Roselane Health Center by Harborview

In the surveyor’s words

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

• Actual harm, isolatedF600Feb 18, 2026

  Based on observations, interviews, record review, and review of the facility policies titled Abuse, Neglect and Exploitation and Reporting Reasonable Suspicion of a Crime, the facility failed to protect two of 33 sampled residents (R)(R57 and R148) from abuse. Harm was identified to have occurred on 11/14/2025 when R57 sustained bruising and a skin tear after staff grabbed her arm. Findings included:1. A review of the electronic medical record (EMR) revealed resident R57 was admitted to the facility on [DATE] with a diagnosis of, but not limited to, the following: Acute embolism and thrombosis of the right femoral vein, history of pulmonary embolism, fibromyalgia, major depressive disorder, and dementia with agitation.A review of R57's quarterly Minimum Data Set (MDS) assessment dated… […]

• Actual harm, isolatedF658Jun 2, 2023

  Based on interviews, review of facility policy, and record reviews, it was determined the facility failed to provide services as outlined by the comprehensive care plan and that met professional standards of quality for one of 24 sampled residents (R) (R#26) related to thoroughly assessing the resident after a significant change in condition and ensuring pain management. Harm was identified to have occurred on 4/23/23, when staff were returning R#26 to their room after a shower and the resident's right foot hit a door frame. The resident immediately complained of pain and stated the pain radiated from their foot upward to the hip. The resident continued to complain of pain after the incident and requested an x-ray of the leg. […]

• Actual harm, isolatedF697Jun 2, 2023

  Based on interviews, review of facility policy, and record reviews, it was determined the facility failed to provide effective pain management for one of 24 sampled residents (R) (R#26). Harm was identified to have occurred on 4/23/23, when staff were returning R#26 to their room after a shower and the resident's right foot hit a door frame. The resident immediately complained of pain and stated the pain radiated from their foot upward to the hip. The resident continued to complain of pain after the incident and requested an x-ray of the leg. […]

• Actual harm, isolatedF656Jan 14, 2022

  Based on observations, record review, staff interviews, and policy review, the facility failed to follow the care plan for one of 39 residents (R#76), who suffered harm during a fall from the bed when staff failed to provide two-person assistance for care. The facility failed to follow the care plan for one of 39 residents (R#71) by failing to apply a right hand splint. In addition, the facility also failed to develop a care plan for R#76 for the use of a low air loss mattress. Findings include: Review of the policy titled, Comprehensive Care Plan, revised May 2021, revealed the center will develop a comprehensive person-centered care plan that identifies each resident's medical, nursing, mental, and psychosocial needs. […]

• Actual harm, isolatedF689Jan 14, 2022

  Based on observations, record review, staff interviews and policy review, the facility failed to provide supervision and care to prevent a fall from the bed for one of one residents (R) R#76 reviewed for falls that had a low air loss mattress in use. Actual harm occurred on October 13, 2021, when R#76 had a fall from the bed during the provision of care that resulted in a laceration to the forehead requiring 11 sutures. Findings include: Review of the facility policy titled, Sava Senior Care Low-Air-Loss Therapy Bed Use date 5/21/2021, documented the low-air-loss therapy bed consists of segmented air-filled cushions that provide surface area for pressure relief. […]