Lillian Carter Health Center by Harborview

In the surveyor’s words

From the most serious findings on record at Lillian Carter Health Center by Harborview, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF909Sep 12, 2025

  Based on observation, interview, record review, review of the Food and Drug Administration (FDA) guidelines and review of Manufacturer's Instructions for Use (MIFU), the facility failed to ensure bed frames and bed rails, if present, were inspected and maintained per the Manufacturer's Instructions For Use (MIFU) to minimize the risks of bed malfunction or resident injury for five Residents (R) (R5, R7, R21, R23, and R25) identified as having bed rails in the sample of 37 residents.Findings include: Review of the facility's policy titled Side Rail Policy and Guidelines dated 1/16/2023 revealed, Policy Statement, Side rails are adjustable metal or rigid plastic bars that attach to the bed. […]

• No harm, potential for more than minimal, patternF641Sep 12, 2025

  Based on interview, record review, and review of the Resident Assessment Instrument (RAI) Manual, the facility failed to ensure four out of 37 sampled Residents (R) (R3, R5, R6, and R27) Minimum Data Set (MDS) assessments were accurately coded. Specifically, the facility failed to accurately code the MDS assessment for (R3) related to falls, (R5) related to (Level II Preadmission admission Screening and Resident Review (PASARR), and (R6 and R27) related to weight loss. This failure had the potential to affect the care planning and provision of needed services.Findings include: 1. […]

• No harm, potential for more than minimal, patternF700Sep 12, 2025

  Based on observation, interview, record review, and review of the facility's policy titled Side Rail Policy and Guidelines, the facility failed to ensure alternatives were attempted prior to the use of bed rails for five out of 48 Residents (R) (R5, R7, R21, R23, and R25) identified with bed rails. This failure had the potential to increase accidental entrapment or injury from bed rail usage when an alternate assistive device may have been effective.Findings include: Review of the facility's policy titled Side Rail Policy and Guidelines dated 1/16/2023 revealed, Policy Statement, Side rails are adjustable metal or rigid plastic bars that attach to the bed.The facility will attempt to use appropriate alternatives prior to installing a side rail. 1. […]

• No harm, potential for more than minimal, patternF880Mar 10, 2024

  Based on observations and staff interviews, the facility failed to maintain an effective infection control program related to labeling and storage of personal care equipment on one of four halls in six bathrooms. The facility census was 53 residents. Findings include: Observation on 3/8/2024 at 8:47 am revealed in the shared bathroom between rooms [ROOM NUMBERS] had four unlabeled, un-bagged wash basins stored stacked on the floor. Observation on 3/8/2024 at 8:58 am revealed in the shared bathroom between rooms [ROOM NUMBERS] urinal sitting inside of specimen hat, inside of bed pan on floor. None were labeled or bagged. An additional two wash basins were stacked unlabeled, un-bagged on the floor. […]

• No harm, potential for more than minimal, isolatedF609Sep 12, 2025

  Based on interviews, record review, and review of the facility's policy titled, Abuse Prohibition Policy and Procedures, the facility failed to ensure allegations of abuse were reported timely for two of two Residents (R) (R20 and R23) reviewed for abuse out of a total sample of 37 residents. The facility failed to report resident-to-resident abuse within two hours to the state survey agency (SSA). Facility staff failed to report an allegation of physical abuse between R20 and R23 to the Administrator. […]