Roselane Health Center by Harborview

Inspectors wroteBased 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.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that kitchen staff wore appropriate beard nets. This deficient practice had the potential to contaminate food and cause food-borne illnesses. The facility had a census of 127.

Inspectors wroteBased on observation, staff interviews, and a review of facility policy titled Puree Food Preparation, it was determined that the facility failed to follow puree preparation guidelines to ensure puree food was prepared in a manner to conserve the nutritive value/appearance, and palatable for eight of eight residents who are on a puree or mechanical diet. This deficient practice places residents at risk for swallowing and choking hazards.

Inspectors wroteBased on observations, staff and resident interviews, record review, and review of the facility's policy titled Residents' Rights, the facility failed to allow choice of personal hygiene care, bathing, or showering of one of 33 sampled residents (R) (R112). This deficient practice had the potential to cause loss of dignity and sense of control over life's needs and contributed to depression and poor skin integrity.

Inspectors wroteBased on record review, staff interviews, and review of the facility's policy titled MDS 3.0 Completion, the facility failed to ensure quarterly Minimum Data Set (MDS) assessments were completed within the required regulatory timeframe for two of three sampled residents (R) (R33 and R104). This deficient practice had the potential to delay the development and implementation of an updated comprehensive care plan and impact regulatory compliance.

Inspectors wroteBased on observations, record review, and resident and staff interviews, the facility failed to ensure that Activities of Daily Living (ADL) care was provided for three of 33 sampled residents (R) (R15, R46, and R125) related to showers and bed baths according to the schedule.

Inspectors wroteBased on observation, record review, staff interviews, and review of the facility's policy titled Oxygen Administration, the facility failed to ensure the oxygen concentrator filter was free of debris for one of 30 residents (R) (R30) receiving oxygen therapy. This deficient practice created the potential for impaired oxygen delivery, inhalation of contaminants, and worsening respiratory symptoms.

Inspectors wroteBased on record review, staff interviews, and review of the facility's policy titled Antibiotic Stewardship Program, the facility failed to ensure antibiotic medications were not administered unnecessarily for two of five sampled residents (R) (R92 and R10) reviewed for unnecessary medications. This deficient practice had the potential to cause adverse drug reactions, medication interactions, and the development of multidrug-resistant organisms (MDROs).

Inspectors wroteBased on observations, record review, and a review of the facility's policies titled Medication Administration, the facility failed to be free of a medication error rate of 5 percent or less for six of 25 observations (24 percent medication error rate). This deficient practice had the potential to cause serious medication side effects and health issues.

Inspectors wroteBased on record review, staff interviews, and review of the facility's policy titled Antibiotic Stewardship Program, the facility failed to implement an effective Antibiotic Stewardship Program to ensure antibiotics were initiated in accordance with nationally recognized infection surveillance criteria, specifically the McGeer criteria, for two of five sampled residents (R) (R92 and R10) reviewed. The facility initiated antibiotic therapy for residents who did not meet established McGeer criteria for urinary tract infection. This deficient practice had the potential to result in unnecessary antibiotic exposure, adverse drug reactions, development of multidrug-resistant organisms (MDROs).

Inspectors wroteBased on observation, staff interviews , and review of the facility policy, the facility failed to ensure all food in the freezer, refrigerator, and dry storage was labeled, dated, and not expired. These failures had the potential to affect all 116 residents in the facility who consumed food from the kitchen.

Inspectors wroteBased on observations and staff interview, the facility failed to ensure garbage was properly disposed of for two out of three facility dumpsters. This had the potential for pests and rodents to enter the dumpsters.

Inspectors wroteBased on record review, staff interviews, and review of the Resident Assessment Instrument (RAI) Manual, the facility failed to ensure residents had an accurate Minimum Data Set (MDS) assessment for three of 36 sample residents (Resident (R) 24, R114, and R11) reviewed for MDS. Specifically, R24's Ozempic was coded as insulin, R114's therapy was not coded, and R11's insulin and antidepressant were coded incorrectly. These failures did not accurately represent the resident's health status.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure one of five residents (Resident (R) 70) had an updated Level I Preadmission admission Screening and Resident Review (PASARR) based on a newly acquired diagnosis of major depression of 36 sample residents. This failure has the potential to cause a negative psychosocial outcome for R70 by not receiving the treatment necessary for an individual with a diagnosis of major depressive disorder.

Inspectors wroteBased on interviews, record review, and review of the facility policy titled Comprehensive Care Plan, the facility failed to ensure a comprehensive care plan was developed for two of 36 sampled residents (Resident (R) 65 and R97) reviewed for care plans. The failure had the potential to lead to unmet care needs.

Inspectors wroteBased on interviews, record review, and review of the facility policy titled, Change in Resident's Condition or Status, the facility failed to identify a resident's need to transfer to the hospital for one of five residents (Residents (R) 171) reviewed of 36 sampled residents, who had experienced a change in condition with altered mental status. This failure placed the residents at risk for increased complications and unmet care needs.

Inspectors wroteBased on resident and staff interviews, record review, and facility policy review, the facility failed to ensure that narcotics were signed out for one of 36 sampled residents (Resident (R) 99). The deficient practice had the potential for drug diversion.

Inspectors wroteBased on record review, resident and staff interviews, and facility policy review, the facility failed to administer physician ordered insulin for one resident (Resident (R) 65) reviewed for insulin administration of 36 sample residents. This failure had the potential to cause hyperglycemia episodes in insulin dependent residents.

Inspectors wroteBased on observations, interviews and review of facility policy, the facility failed to ensure that a glucometer was cleaned properly after blood glucose testing for one of three residents (R) 39) observed for glucometer use of 36 sample residents. This had the potential for cross contamination.

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. Nursing staff assessed the resident's right foot but did not address the resident's continued complaints of pain to the right leg and thigh area or requests for an x-ray until 4/25/23 On 4/24/23 an x-ray was ordered, and R#26 had a fractured femur (bone in the upper part of the leg). [...]

Inspectors wroteBased on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure Minimum Data Set (MDS) assessments were accurate for two of 24 sampled residents (R) (R#93 and R#39).

Inspectors wroteBased on record review, observation, interview, and facility policy review, it was determined the facility failed to develop comprehensive care plans for one of 24 sampled residents (R) (R#66) related to dialysis care and treatment.

Inspectors wroteBased on observations, interviews, record review, and facility policy review, the facility failed to ensure one of 24 sampled residents (R) (R#90) received appropriate care and services to prevent potential urinary tract infections related to an indwelling urinary catheter. Observations revealed staff failed to keep R#90's urinary catheter drainage bag below the level of the bladder and failed to ensure the tubing was not placed in an area that could contribute to contamination.

Inspectors wroteBased on interviews, record review, facility document review, and facility policy review, it was determined that the facility failed to ensure a binding arbitration agreement was explained in a form that the resident understood for one of six residents (R) (R#90) reviewed for binding arbitration agreements.