an interview was conducted with Resident #6, during which she stated she's been here a long time, and they've never cleaned my wheelchair. On 11/12/2019 at approximately 11:20 AM, an interview was conducted with Resident #7, during which he stated they never clean my wheelchair. Also stated they just came in and changed my oxygen tubing. On 11/12/2019 at 11:34 AM, Resident #8's wheelchair was observed with debris around the wheel spokes and frame. Resident #8, stated - never seen my wheelchair cleaned in 5 months. On 11/12/2019 at approximately 11:40 AM, observed was Resident #9' and Resident #10's wheelchairs, with hair and debris, around the wheel spokes and frame. Both Residents were currently in the dining room for the lunch-time meal. On 11/12/2019, observed at 12:00 PM, a wheelchair sitting outside room [ROOM NUMBER]. The wheelchair had several flies on it. There was debris on the wheel spokes and frame. (Photographic evidence obtained) On 11/13/2019 at 1:10 PM, a phone interview was conducted with Staff Member C, the Director of Housekeeping. He stated that resident wheelchair's are cleaned twice a month on a rotating schedule. There was no log maintained for wheelchairs that were cleaned. A document entitled Wheel Chair Cleaning Schedule was presented. The cleaning schedule indicated that wheelchairs are cleaned according to each Unit. Wheelchairs are cleaned every 4 weeks per the cleaning schedule. A review of the facility's policy and procedure entitled Departmental (Respiratory Therapy) indicates The purpose of this procedure is to guide prevention of infections associated with respiratory therapy tasks and equipment, including ventilators, among resident and staff. Under the heading Steps in the Procedure - Infection Control Consideration Related to Oxygen Administration . 1. Obtain equipment (i.e., oxygen tubing, reservoir, and distilled water.) 2. Use distilled water for humidification per facility protocol. 7. Change the oxygen cannula and tubing used PRN (as needed) in a plastic bag when not in use. Under the heading Infection Control Considerations Related to Medication Nebulizer's/Continuous Aerosol: 3. After completion of therapy: a. Remove the nebulizer container; b. Rinse the container with fresh tap water; and c. Dry on a clean paper towel or gauze sponge. 5. Take care not to contaminate internal nebulizer tubes. 7. Store the circuit in plastic bag, marked with date and resident's name, between uses. 9. Discard the administration set-up every seven (7) days.

Based on interviews, observations, and record reviews, the facility failed to provide food and drink that is palatable, attractive, and at a safe and appetizing temperature for 8 of 33 residents observed (#54, 123, 49, 28, 38, 409, 68, & 9). The findings include: On 8/12/2019 at approximately 09:00 am an interview was conducted with resident #54, during which the resident stated that the food was not good for older folks, it is greasy, meat is tough, and it is not right. On 8/12/2019 at approximately 09:20 am an interview was conducted with resident #123, during which the resident stated that the food tastes bland, had no flavor, the temperature was cold, you never get what you order, substitutions are only soup and sandwiches, and stated I have asked for salads but they never have any. On 8/12/2019 at approximately 10:00 am and interview was conducted with resident #49, during which the resident stated that the food is awful, cold, had no taste, you do not get what is on the menu, breakfast is always cold, even the coffee is luke warm, and it really upsets me to start every day this way. On 8/13/2019 at approximately 1:59 pm, an interview was conducted with resident #28 during which the resident revealed that the food was horrible, sometimes I only eat the vegetables, food is too spicy, salty, bland on occasions, and looks like it was just thrown on the plate. She added that I ask for substitution and all I get is soup which is awful, can't eat it, just not enough choices or substitutions, and the food is usually cold. On 8/13/2019 at approximately 12:40 pm, an interview was conducted with resident #38, during which the resident revealed that the meals are awful, reporting that sometimes she does not eat the meal as it upsets her stomach, and she uses her own supplies to replace the meals she cannot eat, the food temperature is warm, never hot, and sometimes cold. Resident #409: On 8/12/19 at 10:53 AM an interview was conducted with Resident #409 for the initial pool process. At that time Resident #409 stated that food arrives cold from the kitchen. On 8/13/19 at 12:01 PM an interview was conducted with Resident #409 after food trays were passed out on the floor. At that time Resident #409 stated that the food had arrived cold. No steam was observed coming off the food. There were items that were difficult to identify on the plate as well. Resident #409 then stated, I think to myself, this must be like prison. He stated that he would characterize the food as lukewarm. He then placed a piece of okra in the surveyor's hand and asked, how does it feel to you? It felt cool to the touch. Resident #68: On 8/12/19 at 10:39 AM an interview was conducted with Resident #68. At that time Resident #68 stated, meals are brought to us cold and there is never coffee with breakfast. On 8/13/19 at 12:11 PM an interview was conducted with Resident #68 after lunch trays were passed on the floor. She stated that the meal was brought cold and tasted terrible. No steam was seen rising from the plate. On 08/12/2019 at approximately 12:26 PM in interview with resident #9 concerning the quality of food, the resident expressed that the food is often cold and that it does not taste good. On 8/13/2019 at approximately 3:33 PM in interview with the resident about lunch served that day the resident expressed that the food was not worth eating, the chicken served was tough, and the okra and peas were not cooked properly and that the resident did not like any of the items he was served. A review of the facility Grievances for 2019, revealed nine food complaints, dated between 5/20-6/20/2019. These complaints involved cold food temperatures, no substitutions, not enough choices, and food not appetizing and tasteless.

Based on interview and record review the facility failed to ensure adequate staffing on a 24 hour basis for resident's needs for 8 of 38 (#409, 459, 68, 104, 99, 38, 94,28) residents sampled in the initial pool, and failed to ensure toileting care and call lights were answered in timely manner for 2 of 2 residents (#102 and #459). The findings include: On 8/11/19 at 3:13 PM an interview was conducted with Resident #409. At the time of the interview Resident #409 stated that residents wait hours for staff to respond to call lights and sometimes the staff just never come. On 8/12/19 at 7:51 AM an interview was conducted with Resident #459. At the time of the interview the resident stated that while waiting for staff to respond to the call light they messed themselves because no one came for over 3 hours. On 8/12/19 at 10:16 AM an interview was conducted with Resident #68. At the time of the interview the resident stated that she fell and received a black eye because no one had responded to her call light. She stated she could hear staff cutting up in the hallway, but no one came. She said that she attempted to self transfer from the bed and fell and hit her face resulting in a black eye. On 8/12/19 at 10:31 AM an interview was conducted with Resident #104. At the time of the interview the resident stated that there was not enough staff. The resident further stated that it was not longer than an hour that they waited for staff to respond, but was unsure of exactly how long they had to wait. On 8/12/19 at 11:53 AM an interview was conducted with Resident #99. At the time of the interview Resident #99 stated that staff do not respond to call lights and reported it can take 2-3 hours to get to them. The resident further stated that it is worse on the night shift. On 8/12/19 at 12:49 PM an interview was conducted with Resident #38. When asked about call light response time the resident responded, They don't always come, it takes 30 minutes to 1 hour. I have to get up and holler. I've already told someone and nothing has happened. The 3-11 shift is the worst. On 8/12/19 at 1:00 PM an interview was conducted with Resident #94. At that time Resident #94 stated that when residents use their call light it takes more than 20 minutes to get someone to respond. On 8/12/19 at 1:33 PM an interview was conducted with Resident #28. At that time Resident #28 stated their roommate, hollers so they don't come in. It sometimes takes 4-5 hours to get a response. The resident further stated that they had complained to the CNA but nothing happens. On 08/11/19 at 2:13 PM an interview was conducted for Resident #102 during which she stated that staffing could be better. She then stated I believe they have enough staff they just must want to do their job. Some do not. During a follow up interview on 8/12/19 at 8:09 AM the resident stated that she had laid in a bowel movement for 3-4 hours. She further stated that the last occurrence was last week on evening shift when the licensed practical nurse had to change her. On 8/14/19 at 4:13 PM an interview was conducted with staff member L, an Licensed Practical Nurse (LPN) during which she stated that she does receive complaints from residents the major concern they seem to have is regarding call lights not being answered. She then stated that Resident #102 had mentioned that recently her call light had not been answered timely and that the LPN provided incontinence care to her after a bowel movement. When asked where the Certified Nursing Assistants (CNA) were at during this time she stated they were in the dining room. The night I cleaned her up we had 4 CNAs with 52 residents. Two CNAs were in the dining room and the other two CNAs were answering call lights or assisting residents with eating. She then stated that the resident had not complained about a specific CNA she just said she had a bowel movement and needed to be cleaned up, and that the resident had not mentioned how long she had been waiting. She was asked if the facility staffed according to acuity of residents and she said, we staff according to the number of residents we have. When asked if this had occurred before she said that Resident #102s roommate came to the desk to say (Resident #102) needed assistance. It was more than three weeks ago. I got a CNA and we went in to clean her up. Resident #459 was admitted to the facility on Thursday 8/8/19. She was interviewed on 8/12/19 at 7:51 AM. She relates she needed to go to the bathroom Friday night 8/9/19 into Saturday morning 8/10 and did not receive care. She stated, I messed myself and no one came for over 3 hours. A review of her care plan revealed a care plan initiated on 8/8/19 to assist with toileting. A follow up interview was conducted on 8/15/19 at 9:15 AM. She related the same story and said she had to call her son to call the facility to get help. She was asked if she had filed a grievance and she said she had not. The Social Worker Employee F was interviewed on 8/15/19 at 09:20 AM. The situation with Resident #459 was not receiving care she needed. She was told the resident said she had to call her son to get assistance because her call light was not answered, and she messed herself. Employee F returned on 8/15/19 at 11:45 came back and showed the grievance filed. She said she had called the son and he confirmed the resident had contacted him about being dirty and not receiving help. On 8/14/19 at approximately 10:15 AM, during the Resident Council Meeting resident #19 expressed that she was required to wait approximately 2 hours to have her call light answered. The resident reported that the event occurred within the last two weeks. Also during the meeting Resident #38 identified that the Certified Nursing Assistant's (CNA's) had not been paying attention to call lights unless the State was in the building. Resident #38 further expressed that the CNAs are ugly-acting at times and walk around with ear buds in their ears ignoring the residents. The resident also stated that if a grievance was filed against the CNA's, the CNA may not give the resident a shower. Resident stated the concerns were ongoing. On 8/13/2019 at 11:42 AM An interview was conducted with resident #149 during which the resident revealed that at approximately 8:15 PM on 8/12/2019 the resident had pushed the call light button for assistance. The resident reported that the call light was not answered until approximately 9:00 PM. The resident revealed she called her spouse to request assistance. She also stated that in the near past, the call light was not answered during the entire 3-11 shift. A review of grievances for the last 90 days was conducted which revealed the following: 5/25/2019 Resident #72 reported to the Quality of Life Director, .states he doesn't know if there is enough staff because his meals are served late in the halls. Findings: .due to challenges in the kitchen, meals have been late in some days. there has been sufficient staff - late meals not related to inadequate staffing - Performance Improvement Plan in place. 5/28/2019 Resident #95's daughter reported to the Assistant Director of Nursing that she was, concerned there isn't enough staff in the building . Findings: Staffing roster reviewed and facility has maintained adequate staffing ratios compliant with federal and state regulations. 5/30/2019 Resident #77 reported to the activities director that, .He is concerned we don't have the amount of staff we need Findings: See attached. However, there was nothing attached to the grievance form and staff were not able to produce anything prior to exit. 6/13/2019 Resident #120 reported to the social worker during resident council that, her call light isn't answered timely. Findings: Resident states she doesn't have any complaints and staff does good job. On 8/15/19 at 1:02 PM an interview was conducted with the administer and Director of Nursing. At that time they were informed that throughout the survey there were numerous residents that complained about staffing and that this was backed by information found in grievances and within resident council. They were then asked why they thought the residents were feeling like there were not enough staff. They stated that it might be related to the call light response time. They admitted that they were having problems with staff responding to the call lights in a timely manner. When asked what concrete steps had been taken to alleviate the issue they stated that they had done in-services about properly answering call lights. They went on to say that they were invited to a resident council meeting in which residents complained of staff loitering at the nurses' station, being on their phones or using ear buds while working. They denied feeling like there were staffing concerns at that time and later went on to say that they had formulated a performance improvement plan for staffing issues.

Based on interviews and record review, the facility failed to act promptly upon grievances voiced during Resident Council Meeting for 5 of 5 residents (residents #28, #54, #70, #83, and #120) The findings are: An interview during the resident council meeting on 8/14/2019 at approximately 10:15AM with Resident #28 revealed that the resident had made complaints regarding the food including the rice served was crunchy and the food was cold. The resident stated that, complaints are ignored. Record review of the grievance/complaint log showed that the above concerns were not noted on the log nor had a grievance filed. Record review of Elder Council Meeting Minutes, dated 4/11/2019 showed that resident #54 voiced complaints during resident council of clothes coming back from laundry wrinkled and that 2 pair of shoes had been lost. Additionally, resident #156 voiced a complaint regarding the bathroom and floors not being cleaned. Record review of the grievance/complaint logs showed there were no grievances for the identified concerns. Record review of Elder Council Meeting Minutes, dated 5/9/2019 showed that resident # 70 voiced a complaint that the east shower Certified Nursing Assistant (CNA), was not cleaning the shower between resident uses. Record review of the grievance/complaint logs showed there were no grievances for the identified concerns. Record review of Elder Council Meeting Minutes dated 6/3/2019 showed that multiple unnamed residents voiced complaints that the CNA's should introduce themselves to residents and that the shower rooms cleanliness continued to be a concern. Resident #83 reported discoloration of clothing returned from laundry. Record review of the grievance/complaint logs showed that there were no grievances for the identified concerns. Record review of Elder Council Meeting Minutes, dated 7/11/2019 showed that resident #120 voiced complaints that CNA's were not introducing themselves, not making the bed, that call lights were not answered, and that employees were in the hallway. Record review of the grievance/complaint logs shows that there were no grievances for the identified concern. Record review of a complaint/grievance report dated 7/15/2019 identified a complaint that was identified through Resident Council members meeting regarding resident care including concerns that CNA's were on their phone, using earbuds in the hallways, the showers were not being cleaned between residents, and that call lights were being turned off without answering needs. The completion date of the grievance was 7/18/2019. The grievance report was completed two months after the concern was identified in the Resident Council meeting on 5/9/2019 and one month after being identified in the 6/3/19 meeting. An interview was conducted on 8/14/2019 at approximately 4:03 PM with Employee G, Activities Director. The employee confirmed the Social Worker attends the Resident Council meetings and was the person who was responsible for following up with residents' concerns identified during the Resident Council meetings. Employee G confirmed there have been concerns voiced in the Resident Council meeting regarding CNA's and care. An interview was conducted on 8/14/2019 at approximately 4:12 PM with Employee F, Social Services Director. The employee confirmed a grievance form was to be completed when a complaint was submitted. Employee F expressed that the complaint was then to be submitted to the responsible department head for investigation of the complaint and implementation of corrective action. She expressed that the resident would be presented with a copy of the grievance form to acknowledge and sign once it was completed. She confirmed the grievance was not logged until the investigation was completed, and the resident had signed the form. During record review of Resident council meeting minutes with Employee F of concerns identified in the meetings dated 4/11/2019, 5/9/2019 and 7/11/2019 it was confirmed that there were no corresponding grievances filed at that time. An interview was conducted on 8/15/19 at approximately 11:30 AM with Employee F who expressed that a complaint or concern would be considered a grievance if the issue could not be resolved immediately or was an on-going process. Employee F confirmed lost clothing or damaged clothing would be considered a grievance.

Based on observation, interviews and record review, the facility failed follow the established policy regarding missing and damaged items by failing to initiate grievance documentation to track and ensure prompt resolution for 1 of 3 sampled residents sampled for missing property (resident #99). The findings include: On 08/12/2019 at approximately 1:24 PM, in interview with resident #99 it was expressed that the facility had damaged a sweater of the residents which resulted in a discoloration of the item. The resident stated that she had reported the damaged item to staff approximately 4 weeks prior but there had been no resolution or update. The resident then pulled a sweater from her hamper and showed where it had a large red discoloration on the back of the sweater. (photographic evidence obtained) On 8/14/2019 at approximately 1:55 PM, in interview with resident #99's Certified Nursing Assistant (CNA), Staff E, stated that she was aware of the damaged item, had not filed a grievance but had reported it to the floor nurse, Staff D, an Licensed Practical Nurse (LPN). On 8/14/2019 at approximately 2:51 PM, in interview with Staff D, LPN, it was expressed that a grievance had not been filed for the resident's damaged item and that she was unaware of a damaged item. A review of facility policy and procedure titled Resident's Damaged or Missing Property, identifies that when staff identify that an item has been damaged that staff member must immediately report it to their supervisor and the staff member reporting the item must file a grievance.

Based on observation, staff interview and record review the facility failed to implement the care plan for 1 of 1 (#7) resident sampled for tube feeding. The findings include: A record review was conducted for resident #7 which revealed a care plan for tube feeding dated 6/22/18 with an approach identified to administer tube feedings and water flushes as ordered. The review further revealed a physician order [REDACTED]. Flush with 100 cc (cubic centimeter) of water before and after feeding for a total of 200 cc per feeding. On 8/13/19 at approximately 4:45 PM an observation of Staff member J, an Licensed Practical Nurse (LPN) was made during which she administered a [MEDICATION NAME] bolus to resident #7. The nurse obtained the required supplies as well as a 120 cc cup of water. She was observed to flush the tubing with 60 ccs of water then administered the [MEDICATION NAME] bolus. After the bolus was completed she flushed the tubing with approximately 10-20 ccs of water. She completed the feeding but did not administer the ordered 100 cc water flush before and after the feeding as ordered. A review of the Medication Administration Record [REDACTED]. Review of the nursing documentation for each feeding between 8/1/19 and 8/14/19 found that the nurses were only providing 100ccs of water with each feeding. On 8/13/19 at approximately 4:51 PM an interview was conducted with staff member J, an LPN during which she was asked about the flushes before and after the [MEDICATION NAME] boluses. She stated she gave a little during the bolus feeding but had not given the 100 cc flush after the feeding. On 8/14/19 at approximately 8:47 AM an interview was conduced with the unit manager for West Hall during which she discussed the issue with the flushes before and after the bolus [MEDICATION NAME] feeding. The MAR indicated [REDACTED].

Based on record review, resident and staff interview the facility failed to treat 1 of 2 (#102) residents with dignity by not providing toileting care in a timely manner. The findings include: On 08/11/19 at approximately 2:13 PM, an interview was conducted with Resident #102 in which she stated she was not getting the toileting help she needed. During a follow up interview conducted on 8/12/19 at 8:09 AM the resident was asked if staff treated her with respect and dignity and she stated they did not. She stated, I have laid in stool 3-4 hours. It usually happens on the evening shift. I have hollered out for help and no one came. My roommate had to go and tell them to help me. She reported that the last occurrence was last week on the evening shift when the licensed practical nurse had to change her. A review of the residents Minimum Data Set ((MDS) dated [DATE] revealed the resident required two person physical assist for all Activities of Daily Living (ADL). On 08/14/19 at approximately 4:13 PM, an interview was conducted with staff member L, an Licensed Practical Nurse (LPN) during which she stated that she does receive complaints from residents with the major concern being with call lights not being answered. She then stated that Resident #102 did mention her call light was not answered recently. She said she did need to be cleaned up after a bowel movement. She was asked where the Certified Nursing Assistants (CNA) were and she said they had been in the dining room. She further stated The night I cleaned her up we had 4 CNAs with 52 residents. Two CNAs were in the dining room and the other two CNAs were answering call lights or assisting residents with eating. She then said the resident did not complain about a specific CNA she just said she had a bowel movement and needed to be cleaned up, she did not mention how long she had waited. She was asked if the facility staffed according to acuity of residents and she said, we staff according to the number of residents we have. When asked if this had occurred before she stated Resident #102's roommate came to the desk to say the resident needed assistance. It was more than three weeks ago. I got a CNA and we went in to clean her up.

Based on observation, record review, and interview the facility failed to ensure Activity of Daily Living (ADL) care was performed on residents who were unable to perform ADL care independently for 1 of 2 sampled residents (resident # 128). The findings include: On 8/12/2019 at approximately 04:09 PM an interview and observation of resident #128 was conducted in the resident's room. At this time it was noted that the resident's facial hair was approximately 1/8 to ¼ of inch long, the resident had a foul odor coming from his mouth when he spoke. The resident's fingernails were noted to be approximately ½ of an inch longer than the tip of the finger for all of his fingernails and there was a brown residue observed beneath each nail bed. At this time the resident expressed that he prefers to be clean shaven daily, but the staff only shave him once a week and that they very seldom provide mouth care for him. The resident further expressed the he wished the staff would help clip his fingernails but they don't have time for that. A review of resident #128's medical record revealed that the resident was admitted on [DATE] with pertinent [DIAGNOSES REDACTED]. The resident's care plan dated 2/4/2019 indicated that the resident was at risk for dental health problems with intervention of providing mouth care daily indicated and that the resident was at risk for complications with decreased ADL self-performance. (Photographic evidence of fingernails obtained) On 8/13/2019 at approximately 3:00 PM in interview with staff A, Certified Nursing Assistant (CNA), and observation of resident #128 it was noted that the resident's fingernails were in the same conditioned as observed on 8/12/2019 at approximately 4:09PM and that the resident's facial hair was partially shaven with several patches of hair observed. Staff A, a CNA, stated that it is standard practice for the CNA's to give a male a clean shave when they receive morning care and confirmed that the resident had several patches of facial hair. Additionally, Staff A, CNA, confirmed the resident's fingernails were approximately ½ of an inch past the tip of the resident's fingers and that there was a brown residue visible on the underside of the exposed nails. During the interview with staff A, CNA, when she was asked if the resident had refused care to his nails, the resident raised his hands and stated, please do it and expressed that he wanted to be clean shaven daily and not once a week. At that time, Staff A, CNA, asked the resident if he would like to have his fingernail's cleaned, trimmed and receive a clean shave and the resident agreed. On 8/14/2019 at approximately 9:18 AM in interview with Staff B, a CNA, the CNA expressed that she routinely worked with resident #128 and was familiar with his care. The CNA expressed that every morning the resident should receive a clean shave, oral care, and should receive nail care each shower day (three times a week). If the resident refuses three times in the shift, then it should be logged on a stop and watch form and the nurse on duty for the resident would be notified. On 08/14/2019 at approximately 09:46 AM in interview with Staff D, Licensed Practical Nurse (LPN), it was expressed that the LPN routinely gave care to resident #128 and was familiar with his needs. Staff D, LPN, expressed that clean shaves, and mouth care were an expected part of morning care and that fingernail care should be provided every shower day and as needed or requested by the resident. It was also expressed that every time a resident refuses care throughout the shift that a stop and watch form should be filled out and that the nurse would be notified and intervene as necessary and that there would be a nursing progress note reflecting that the resident refused and the intervention the nurse took. On 8/14/2019 at approximately 10:03 AM during review of the CNA shower sheets for the past 30 days as well as the stop and watch forms it was identified that the stop and watch forms only identified one day of refusal of care for fingernails dated 8/11/2019 since 5/22/2019. Review of shower notes showed that on 8/5/2019, 8/9/2019, 8/12/2019, 7/29/2019, 7/26/2019, 7/24/2019, 7/23/2019, 7/22/2019, 7/19/2019, and 7/17/2019 showed documentation that the resident refused nail care. No shower sheet or stop and watch identified refusal of mouth care or facial hair shaves. Review of nursing progress notes showed there were no progress notes addressing refusal of care or nurse intervention. On 8/14/2019 at approximately 10:34 AM in interview with Staff C, Registered Nurse (RN) Assistant Director of Nursing (ADON)and Unit Manager on the hall resident #128 resided expressed that the floor nurse on duty would intervene each day that the resident refused care and that a stop and watch form would be filed out.

Based on staff interview, observation of medication cart, and record review the facility failed to remove expired medications from active use for 1 of 3 medication carts (#1 Rehab Front Hall). The findings include: On 8/15/19 at 10:40 AM medication cart #1 Rehab Front hall was checked for correct labeling and expired outdated medications with Employee N, a Licensed Practical Nurse (LPN). During the review the narcotic [MEDICATION NAME] 50 mg was found in the controlled substances drawer with an expiration date of 2/2019. There are 8 pills remaining. (Photographic evidence obtained). At this time Employee N was asked if the medication was expired and she stated yes. She was then asked when the medication was last given-she reviewed the controlled record sheet and pointed out that it was last given on 6/26/19 at 4:15 pm. Further review of the record revealed the [MEDICATION NAME] was given 7 times after the noted expiration date on 3/9, 3/29, 6/8, 6/11, 6/13, 6/16 and the last time on 6/26/19 at 4:15 pm.

Based on observations, record review and staff interview, the facility failed to provide appropriate care to include, dating a wound dressing and documenting a physician treatment order for 1 of 6 sampled residents reviewed for skin conditions (#124). The findings include: Observations of resident #124 were conducted on 7/16/18 at 3:17 PM, 7/17/18 at 8:37 AM and 7/17/18 at 11:37 AM. The resident had a clear, transparent, undated dressing on the top of his left hand with a visible brown substance observed to be under the dressing. Review of the record for resident #124 revealed documentation on 7/12/18 indicating the resident was observed to strike his left hand on a door while propelling himself in the wheelchair. The documentation indicated the physician was notified and a treatment order was obtained. No physician order for [REDACTED]. An interview was conducted with employee A (Licensed Practical Nurse) on 7/17/18 at 12:50 PM. Employee A observed the dressing on resident's left hand and confirmed it was not dated. She confirmed a nurse would require a physician order to apply a dressing. Further interview was conducted with employee A on 7/17/18 at 1:29 PM. She reviewed the record and stated she could not find an order for [REDACTED].

Based on record review, and staff and resident interview, the facility staff failed to report resident grievances concerning the facility pet to the facility's grievance official so that prompt efforts could be made to resolve resident grievances for 2 of 5 residents interviewed. Findings Include: On 1/24/18 at 11:00am entrance was made to the facility and a tour of the facility was conducted. A strong pet odor was noted in the main hallway and west wing of the facility. There was a large dog, Husky type breed, observed wandering through the main hallway and chapel area. The administrator confirmed that the dog belonged to the facility residents and was named Gracie. An interview was conducted with resident #1 on 1/24/18 at 12:00pm. The resident asked if this surveyor had met the facility dog named Gracie, and stated that the nursing home was no place for a dog to be wandering around freely. Resident #1 stated the dog had come into her room and jumped on her bed while she was out of her room, and stated that she was afraid of the dog and scared that the dog would come into her room and jump on her bed while she is in the bed. She said that the dog urinated and defecated in the hallway and she was afraid that someone would slip, fall and hurt themselves. She also stated that the dog would go into the dining room a lot during activities and a lot of the residents are afraid of the dog. She stated that she was never asked if she wanted a dog, but was told that a dog was coming. She stated that she had complained to the Certified Nursing Assistants (CNAs) and to the nurses, and was told sorry, but Gracie isn't going anywhere. At 1:15pm an interview was conducted with resident #2 who stated that she was afraid of the dog because it had almost made her fall several times. She stated that she uses a rolling walker when ambulating through the facility and that the dog would come up and walk between her legs sometimes, and that she can't always lock the brakes on her walker quick enough when she sees the dog coming. Resident #2 also stated the dog goes into the dining room and they have to shoo the dog away, and that the dog often used the bathroom on the floor. Resident #2 went on to say that many of the staff were afraid of the dog and could not do their job because they were always scared the dog was going to come around the corner. She stated that she used to sleep with her door open, but now slept with it closed at night because she was afraid the dog would come into her room. Resident #2 stated her concerns had been reported to staff and administration. On 1/24/18 at 1:40pm an interview was conducted with staff A who stated that there had been resident and staff concerns with the dog using the bathroom on the floors throughout the facility, barking at some of the residents, and going into resident rooms and messing with their things. Staff A stated that no formal complaint had been made because the dog belonged to the administrator and staff were scared for their jobs. At 2:13pm and interview was conducted with staff B who stated that there had been resident concerns about the dog going into their rooms and chewing up their personal belongings and using the bathroom on the floors throughout the facility. Staff B stated there had been staff concerns about the dog eating food from resident trays, going into the dining room during meal times, and being aggressive with some of the residents. Staff B stated that these complaints had been brought to the attention of the administrator who told them that Gracie was not going anywhere and that if the staff didn't like that, they could leave. At 2:38pm an interview was conducted with staff D who stated that many of the residents in the facility were scared of the dog and that the dog would go in their rooms, jump up on their beds, and get into their things. She stated that the dog also used the bathroom all over the facility and that complaints had been made to administration, but they don't mean anything. Review of the facility's grievance log for the past six months showed there had been no complaints logged concerning the facility dog. On 1/25/18 at 10:38am an interview was conducted with the facility social services director who stated that no residents had come to her with any complaints about the dog, but stated that she was aware of complaints by staff, stating that staff just had general concerns about the dog being in the building. On 1/25/18 at 11:20am an interview was conducted with the facility administrator who stated that she had gotten the dog to try as the facility pet. She stated that when they first got Gracie, she did a poll of about 111 residents and found that 67 liked the dog, 13 loved the dog, 14 didn't like the dog and didn't like pets, and 6 didn't think the dog belonged in the nursing home. She stated that some family members were also not crazy about the dog. She stated that at the time she completed the poll, she told the residents who did not like the dog to let her know if it became an issue. She was asked if there had been any accidents related to the dog, and stated that right after they got the dog, one of the CNAs stated they fell in dog urine. She stated there was no facility policy related to pets, and confirmed that the dog was allowed to roam freely through the facility. She also stated that she was not aware of the dog going in the dining area or in and out of resident rooms, and had only seen the dog bark at one resident, but that was because the resident was kicking at the dog.

Based on observation, resident interview, and staff interview, the facility failed to maintain a clean and sanitary environment on the main admission hallway and for 2 of 3 wings of the facility. The facility further failed to maintain a safe environment for 2 of 5 sampled residents (Resident #1 and #2). The findings are: On January 24, 2018 at approximately 11:00 am, immediately upon entrance into the facility, a strong odor denoting the presence of a pet was apparent. During a tour of the facility, the strong odor was pervasive throughout the main admission hallway and the west wing. On the east wing, the same odor lingered, but it was not as strong as on the main admission hallway and on the west wing. During the entrance conference, a large Siberian Husky was observed lying on a blanket in the administrator's office. On January 24, 2018 at approximately 1:00 pm, an interview was conducted with resident #5. This resident stated the facility has a dog named, Gracie. Resident #5 also stated the dog likes to nip at residents because she is still a puppy and they need to understand that she just wants to play. She's not going to bite them, and she has never broken their skin. This resident also stated the dog had chewed up her headphones and both urinated and defecated on the floor. On January 24, 2018 at approximately 1:15 pm, an interview was conducted with resident #2. This resident stated she was afraid of the dog. She stated the dog had almost caused her to fall several times. She stated while using her rolling walker, the dog would come up and walk between her legs and she cannot always lock her brakes on her walker quickly enough when she sees the dog coming. The resident further stated that she used to sleep with her door open, but now slept with it closed at night because she was afraid the dog would come into her room. She stated the dog used the bathroom on the floor in the facility, and that she has reported issues concerning the dog to the staff. On January 24, 2018 at approximately 1:30 pm, an interview was conducted with resident #3. This resident stated that he has reported to staff that he does not like the dog in the facility, and does not like when the dog uses the bathroom on the floor. On January 24, 2018 at approximately 2:53 pm, an interview was conducted with resident #4. This resident stated the dog had caused issues at the facility, like urinating on the floor and doing the other thing on the floor and eating off the residents' trays. Resident #4 also stated that some residents were scared of the dog. This resident further stated, I just feel that she needs to be outside where she can be free. She doesn't need to be stuck indoors. Also it is just not right that she is doing 'you know' on the floor. Nobody wants to live in a house with that on the floor all the time. On January 25, 2018 at approximately 10:15 am, an interview was conducted with resident #1. This resident stated, The nursing home is no place for a dog to be wandering around freely. The dog came into my room and jumped on my bed while I was out. I am afraid of the dog and scared that the dog will come into my room and jump on my bed while I'm in the bed. The dog also urinates and defecates in the hallways and I'm afraid someone will fall and hurt themselves. Resident #1 also stated, I was never asked if I wanted a dog, but was told that a dog was coming. Resident #1 confirmed that concerns related to the dog had been communicated to the staff. On January 24, 2018 at approximately 1:40 pm, an interview was conducted with Staff A. This staff stated the dog had free reign throughout the facility and urinated and defecated in the hallways and in residents' rooms. This staff further stated that some residents were afraid of the dog and the dog would bark at these residents. Staff A stated that some residents have started keeping their doors closed at night because they think the dog may come into their room, and the dog had damaged items in the residents' rooms and had dragged diapers from the residents' trash cans and smeared the feces in the room and down the hallway. On January 24, 2018 at approximately 2:13 pm, an interview was conducted with Staff B. This staff stated that the dog urinated and defecated anywhere and everywhere and stated the situation would be different if someone supervised the dog or if the dog had a designated area. Staff B had observed residents feeding the dog and sometimes did not know if the resident consumed their meal, or if the dog consumed the meal. This staff stated the dog had damaged residents personal items, damaged the facility furniture, did not know how to act with many of the residents, and had to be kept out of the dining room. Staff B stated she had made complaints to other staff and the administrator. On January 24, 2018 at approximately 2:25 pm, an interview was conducted with Staff C. This staff stated she had made complaints about the dog to the administrator. She stated the dog was very aggressive and ran up and down the hallways. Staff C stated the dog aggressively barked at some residents, ran through the facility unsupervised, and had damaged residents' items like their headphones and shoes. This staff further stated the dog urinated and defecated throughout the facility and left a bad smell in the facility. On January 24, 2018 at approximately 2:38 pm, an interview was conducted with Staff D. This staff stated that the dog ran throughout the building and many residents were afraid of the dog. Staff D also stated the dog went into residents' rooms and jumped up on their beds, got in their things, and constantly urinated and defecated throughout the facility. This staff stated that they had been told that they had no choice in cleaning up behind the dog. On January 24, 2018 at approximately 3:08 pm, an interview was conducted with Staff E. This staff stated that before they were able to clean a resident's room, staff had to clean behind the dog that had urinated and defecated in the facility during the overnight shift. This staff also stated throughout the day it was constant cleaning of dog hair, urine, and feces. Staff E had witnessed the dog in a resident's room, eating off of their tray, on more than one occasion. Staff stated these incidents were reported to the Director of Nursing (DON). On January 24, 2018 at approximately 11:10 pm, an interview was conducted with Staff F. This staff had observed the dog's urine and feces in the hallway, had observed the dog going into the residents' rooms, and also eating a sandwich in the middle of the main hallway. This staff had made complaints about issues with the dog but was told, this is the dog's home and she can roam freely. On January 24, 2018 at approximately 11:45 pm, an interview was conducted with Staff G. This staff stated that the dog wandered up and down the hallways, urinated and defecated on the floors, and tore up clean diapers that were used for the residents. On January 25, 2018 at approximately 12:00 am, an interview was conducted with Staff H. This staff stated that the dog had a bed on the west wing and that the dog had a horrible smell. Staff H stated the dog mainly slept through the night, but was awake between 4:00 - 5:00 am. Staff H further stated that after the dog woke up, it ran up and down the hallways and barked, which wakes up the residents. This staff stated that residents have complained that the barking bothers them. On January 25, 2018 at approximately 12:15 am, an interview was conducted with Staff I. This staff stated the dog had a bed under the nurse's station on the west wing. Staff I also stated the residents on west wing complained about the dog waking them. This staff further stated that even when the dog was let out into the courtyard after waking up, the dog would still urinate and defecate in certain areas of the facility. This staff stated that they had complained about the dog damaging items and had observed the dog taking food and other items out of the trash. On January 25, 2018 at approximately 10:38 am, an interview was conducted with the Social Services Director. She stated that she had not received any concerns from residents regarding the dog. She also stated that she had seen the dog have accidents in the facility but these had been immediately cleaned by staff. On January 25, 2018 at approximately 10:45 am, an interview was conducted with the Director of Nursing. When asked if she had a process for monitoring and ensuring that the dog was not urinating and defecating on the floors, entering residents' rooms, or entering the dining room, she stated that the staff was able to close the doors to resident rooms and the dining rooms. She also stated that if the dog was roaming the halls they were not able to monitor at all hours and could not ensure that the dog was not entering residents' room. She confirmed that the facility did not have a process to monitor the dog, but she did state that the facility would begin working on a process. On January 25, 2018 at approximately 11:20 am, an interview was conducted with the Administrator. She stated that the facility had been looking for a pet for about two years and the opportunity finally arose to acquire a dog. She stated that the dog, Gracie, came to live at the facility around August of 2017. The Administrator was able to provide documentation of the dog's vaccination record and [MEDICATION NAME] school training. She stated that the facility followed the Eden Principles and part of those principles were having things that cured boredom and loneliness and provided a homelike environment. The Administrator further stated that she polled the residents in October of 2017 and the majority of the residents liked Gracie. For the ones that did not like having the dog, she stated that she informed the residents to come to her if there were any problems. The Administrator confirmed that she had seen a wet puddle on the floor, but staff cleaned it up immediately. The Administrator confirmed that Gracie was allowed to roam free and it was a team effort to monitor the dog.

Based on interviews with residents and staff, the facility failed to ensure that the residents' rights to retain and use personal possessions was respected for 1 of 5 residents interviewed (#5), by failing to ensure the facility pet did not tear up resident property, and failed to ensure that the facility and floors were kept clean and free of dog hair and excrement. Findings Include: On 1/24/18 at 11:45am a tour of the facility was conducted. During the tour, a strong pet odor was noted in the main hallway and west wing of the facility. There was a large dog, Husky type breed, observed wandering through the main hallway and chapel area. An interview was conducted with resident #1 on 1/24/18 at 12:00pm. The resident asked if this surveyor had met the facility dog named(NAME) and stated that the nursing home was no place for a dog to be wandering around freely. Resident #1 stated the dog urinated and defecated in the hallway and she was afraid that someone would slip, fall and hurt themselves. At 1:15pm an interview was conducted with resident #2 who stated that she was afraid of the dog, and that the dog often used the bathroom on the floor throughout the facility. At 1:30pm an interview conducted with resident #3 revealed that the resident did not like having the dog in the house. The resident stated the dog often used the bathroom on the floor and staff would have to clean it up. At 1:40pm an interview was conducted with staff A who stated that dog had free reign of the facility and would urinate and defecate anywhere including hallways and resident rooms. Staff A also stated that the dog has gone in resident rooms and messed up items on their dressers and has dragged adult briefs out of resident trash cans, smearing feces in the room and hallway. At 2:13pm an interview with staff B revealed the dog was king of the building, and would pee and poop anywhere and everywhere. Staff B also stated that the dog had torn up resident items and facility furniture, including a Raggedy(NAME)doll that had been given to one of the residents by her husband and furniture that had been at the end of the main hall. Interview with staff C at 2:25pm revealed the dog had full run up and down the hallways, and that the dog would pee and poop wherever she wanted. Staff C stated that the dog had torn up resident items including a pair of headphones one resident had, and that the dog had chewed through some residents' shoes. The staff member stated the smell in the facility from the dog was bad because the housekeeping staff had to find where she had used the bathroom. At 2:38pm staff member D stated that the dog ran throughout the building and would go into residents' rooms and jump on their beds and get into their things, stating, I have seen combs and hairbrushes chewed up by the dog. The biggest thing is constantly cleaning up behind her. She constantly pees and poops everywhere because no one is responsible for her. At 2:53pm an interview was conducted with resident #4 who stated that the dog had caused issues by using the bathroom on the floor. The resident stated that the dog should be outside where she could be free and that it was not right that the residents had to live in a home with dog waste on the floor all the time. At 3:00pm an interview with resident #5 revealed that the dog had chewed up her headphones, but they were not expensive, so she told staff not to worry about it. She stated that the dog did use the bathroom on the floor. At 3:08pm an interview with staff E revealed that when staff arrive in the mornings, they often have to clean up behind the dog before they can begin cleaning or caring for the residents. Staff E stated that the dog urinated all by the front door, the chapel, the administrator's office, all along the front hallway and then certain places throughout the building. The staff member also stated that staff were constantly wiping down the walls and sofas so that the residents could have a clean place to sit without having dog hair all over them. The staff member stated that the dog had even torn up one of the residents' sofas in the front of the building, and had, many times, gotten the diaper out of the trash and dragged it down the hallway leaving a trail of poop. At 11:10pm on 1/24/18 an interview was conducted with staff member F who stated that the facility was unclean because of the dog using the bathroom in the hallways. Staff F also stated that the dog did go into resident rooms and that the dog roamed freely throughout the facility. At 11:20pm an interview was conducted with staff J who stated that the dog can go anywhere in the facility, but often stayed on the west wing. The staff member stated they had seen dog pee and poop on the floor and had observed the dog go into a resident's room once and it got a hold of a tube of the resident's lipstick that staff had to get from the dog. At 11:45pm an interview was held with staff G who stated the dog wandered down the hallways and used the bathroom on the floor of the facility often. The staff member stated the dog would tear up resident incontinent briefs or anything else it could get a hold of. On 1/25/18 at midnight, an interview was conducted with staff member H who stated that the dog smelled horrible, and caused an odor in the facility no matter how much air freshener they sprayed, and confirmed the dog did use the bathroom in the hallways of the facility. At 12:15am an interview was conducted with staff I who stated the dog would pee and poop on the floor, and would drag items from the facility and resident trash cans and would take it down the hallways.

Based on observation and interview, the facility failed to provide an environment that recognized the individuality and enhanced the quality of life for each resident by allowing the facility pet dog to have unsupervised access to resident living, dining, and common areas, despite objections made by 4 of 5 residents interviewed (#1, #2, #3, #4). Findings Include: On 1/24/18 at 11:45am a tour of the facility was conducted. During the tour, a strong pet odor was noted in the main hallway and west wing of the facility. There was a large dog, Husky type breed, observed wandering through the main hallway and chapel area. An interview was conducted with resident #1 on 1/24/18 at 12:00pm. The resident asked if this surveyor had met the facility dog named(NAME) and stated that the nursing home was no place for a dog to be wandering around freely. Resident #1 stated the dog had come into her room and jumped on her bed while she was out of her room, and stated that she was afraid of the dog and scared that the dog would come into her room and jump on her bed while she is in the bed. She said that the dog urinated and defecated in the hallway and she was afraid that someone would slip, fall and hurt themselves. She also stated that the dog would go into the dining room a lot during activities and a lot of the residents are afraid of the dog. She stated that she was never asked if she wanted a dog, but was told that a dog was coming. She stated that she had complained to the Certified Nursing Assistants (CNAs) and to the nurses, and was told sorry, but(NAME)isn't going anywhere. At 1:15pm an interview was conducted with resident #2 who stated that she was afraid of the dog because it had almost made her fall several times. She stated that she uses a rolling walker when ambulating through the facility and that the dog would come up and walk between her legs sometimes, and that she can't always lock the brakes on her walker quick enough when she sees the dog coming. Resident #2 also stated the dog goes into the dining room and they have to shoo the dog away, and that the dog often used the bathroom on the floor. Resident #2 went on to say that many of the staff were afraid of the dog and could not do their job because they were always scared the dog was going to come around the corner. She stated that she used to sleep with her door open, but now slept with it closed at night because she was afraid the dog would come into her room. Resident #2 stated her concerns had been reported to staff and administration. At 1:30pm an interview conducted with resident #3 revealed that the resident did not like having the dog in the house. The resident stated that the dog often went into the dining room and staff would have to make her leave. Resident #3 also stated that the dog often used the bathroom on the floor and staff would have to clean it up. Resident #3 confirmed that staff had been made aware of his concerns with the dog being in the facility and using the bathroom on the floor, but stated, I don't guess they can do anything about it. At 2:53pm an interview was conducted with resident #4 who stated that the dog had caused issues by using the bathroom on the floor and eating off of residents' trays, and that some residents were frightened of the dog. The resident stated that the dog should be outside where she can be free and that it was not right that the residents had to live in a home with dog waste on the floor all the time. On 1/25/18 at 11:20am an interview was conducted with the facility administrator who stated that she had gotten the dog to try as the facility pet. She stated that when they first got(NAME) she did a poll of about 111 residents and found that 67 liked the dog, 13 loved the dog, 14 didn't like the dog and didn't like pets, and 6 didn't think the dog belonged in the nursing home. She stated that some family members were also not crazy about the dog. She stated that at the time she completed the poll, she told the residents who did not like the dog to let her know if it became an issue. She was asked if there had been any accidents related to the dog, and stated that right after they got the dog, one of the CNAs stated they fell in dog urine. She stated there was no facility policy related to pets, and confirmed that the dog was allowed to roam freely through the facility. She also stated that she was not aware of the dog going in the dining area or in and out of resident rooms, and had only seen the dog bark at one resident, but that was because the resident was kicking at the dog.