Life Care Center Of Mount Vernon

F-F644 - 483.20(e) Coordination of PASARR and Assessment

Refer to

F-F758- 483.45(e)(1)-(5) Free from unnecessary psychotropic medications

Reference WAC 388-97-0960 (1)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 57 of 67 505272 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 505272 B. Wing 04/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Life Care Center of Mount Vernon 2120 East Division Street Mount Vernon, WA 98273

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0756 Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 44110

Residents Affected - Few Based on interview and record review, the facility failed to act on the consultant pharmacist's monthly medication regimen review (MRR) recommendations in a timely manner for 2 of 5 residents (Residents 14, and 30) reviewed for unnecessary medications. Failure to act timely on the pharmacist's recommendations placed all residents at risk for experiencing adverse side effects, medical complications, and a decreased quality of life.

Findings included .

Review of the facility policy titled, Medication Regimen Review, revised 06/01/2024, the provider should address the consultant pharmacist's recommendations no later than their next scheduled visit.

<RESIDENT 14>

Resident 14 admitted to the facility on [DATE REDACTED] they have diagnoses that include hyperlipidemia (high levels of fats in blood), diabetes, and history of heart attack.

In a review of Resident 14's MRR recommendations dated 11/21/2024 the pharmacist documented a fasting lipid panel (blood test to check the levels of fats in the blood) was ordered on 08/07/2024 by the physician, please upload the results into the medical record.

In a review of Resident 14's laboratory results on 04/07/2025 the fasting lipid panel was not completed until 01/13/2025, five months after the order was completed.

In a telephone interview on 04/08/2025 at 10:30 AM, Collateral Contact (CC) 1, Pharmacist stated they performed MRR once a month at the facility, around the third week of the month. CC1 stated the facility would usually have access to their report within 72 hours of completion. CC1 stated their expectation was that an MRR that required action would be completed within 30 days of the request.

In an interview on 04/08/2025 at 3:21 PM, Staff C, Regional Director of Clinical Services (RDCS) stated the expectation was the facility would complete all MRR requests within 30 days. Staff C stated the MRR for Resident 14 should have been done back in August originally, and then again should have been caught

during the November review. Staff C stated they were not sure what occurred or why it was completed five months late.

47047

<RESIDENT 30>

Resident 30 was admitted to the facility on [DATE REDACTED] with diagnoses which included history of falling, depression and anxiety.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 58 of 67 505272 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 505272 B. Wing 04/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Life Care Center of Mount Vernon 2120 East Division Street Mount Vernon, WA 98273

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0756 In a review of Resident 30's monthly pharmacy review dated 10/23/2024 showed a recommendation for Basic Metabolic Panel (BMP-blood test that provides important information about a person's metabolism, Level of Harm - Minimal harm or fluid balance and kidney function) to be completed to assess their kidney function. The note showed that potential for actual harm Resident 30 had not had an assessment of kidney function in the last year. Residents Affected - Few

In a review of Resident 30's monthly pharmacy review dated 01/23/2025 showed a repeated recommendation from 10/23/2024 for a BMP to be completed to assess their kidney function. The recommendation was noted by a registered nurse and the nurse practitioner on 02/05/2025 with directions to complete a BMP and at least every 6 months thereafter.

In a review of Resident 30's monthly pharmacy review dated 03/16/2025 showed a repeated recommendation for a BMP to be completed.

In a review of Resident 30's electronic health record showed there were no labs completed on or after 10/23/2024.

In an interview on 04/04/2025 at 1:34 PM Staff H, Licensed Practical Nurse (LPN)-Unit Coordinator, stated

the pharmacy recommendations are reviewed by the provider and lab results are found in the electronic medical record under results. When asked about the pharmacy recommendation for Resident 30 to have a BMP, they stated they had given all the information they could.

In an interview on 04/04/2025 at 2:41 PM Staff C, RDCS, stated they found the pharmacy recommendation from January 2025 which was noted by the nurse practitioner and a facility nurse, but unable to locate any orders or documentation of the BMP being completed.

Reference WAC 388-97-1300 (1)(c)(iii), (4)(c)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 59 of 67 505272 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 505272 B. Wing 04/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Life Care Center of Mount Vernon 2120 East Division Street Mount Vernon, WA 98273

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0809 Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to Level of Harm - Minimal harm or eat at non-traditional times or outside of scheduled meal times. potential for actual harm 36787 Residents Affected - Few Based on interview and record review, the facility failed to consistently offer and/or provide a nutritional snack when ordered or requested for 4 of 6 resident's (5, 11, 54, and 265) residents reviewed for dining preferences. This failure to provide nutritional snacks at non-traditional times and meet resident choices placed residents at risk for inadequate nutrition.

Findings included .

<REVIEW OF RESIDENT COUNCIL MINUTES>

Review of the resident council meeting minutes on 01/28/2025 documented the concern of residents wanting more snacks and different snack options.

<RESIDENT COUNCIL>

In an interview with resident council representatives on 04/07/2025 at 11:36 AM, Resident's were asked do you received snacks at bedtime or when you request them? Residents responded.

Resident 5 stated they asked for snacks and staff tells them there are only saltine crackers available.

Resident 11 stated the staff fill the snack bins after breakfast and lunch and will give you graham crackers. Resident 11 stated they would like a snack at 10:30 at night since they are up late but staff report there is nothing left.

Resident 54 stated they ask for snacks a lot and staff say there aren't any. Resident 54 stated they would like Jello.

Resident 265 stated they were on a pureed diet and night staff were not aware of that and gave them potato chips and cookies for snacks. Resident 265 stated they tell the staff they are not supposed to have chips or cookies, and staff would respond, the facility is out of everything. Resident 265 would like to have pudding or yogurt since they shouldn't have chips.

In a joint interview on 04/09/2025 at 10:00 AM with Staff B, Director of Nursing and Staff C, Regional Director of Clinical Services stated the expectation is snacks are passed at night. Staff C said everyone should be offered a snack and they will investigate that. Staff B stated Snacks are in the standard orders.

No additional information was provided.

Reference: (WAC) 388-97-1120 (1)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 60 of 67 505272 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 505272 B. Wing 04/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Life Care Center of Mount Vernon 2120 East Division Street Mount Vernon, WA 98273

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food

in accordance with professional standards. Level of Harm - Minimal harm or potential for actual harm 51312

Residents Affected - Some Based on observation, interview and record review, the facility failed to store, prepare, distribute and serve food under sanitary conditions in the facility kitchen. This failure placed residents at risk for cross-contamination and foodborne illnesses.

Review of document titled 'Sanitation and food safety' with a revision date of 09/08/2022 documented under Procedure that:

Staff will wash their hands.

* After handling raw or unwashed foods

* After handling dirty dishes, soiled equipment or utensils

* During food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks.

* Before donning gloves to initiate a task that involves working with food.

During an observation on 04/02/2025 at 12:47 PM, Staff EE, Food Service Director (FSD), entered the kitchen from his office, did not wash his hands, put on gloves, and prepared chicken for the residents.

During an observation on 04/02/2025 at 2:24 PM, Staff DD, dietary aid, placed dirty dishes into the dishwasher. Once the dishwasher had completed its cycle, the clean dishes were removed without proper handwashing. Staff DD performed this task multiple times.

During an interview on 04/02/2025 at 2:24 PM, Staff DD stated that the dishes they took out of the dishwasher were clean, and they were waiting for them to dry before putting them away. Staff DD mentioned that they should wash their hands before touching clean dishes.

During an interview on 04/02/2025 at 3:28 PM, Staff EE, FSD indicated that dirty dishes should be removed from the cart and placed in the dishwasher. Afterward, staff should wash their hands before handling the clean dishes from the dishwasher.

During an observation on 04/07/2025 at 9:12 AM, dust was present on the rack above the food service area that held measuring cups. The rack above the second food prep area, contained spices, and had dust accumulation. The stove top hood showed signs of dust. The food prep sink, where knives were stored on

the wall, had debris splashes on the surrounding area. The front of the steam table used during food distribution had drips of moisture. The fan directly above the food prep area contained a significant amount of dust.

WAC 388-97-1100(3)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 61 of 67 505272 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 505272 B. Wing 04/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Life Care Center of Mount Vernon 2120 East Division Street Mount Vernon, WA 98273

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0838 Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies. Level of Harm - Minimal harm or potential for actual harm 37890

Residents Affected - Some Based on interview and record review, the facility failed to document a facility-wide assessment to determine what resources were necessary to care for its residents competently during both day-to-day operations and emergencies.

Findings included .

Review of the facility assessment provided by the facility dated 07/30/2024, included the names of the prior facility Administrator and Director of Nursing Services. The facility assessment only included a Part I template and failed to include the following required elements:

- The care required by the resident population considering the types of diseases, conditions, physical and cognitive disabilities, overall acuity, and other pertinent facts that are present within that population;

- The staff competencies that are necessary to provide the level and types of care needed for the resident population;

- The physical environment, equipment, services, and other physical plant considerations that are necessary to care for this population;

The facility's resources, including but not limited to, all buildings and/or other physical structures and vehicles;

- Equipment (medical and non- medical);

- Services provided, such as physical therapy, pharmacy, and specific rehabilitation therapies;

- All personnel, including managers, staff (both employees and those who provide services under contract), and volunteers, as well as their education and/or training and any competencies related to resident care;

- Contracts, memorandums of understanding, or other agreements with third parties to provide services or equipment to the facility during both normal operations and emergencies; and

- Health information technology resources, such as systems for electronically managing patient records and electronically sharing information with other organizations.

In an interview on 04/02/2025 at 1:40 PM, Staff A, Administrator, stated the facility assessment provided was

the most current and they were unable to provide any further information.

No associated WAC reference.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 62 of 67 505272 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 505272 B. Wing 04/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Life Care Center of Mount Vernon 2120 East Division Street Mount Vernon, WA 98273

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0865 Have a plan that describes the process for conducting QAPI and QAA activities.

Level of Harm - Minimal harm or 37890 potential for actual harm Based on interview and record review, the facility failed to ensure the Quality Assessment and Performance Residents Affected - Some Improvement (QAPI) program self-identified deficiencies and failed to develop/implement effective plans of action to sustain plan of corrections for previous deficiencies. Failure to have an effectively functioning QAPI program that consistently self-identified deficient practices led to repeated deficiencies, and a pattern of deficiencies that placed residents at repeated risk for unmet needs that could negatively impact their safety, quality of life and quality of care.

Findings included .

Review of the facility QAPI plan/policy dated 01/21/2025 documented the facility's QAPI committee was responsible for ensuring compliance with state and federal requirements and for continuous improvement in quality of care and customer satisfaction.

Review of the facility [NAME] 3 facility report showed the following repeat deficiencies from Statement of Deficiencies dated 08/06/2024:

F - 0550 - 483.10(a)(1)(2)(b)(1)(2) - Resident Rights/exercise Of Rights S-S= E

F - 0610 - 483.12(c)(2)-(4) - Investigate/prevent/correct Alleged Violation S-S= E

Review of the facility [NAME] 3 facility report showed the following repeat deficiencies from Statement of Deficiencies dated 05/01/2024:

F - 0584 - 483.10(i)(1)-(7) - Safe/clean/comfortable/homelike Environment S-S= E

F - 0657 - 483.21(b)(2)(i)-(iii) - Care Plan Timing and Revision S-S= D

F - 0676 - 483.24(a)(1)(b)(1)-(5)(i)-(iii) - Activities Daily Living (adls)/mntn Abilities S-S= D

F - 0684 - 483.25 - Quality of Care S-S= D

F - 0688 - 483.25(c)(1)-(3) - Increase/prevent Decrease In Rom/mobility S-S= D

F - 0689 - 483.25(d)(1)(2) - Free of Accident Hazards/supervision/devices S-S= E

F - 0692 - 483.25(g)(1)-(3) - Nutrition/hydration Status Maintenance S-S= D

F - 0758 - 483.45(c)(3)(e)(1)-(5) - Free from Unnec Psychotropic Meds/prn Use S-S= D

WAC 388-97-1080 - Nursing Services

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 63 of 67 505272 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 505272 B. Wing 04/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Life Care Center of Mount Vernon 2120 East Division Street Mount Vernon, WA 98273

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0865 In an interview on 04/09/2025 at 11:09 AM, Staff A, Administrator, acknowledged the findings of repeat deficiencies and stated they could not speak to prior leadership. Staff A stated that the expectation of the Level of Harm - Minimal harm or QAPI team was to follow the processes established, hold staff accountable and be consistent. Staff A stated potential for actual harm they were focused on retention of management staff.

Residents Affected - Some Reference WAC 388-97-1760(1)(2)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 64 of 67 505272 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 505272 B. Wing 04/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Life Care Center of Mount Vernon 2120 East Division Street Mount Vernon, WA 98273

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 36787 potential for actual harm Based on observation, interview, and record review the facility failed to ensure the staff were compliant with Residents Affected - Few Infection Prevention and Control Guidelines and standards of practice for 2 of 3 units. The facility failed to ensure the staff used appropriate hand hygiene practices during personal care, and disposal of soiled garbage in accordance with infection control standards of practice. This failure placed all residents and staff at risk of potential infection.

Findings included .

Review of the facility polity titled, Hand Hygiene, revised 12/04/2020, documented hand hygiene should be completed before and after any resident contact, before applying gloves (donning), after removal of gloves (doffing), contact with potential contaminated personal protective equipment and after any potential contact with infectious materials i.e., blood, bodily fluids, or contaminated surfaces.

Review of the facility policy titled, Clostridium Difficile reviewed 06/04/2024 documented the facility would care for residents with suspected and actual Clostridium difficile (C. Diff) in accordance with local, state, and federal guidelines. The physical action of washing and rinsing hands under such circumstances is recommended as alcohol gel has poor activity against spores.

<RESIDENT 116>

Resident 116 was placed on enteric precautions (specific infection control measures) on 04/04/2025 for suspected C. Diff (inflammation of the colon caused by Clostridium difficile bacteria, resulting in diarrhea and pain).

In an observation on 04/04/2025 at 8:24 AM, a new contact enteric precaution sign was observed on room [ROOM NUMBER]'s door. The Personal Protective Equipment (PPE) bin was placed against the trash bin outside the room. There were soiled gown straps going from the trash receptacle into the top drawer of clean PPE bin. Staff O, Nursing Assistant Registered (NAR) left room [ROOM NUMBER] with their mask on and did not remove it. Staff M, Nursing Assistant Certified (NAC) came out of the room with a surgical mask on. Staff O and M used hand gel only and walked down the hall with full bags of soiled linens in their hands. The masks were not removed after exiting room [ROOM NUMBER] and walking down the hall.

In an interview on 04/04/2025 at 9:07 AM, Staff M, NAC stated they provided care to Resident 116 and had to do a complete bed linen change. Staff M stated they were informed the resident had C. Diff, so they had to wear full PPE, and they put on a gown, mask, gloves and eye protection. Staff M stated they used hand sanitizer going into room [ROOM NUMBER] and hand sanitizer going out of the room. Staff M stated they washed their hands when disposing of the soiled linen down the hall.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 65 of 67 505272 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 505272 B. Wing 04/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Life Care Center of Mount Vernon 2120 East Division Street Mount Vernon, WA 98273

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 In an interview on 04/04/2025 at 9:49 AM, Staff O stated when providing care to Resident 116 then had put

on a gown, gloves and mask. They stated they stripped the residents bed, put new bedding on and disposed Level of Harm - Minimal harm or of dirty bedding. They stated they disposed of the dirty linen and sanitized their hands when they left the potential for actual harm room. Staff O stated they were told the residents had C. Diff and they did have loose stools. Staff O stated

they were to follow the posted signs on the door. Residents Affected - Few

In a continuous observation on 04/04/2025 at 9:18 AM, Staff L, housekeeping assistant bagged up soiled linen from the trash can outside of room [ROOM NUMBER]. Staff L had gloves on, then removed them and with no hand hygiene performed before putting new gloves on. Staff L closed their cart, and their soiled left gloved hand went into their left scrub pocket, then donned new gloves, without performing hand hygiene. Staff L went into room [ROOM NUMBER] to get their trash and placed their left hand into their left pocket to get a trash bag out. No hand hygiene was observed until interview with Staff L at 9:22 AM. Staff L stated they would read the posted signs outside the room to know about any infection control precautions. Staff L stated

they were unsure what enteric precautions were. Staff L then asked if they should have been wearing a gown when collecting the soiled garbage from outside the room of 104.

In observations on 04/07/2025 at 10:10 AM, 1:24 PM, 2:01 PM, and 2:51 PM, the clean PPE cart was right up to the soiled garbage can.

In an observation on 04/08/2025 at 8:37 AM, Staff M opened the door to room [ROOM NUMBER] and was observed inside the room wearing a gown and gloves with no mask on.

In an interview on 04/08/2025 at 12:52 PM, Staff P, Infection Preventionist stated their expectation for hand hygiene was before and after contact with the resident, when leaving rooms, passing trays, and if they go to

the bathroom. Staff P stated staff should wash their hands vigorously after contact with C. Diff.

51312

<Resident 266>

Resident 266 was admitted to the facility on [DATE REDACTED]. According to the MDS dated [DATE REDACTED], Resident 266 was severely cognitively impaired.

During an observation on 04/02/2025 at 10:21 AM, Staff E, NAC, entered the room of Resident 266 without performing hand hygiene. Staff E provided perineal care and assisted the resident with a brief change. Staff E then assisted Resident 266 with dressing, moving the wheelchair, and using a walker, without conducting hand hygiene or changing gloves during the process. Staff Z, NAC, entered Resident 266's room to assist with a transfer without performing hand hygiene. Staff Z assisted with the transfer and then brushed the resident's hair.

During a joint interview on 04/02/2025 at 10:24 AM, Staff Z indicated that proper hand hygiene was not performed upon entering resident 266's room. Staff E noted that hand hygiene and a glove change should have been carried out after performing perineal care and changing the brief.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 66 of 67 505272 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 505272 B. Wing 04/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Life Care Center of Mount Vernon 2120 East Division Street Mount Vernon, WA 98273

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 During an observation on 4/4/2025 at 10:26 AM, Staff Z entered the room of Resident 266 without performing hand hygiene. Staff Z provided perineal care and assisted the resident with a brief change. They then Level of Harm - Minimal harm or assisted Resident 266 with dressing, without conducting hand hygiene or changing gloves during the potential for actual harm process.

Residents Affected - Few During an interview on 4/4/2025 at 10:40 AM, Staff Z indicated that hand hygiene should be performed upon entering the resident's room and after completing perineal care. However, Staff Z also stated that hand hygiene was not performed.

Reference WAC 388-97-1320 (1)(a)(c)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 67 of 67 505272