Life Care Center Of Mount Vernon

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

at the leg, it looked really tight. Staff F stated the other nurses on day shift informed them the residents family did not want to remove the compression stocking, and added I just don't think they knew what to do, I really don't know why they never got a better order or cleared it up, I am sure someone called the doctor to see what was the clarification. Staff F confirmed they never contacted the provider about removing the compression stocking and assumed the day shift was handling the situation. In an interview on 11/18/2025 at 12:49 PM, Staff D, LPN/Resident Care Manager (RCM) stated the resident had a recent total knee replacement on the right leg, and they should have been monitored as they were at risk for blood clots.

Staff D confirmed they were conducted the readmission skin assessment on 10/23/2025, and that they never removed the compression stocking to Resident 1's right leg. Staff D confirmed that Resident 1's medical record lacked any communication with the physician regarding the resident's refusal of care. In an

interview on 11/18/2025 at 1:57 PM, Staff B, RN/Outgoing DNS/Incoming RCM stated they were familiar with Resident 1 and stated they were aware the resident had been refusing to allow staff to remove the compression stockings after they had a right total knee replacement surgery. Staff B stated they knew the resident was on a blood thinner and was at risk for blood clots. They stated that Resident 1's care plan for post-knee replacement surgery was never incorporated into Resident 1's care plan, so there was no assessment or monitoring for blood clots. Staff B confirmed there was no documentation of the refusals, and that no licensed staff had contacted the provider. In joint interview on 11/18/2025 at 2:31 PM, Staff A, Administrator, Staff C, Incoming DNS/RN, Staff A, confirmed that the investigation showed the facility had a lack of notification, documentation, care planning, monitoring and assessment of Resident 1's right foot post-surgical procedure. This resulted in Resident 1 having significant wounds to their right foot, required hospitalization and surgical repair with risk for loss of limb. Staff C agreed. No further documentation was provided. Refer to WAC 388-97-1060(1)

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/18/2025

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 0684

documented that the resident had refused and never notified the provider that the resident had been refusing to remove the compression stocking to the right foot.

Level of Harm - Actual harm Residents Affected - Few

In an interview on 11/18/2025 at 1:57 PM, Staff B, RN/Outgoing DNS/Incoming RCM stated all the department managers are responsible for ensuring the residents plan of care was updated appropriately.

Staff B stated skin checks are completed on all residents weekly, and if there was a concern the staff were to report to the provider, get new orders and place a referral to our contracted outside wound provider, and place the resident on monitoring. Staff B stated the standard order for compression stockings would be on

in the morning and off at night, unless there was a specific order to follow. Staff B stated if the orders are not clear they should be contacting the provider to ensure we have a clear order to follow and get it updated. Staff B stated they were familiar with Resident 1 and stated they were aware the resident had been refusing to allow staff to remove the compression stockings. Staff B stated they were not sure if any licensed staff ever contacted the provider about the clarification of the compression stockings or that they were refusing to allow them to be removed. Staff B stated they knew the resident was on a blood thinner and was at risk for blood clots. Staff B confirmed that the plan of care for post-knee replacement surgery was never incorporated into Resident 1's care plan, that there was no assessment or monitoring for blood clots, no documentation of the refusals, and that no one had contacted the provider.

In joint interview on 11/18/2025 at 2:31 PM, Staff A, Administrator, Staff C, Incoming DNS/RN, Staff A and Staff C were asked if there was any notification, documentation, care planning, monitoring or assessment of Resident 1's right leg, or right foot after their surgery. Staff A & Staff C both stated there was not.No further information was provided by Staff A, and Staff C. <CARE PLAN> <RESIDENT 2> Resident 2 was admitted on [DATE REDACTED] with diagnoses to include left knee replacement surgery.

Resident 2 had physician orders to include ted hose (compression socks) on everyday shift and staff were to monitor for edema every shift with a start date of 10/28/2025.

Resident 2's care plan did not show care interventions for the ted hose or edema monitor. <RESIDENT 3> Resident 3 was admitted on [DATE REDACTED] with diagnoses to include right hip fracture.

Resident 3 had physician orders to include ted hose on every morning with a start date on 10/13/2025.

Resident 3's care plan did not include care interventions for the ted hose.

In an interview on 11/18/2025, at 12:48 PM, Staff D, LPN/RCM, stated that residents who have ted hose orders should be in the care plan.

Refer to WAC 388-97-1060(1-3)

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/18/2025

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 0686 Level of Harm - Actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

plan of care was updated appropriately. Staff B stated when a resident returns from a procedure the orders and care plan should be updated and/or revised. Staff B stated they were familiar with Resident 1, and that

they were at risk for skin breakdown. Staff B confirmed that the plan of care for the residents to be risk for skin breakdown was never revised after their post-knee replacement surgery. Staff B stated there was no documentation of the refusals, and that no licensed nurse had contacted the provider. In joint interview on 11/18/2025 at 2:31 PM, Staff A, Administrator, Staff C, Incoming DNS/RN, Staff A said there had been a lack of care planning and appropriate monitoring of Resident 1's skin. Staff A and Staff C stated that PIs to Resident 1's foot were significant injuries. Reference WAC 388-97-1060(3)(b)

Event ID:

Facility ID:

If continuation sheet