Harborview Post Acute

In the surveyor’s words

From the most serious findings on record at Harborview Post Acute, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Oct 3, 2021

  Based on policy review, facility investigation review, medical record review, and interview, the facility failed to provide adequate supervision to prevent neglect for 1 of 6 sampled residents (Resident #1) reviewed for wandering and elopement. The facility's failure resulted in Immediate Jeopardy when Resident #1, a cognitively intact resident assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1 exited the facility through the front doors, walked down a heavily traveled street, and crossed more than one major intersection late in the evening. […]

• Immediate jeopardy, isolatedF689Oct 3, 2021

  Based on policy review, facility investigation review, medical record review, and interview, the facility failed to provide adequate supervision to a resident assessed for wandering and having exit seeking behaviors for 1 of 6 sampled residents (Resident #1) reviewed for wandering/exit-seeking behaviors. The facility's failure resulted in Immediate Jeopardy when Resident #1, a cognitively intact resident assessed with wandering and exit seeking behaviors, eloped from the facility without staff knowledge. Resident #1 exited the facility through the front doors, walked down a heavily traveled street, and crossed more than one major intersection late in the evening. […]

• Actual harm, isolatedF726Oct 27, 2025

  Based on the Facility Assessment review, policy review, job description review, medical record review, facility investigation review, [Named Hospital] emergency room (ER) report, and interview, the facility failed to ensure all nursing staff possessed the competencies and skill sets necessary to provide nursing and related services to meet the residents' needs safely and in a manner that promotes each resident's rights and physical, mental and psychosocial well-being for 1 of 3 (Resident #1) sampled residents reviewed for falls. On 3/30/2023, Resident #1 sustained an unwitnessed fall with head injuries. Staff failed to conduct assessments, recognize injuries, and delayed transfer for medical treatment for 7 hours, resulting in actual harm to Resident #1. The findings include: 1. […]

• Actual harm, isolatedF692Feb 22, 2023

  Based on policy review, medical record review and interview, the facility failed to accurately assess the nutritional status and to follow the facility's policy for monitoring weights for 1 of 3 (Resident #3) sampled residents reviewed for weight gain. The facility's failure to provide and monitor the interventions resulted in Actual Harm when Resident #3 had severe weight gain of 18.8 pounds in a five (5) day period. Resident #3 was transferred to a local hospital for evaluation and treatment with admission to the Intensive Care Unit (ICU). The findings include: 1. […]

• No harm, potential for more than minimal, widespreadF812Apr 21, 2022

  Based on policy review, observation, and interview, the facility failed to ensure food was stored, prepared, and served under sanitary conditions as evidenced by carbon build-up on the pots and pans, dirty storage racks, pink substance build-up on the water curtain of the ice machines, dirty floors, a dirty dish machine, dirty utility carts and a dirty prep (prepare and make ready) table. The facility had a census of 93 with 85 of those residents receiving a tray from the Kitchen. The findings include: Review of the CLEANING SCHEDULE, revealed .Carts - Spray and wipe down outside Friday AM [morning] Aide .Kitchen Floors - Sweep Daily AM Aide . […]