Life Care Center Of Port Orchard

F-F656

Reference WAC 388-97-1060 (3)(b)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 24 505210 Department of Health & Human Services Printed: 09/07/2025 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 505210 B. Wing 02/28/2025

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

Life Care Center of Port Orchard 2031 Pottery Avenue Port Orchard, WA 98366

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 0760 Ensure that residents are free from significant medication errors.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 37044 potential for actual harm Based on interview and record review, the facility failed to ensure 1 of 3 residents (Resident 21) reviewed for Residents Affected - Few insulin administration were free of significant medication errors. The failure to administer insulin in accordance with physician orders, and to hold insulin when blood glucose (BG) levels were below the ordered parameters for administration, placed residents at risk for hypoglycemia, seizures, coma and death.

Findings included .

Resident 21 admitted to the facility on [DATE REDACTED]. Review of 11/21/2025 Annual Minimum Data Set (MDS, an assessment tool), showed the resident was cognitively intact, had a diagnosis of diabetes (a condition where

the body cannot use insulin correctly and glucose builds up in the blood), and required insulin injections on seven of seven days during the assessment period.

Review of the electronic health record showed Resident 21 had the following insulin orders:

a) A 02/08/2025 order for Aspart insulin (fast acting), with meals. Hold for a BG less than 150.

b) A 11/14/2024 order for Aspart insulin sliding scale coverage three times a day.

c) A 02/07/2025 order for Lantus insulin (long acting), 11 units every morning and 18 units every evening. Hold if BG is less than 100.

Review of the January and February 2025 Medication Administration Records showed on the following date(s)/time(s), facility nurses failed to hold Resident 21's insulin for BGs levels below than the physician ordered parameters for administration.

January 2025

a) Aspart insulin with meals, hold for BG less than 150.

01/01/2025 8:00 AM, BG= 110; insulin administered.

01/01/2025 12:00 PM, BG= 131; insulin administered.

01/12/2025 5:00 PM, BG= 134; insulin administered.

01/26/2025 8:00 AM, BG= 136; insulin administered.

01/27/2025 8:00 AM, BG= 131; insulin administered.

01/29/2025 8:00 AM, BG= 122; insulin administered.

b) Lantus insulin, hold for BG less than 100.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 24 505210 Department of Health & Human Services Printed: 09/07/2025 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 505210 B. Wing 02/28/2025

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

Life Care Center of Port Orchard 2031 Pottery Avenue Port Orchard, WA 98366

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 0760 01/21/2025 8:00 AM, BG=77; insulin administered.

Level of Harm - Minimal harm or February 2025 potential for actual harm a) Aspart insulin with meals, hold for BG less than 150. Residents Affected - Few 02/01/2025 5:00 PM, BG= 147; insulin administered.

02/02/2025 8:00 AM, BG= 147; insulin administered.

02/08/2025 8:00 AM, BG= 90; insulin administered.

02/08/2025 12:00 PM, BG=148; insulin administered.

02/12/2025 5:00 PM, BG=124; insulin administered.

02/14/2025 8:00 AM, BG=136; insulin administered.

02/16/2025 8:00 AM, BG= 79; insulin administered.

02/18/2025 8:00 AM, BG=138; insulin administered.

02/19/2025 8:00 AM, BG=92; insulin administered.

02/20/2025 5:00 PM, BG=147; insulin administered.

02/21/2025 12:00 PM, BG=147; insulin administered.

b) Lantus insulin, hold for BG less than 100.

02/08/2025 8:00 AM, BG=90; insulin administered.

02/19/2025 8:00 AM, BG=92; insulin administered.

On 02/28/2025 at 10:46 AM, Staff C, Resident Care Manager, confirmed on the 20 occasions referenced above, facility nurses administered Resident 21's insulin, rather than holding it as ordered.

Reference WAC 388-97-1060 (3)(k)(iii)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 24 505210 Department of Health & Human Services Printed: 09/07/2025 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 505210 B. Wing 02/28/2025

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

Life Care Center of Port Orchard 2031 Pottery Avenue Port Orchard, WA 98366

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** 50945 potential for actual harm Based on observations, interview and record review, the facility failed to enforce Enhanced Barrier Residents Affected - Few Precautions (EBP) for 1 of 8 sampled residents (Resident 331) reviewed for infection control practices, to prevent residents' urinary catheter/foley (tube that goes into the bladder to drain urine) tubing or bags from touching the ground for 2 of 2 residents (Resident 331 &39) reviewed for urinary catheters, to ensure contact precautions were understood and followed outside of resident rooms for 2 of 2 sampled residents (Resident 39 & 131) reviewed, and to ensure staff complied with current infection control guidelines and standards of practice regarding proper hand hygiene/gloving practices for 1 of 1 sampled resident (Resident 22) reviewed for wound care. This failure placed residents at risk of infection, the spread of multidrug resistant organisms (MDROs), worsening of wounds, and a diminished quality of life.

Findings included .

<Enhanced Barrier Precautions>

Review of the facility policy, titled, Enhanced Barrier Precautions, dated with a review date of 06/03/2024, defined EBP as refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities. The policy defined high contact care activities as include dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, medical device care or use, and wound care.

Resident 331 was admitted to the facility on [DATE REDACTED]. Resident 331 had a urinary catheter/foley and was on EBP.

During an observation on 02/25/2025 at 12:11 PM, Staff J, Licensed Practical Nurse (LPN), entered Resident 331's room to give them their insulin dose. Staff J cleaned Resident 331's abdomen and injected them with insulin, without wearing a gown.

During an interview on 02/25/2025 at 1:12 PM, Staff J, LPN, said Resident 331's room was under EBP for a urinary catheter/foley.

During an observation on 02/28/2025 at 11:52 AM, Staff L, Certified Nursing Assistant (CNA), was observed to assist Resident 331 with moving, from sitting on the side of the bed to moving to their wheelchair. Staff L was not wearing a gown, put a gait belt on the resident, moved the resident's foley bag, touched the gait belt again, and then helped Resident 331 to stand and pivot to the wheelchair.

During an interview on 02/28/2025 at 12:29 PM, Staff L, CNA, said for EBP rooms they should wear gown and gloves for any patient contact, and that they had forgotten to wear a gown for assisting Resident 331.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 24 505210 Department of Health & Human Services Printed: 09/07/2025 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 505210 B. Wing 02/28/2025

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

Life Care Center of Port Orchard 2031 Pottery Avenue Port Orchard, WA 98366

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 interview on 02/28/2025 at 2:20 PM, Staff F, Infection Preventionist/Assistant Director of Nursing (IP/ADON), said EBP precautions were to be used for residents with urinary foleys, and staff should wear Level of Harm - Minimal harm or gown and gloves when providing care to residents. When informed of staff not using gowns in Resident potential for actual harm 331's room, Staff F said their expectation was for staff to have worn gowns when they were touching residents on EBP. Residents Affected - Few <Foley Bag Touching Ground>

Review of the Centers for Disease Control and Prevention's (CDC) document titled, Guideline for Prevention of Catheter-Associated Urinary Tract Infections, dated 06/06/2009, strongly recommended healthcare facilities do not rest the bag [foley bag] on the floor.

1) Resident 331 was admitted to the facility on [DATE REDACTED] and had a urinary catheter/foley.

During an observation on 02/23/2025 at 12:53 PM, Resident 331 was seen in their wheelchair with their foley bag touching the ground.

During observations on 02/26/2025 at 9:04 AM and 12:51 PM, Resident 331 was seen in their wheelchair with their foley tubing touching the ground.

During an observation on 02/28/2025 at 11:46 AM, Resident 331 was seen sitting on the edge of the bed, with their foley bag in a dignity cover, touching the ground.

During an observation on 02/28/2025 at 11:52 AM, Staff L, CNA, moved Resident 331 from the bed to their wheelchair, and moved the foley bag. The foley bag was in a dignity cover and was observed to touch the ground. Staff L left the room.

During an observation and interview on 02/28/2025 at 11:57 AM, Staff G, LPN, confirmed the foley bag was touching the ground and said it should not have been touching the ground.

During an interview on 02/28/2025 at 2:20 PM, when told of observations of Resident 331's foley bag touching the floor ,Staff F, IP/ADON said they would expect the foley bags to not touch the ground.

2) Resident 39 was admitted to the facility on [DATE REDACTED] and had a urinary catheter.

During an observation on 02/23/2025 at 11:29 AM, Resident 39 was seen in their wheelchair with their foley bag touching the ground.

During an observation on 02/25/2025 at 12:38 PM, Resident 39 was seen in their wheelchair with their foley bag touching ground.

During an observation on 02/26/2025 at 8:54 AM, Resident 39 was seen in their wheelchair with their foley bag in a dignity bag and touching ground.

During an observation on 02/26/2025 at 9:00 AM, Resident 39 was seen in their wheelchair being moved through the hallway with their foley bag in a dignity bag touching the ground, dragging on the floor.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 24 505210 Department of Health & Human Services Printed: 09/07/2025 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 505210 B. Wing 02/28/2025

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

Life Care Center of Port Orchard 2031 Pottery Avenue Port Orchard, WA 98366

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 interview on 02/27/2025 at 12:29 PM, Staff G, LPN, said residents with foley bags in a dignity bag should still not have it touch the ground when outside of room, for infection control purposes. When asked Level of Harm - Minimal harm or about the foley bag or tubing touching the ground, said no it should not. When asked about if any of those potential for actual harm parts should touch the ground when a resident in a wheelchair was being moved through the hall, said no.

Residents Affected - Few During an interview on 02/28/2025 at 2:20 PM, when told of the observation of Resident 39 seen in the hallway with their catheter bag dragging on the floor, Staff F, IP/ADON said their expectation was that the foley bag would be secured without touching the ground.

<Contact Precautions>

Review of the CDC document titled, Frequently Asked Questions (FAQs) about Enhanced Barrier Precautions in Nursing Homes, reviewed on 02/27/2025, had a section defining EBP as [ .] infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes. Enhanced Barrier Precautions involve gown and glove use during high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at risk for MDRO acquisition (e.g., residents with wounds or indwelling medical devices, and contact precautions as [ .] require the use of gown and gloves on every entry into a resident's room, regardless of the level of care being provided to the resident. It also explained that for contact precautions, Residents on Contact Precautions are recommended to be restricted to their rooms except for medically necessary care, including restriction from participation in group activities. Contact Precautions are generally intended to be time limited and, when implemented, should include a plan for discontinuation or de-escalation. The document also explained that contact precautions were recommended if the resident had acute diarrhea, draining wounds, or other sites of secretions or excretions, and that they were unable to be covered or contained.

1) Resident 39 was admitted to the facility on [DATE REDACTED]. The Admission Minimum Data Set (MDS -an assessment tool), dated 01/27/2025, showed that Resident 39 was cognitively intact.

Review of a provider note on 01/28/2025 showed Resident 39 had initial urine and blood culture positive for Extended-spectrum beta-lactamases (ESBL, an MDRO) and E.coli (bacteria). The note mentioned the second blood culture remained negative.

Review of the EHR showed a negative urine culture, collected on 02/08/2025.

Review of a progress note from 02/08/2025, showed the resident was on contact isolation for ESBL to the urine and also on EBP.

Review of the EHR, on 02/23/2025, showed Resident 39 was not on antibiotics for infection of the urine. Resident 39 was on antibiotics for pulmonary infiltrates (shown on imaging, can indicate infection of the lungs).

During an observation on 02/23/2025 at 11:18 AM, Resident 39 had signage outside of their room for both EBP and contact precautions.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 24 505210 Department of Health & Human Services Printed: 09/07/2025 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 505210 B. Wing 02/28/2025

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

Life Care Center of Port Orchard 2031 Pottery Avenue Port Orchard, WA 98366

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 interview on 02/27/2025 at 12:18 PM, when asked if Resident 39 had any restrictions outside of

the room for being on contact precautions, Staff M, CNA said no, they were allowed to come out of the room. Level of Harm - Minimal harm or Staff M said contact was only hands on. When questioned on the difference between EBP and contact, Staff potential for actual harm M said contact was when you were touching or hands on, and EBP was more hands off.

Residents Affected - Few During an interview on 02/27/2025 at 12:29 PM, when asked what precautions there were for Resident 39 for going outside of their room, Staff G, LPN said Resident 39 could go outside of their room.

During an interview on 02/28/2025 at 2:20 PM, when asked if the facility had time limits on contact precautions, Staff F, IP/ADON said usually it was done through the duration of the antibiotics, but for Resident 39 they had an MDRO, and there was no stop date for precautions because they had a catheter and intravenous line. Staff F added that Resident 39 had cellulitis that sometimes would weep, a urinary catheter/foley, and was being treated for pneumonia/cough. When asked what contact precautions were implemented outside of residents' room, Staff F, IP/ADON said, it depends. Staff F said if it could safely be contained, such as in a brief, then hand hygiene should be completed on the way out. Staff F said it depended on what the precaution was for related to the contact precautions, if they could safely leave the room. If they were contagious, then therapy should occur in the room.

During an interview on 02/28/2025 at 4:52 PM, Staff B, DNS, when asked what precautions they expect staff to implement outside of a resident's room while on contact precautions, said it depended on the concern, if a resident had c-difficile then if the resident wore a brief it would be contained and they could leave the room

after washing hands with soap and water. For wounds, Staff B said if covered, then the resident could leave

the room.

37044

2) Resident 131 admitted to the facility on [DATE REDACTED]. Review of the Admission MDS, dated [DATE REDACTED], showed the resident's diagnoses included cellulitis (a bacterial infection affecting the deeper layers of the skin), and venous stasis ulcer (open sore that occurs on the lower legs due to impaired blood flow caused by venous insufficiency) and required antibiotic medication.

During an observation on 02/23/2025 at 12:22 PM, an EBP sign was posted outside of Resident 131's door. Staff Q, LPN, explained it was due to the resident having a stasis ulcer to the right foot.

During an observation on 02/24/2025 at 11:27 AM, an EBP sign was still posted outside of Resident 131's door.

During an observation on 02/25/2025 at 11:14 AM, Resident 131 was noted to have both an EBP and contact precaution sign posted outside their door.

On 02/25/2025 at 11:27 AM, Staff F, IP/ADON, explained a contact precaution sign was added because a

record review showed Resident 131 had history of Methicillin-resistant Staphylococcus aureus (MRSA, an MDRO) wound infections.

During an observation on 02/27/2025 at 10:41 AM, Resident 131 was self-propelling in a wheelchair up and down the hallway using their lower extremities (LEs) navigating around other residents. Resident 131 was wearing shorts exposing their LE edema wraps.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 24 505210 Department of Health & Human Services Printed: 09/07/2025 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 505210 B. Wing 02/28/2025

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

Life Care Center of Port Orchard 2031 Pottery Avenue Port Orchard, WA 98366

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 interview on 02/27/2025 at 12:27 PM, when asked how staff knew what precaution (EBP or contact) should be followed when entering Resident 131's room, Staff P, RN, stated, They don't, they keep Level of Harm - Minimal harm or coming and asking me. Staff P then explained everybody needed to gown and glove prior to entering the potential for actual harm resident's room regardless of their reason for entering to prevent staff/visitors from getting bacteria on their clothing and potentially carrying it to another resident. When asked to clarify why everyone had to gown and Residents Affected - Few glove to enter Resident 131's room, but once the resident exited their room the precautions were no longer required, Staff P stated, it's confusing and indicated they had approached management with the same question and were told it was because the wound was covered. Staff P then said, wait that is EBP not contact precautions . before reiterating that it was confusing.

50392

<Wound Care>

According to CDC recommendations, hand hygiene should be performed immediately before touching a patient, after touching a patient or patient's surroundings, after contact with blood, body fluids, or contaminated surfaces, and before moving from a soiled body site to a clean body site on the same patient.

Review of the facility policy titled, Wound Care Resource Manual, reviewed 05/24/2024, documented that a resident with pressure ulcers would receive necessary treatment and services consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing.

Resident 22 admitted to the facility on [DATE REDACTED]. The Significant Change MDS, dated [DATE REDACTED], documented Resident 22 had one stage 4 pressure ulcer (injury to skin and underlying tissue resulting from prolonged pressure on the skin). Resident 22 had physicians' orders for wound care every day shift and as needed.

During an observation of wound care on 02/26/2025 at 1:55 PM, Staff E, LPN/ Resident Care Manager (RCM), was observed performing hand hygiene and putting on gloves. Staff E then assisted Resident 22 with both gloved hands onto their side (contaminating gloves) and proceeded to provide wound care. Once wound care was completed, Staff E with same gloves that were used for wound care (contaminated gloves) reapplied Resident 22's brief tab, assisted them to their backside position by touching their body, and adjusted Resident 22's clothing.

On 02/26/2025 at 2:24 PM, Staff E, LPN/RCM, when discussing above observations said staff should have changed gloves and performed hand hygiene after assisting the resident to their side and prior to performing wound care, Staff E said, I knew I should have done it. When asked if hand hygiene and glove change should have been done after wound care, Staff E nodded in agreement.

On 02/28/2025 at 1:08 PM, Staff F, IP/ADON, when made aware of the wound care observations for Resident 22, Staff F said she would expect, when ready to perform wound care, staff would only touch the wound and after wound care was completed then gloves would be changed and hand hygiene would be performed before additional care was provided.

Reference WAC 388-97-1320 (1)(c),-1320 (2)(b)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 24 505210

F-F760 Residents Affected - Few Reference WAC 388-97-1620(2)(b)(i)(ii),(6)(b)(i)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 24 505210 Department of Health & Human Services Printed: 09/07/2025 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 505210 B. Wing 02/28/2025

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

Life Care Center of Port Orchard 2031 Pottery Avenue Port Orchard, WA 98366

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 Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 50945 potential for actual harm Based on interview and record review, the facility failed to implement or document on the bowel protocol Residents Affected - Few (how the facility intervenes to a resident with no bowel movement over a certain amount of time) for 2 of 3 sampled residents (Residents 59 & 1) reviewed for constipation. This failure placed residents at risk for unidentified care needs, discomfort, lack of monitoring, and a diminished quality of life.

Findings included .

Review of the facility policy titled, LCC [Life Care Center] Port Orchard Bowel Protocol, undated, showed the following order of medications to be given:

1. Milk of Magnesia (helps stimulate a bowel movement) to be given after 72 hours/on day four of no bowel movement

2. Bisacodyl (helps stimulate a bowel movement) to be given after no bowel movement on day five

3. Fleet Enema (helps stimulate a bowel movement) to be given after no bowel movement on day six

1) Resident 59 was admitted to the facility on [DATE REDACTED] with a diagnosis of constipation. The Admission Minimum Data Set Assessment (MDS), dated [DATE REDACTED], showed Resident 59 had severe cognitive impairment.

Review of Resident 59's orders showed three medications ordered for no bowel movement:

1. Milk of Magnesia (for day four of no bowel movement)

2. Bisacodyl (for day five of no bowel movement)

3. Fleet Enema (for day six of no bowel movement)

Review of Resident 59's bowel record, from 01/28/2025 to 02/25/2025, showed that they did not have a bowel movement recorded from 02/05/2025 to 02/11/2025 (seven days).

Review of the Electronic Health Record (EHR) showed no documentation of interventions for bowel protocol/orders from 02/05/2025 to 02/11/2025.

During an interview on 02/27/2025 at 4:40 PM, Staff C, Resident Care Manager (RCM), confirmed that Resident 59 did not have a bowel movement from 02/05/2025 to 02/11/2025. Staff C said staff should have documented that Resident 59 had refused the bowel protocol and have documented that they did a bowel assessment.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 24 505210 Department of Health & Human Services Printed: 09/07/2025 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 505210 B. Wing 02/28/2025

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

Life Care Center of Port Orchard 2031 Pottery Avenue Port Orchard, WA 98366

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 During an interview on 02/28/2025 at 12:55 PM, Staff B, Director of Nursing Services, said their expectations was for staff to follow bowel protocol and do bowel assessments if there was a refusal, and they had Level of Harm - Minimal harm or requested staff write a progress note or document the refusal on the Medication Administration Record potential for actual harm (MAR).

Residents Affected - Few 37044

2) Resident 1 admitted to the facility on [DATE REDACTED]. Review of the Admission MDS, dated [DATE REDACTED], showed the resident was cognitively intact and was assessed to be constipated during the assessment period.

On 02/24/2025 at 9:54 AM, Resident 1 complained of constipation due to not getting up and moving around enough.

Resident 1 had the following as needed bowel management orders dated 02/07/2025:

1. Milk of Magnesia (If no bowel movement for three days, administer on day four.)

2. Bisacodyl (for day five of no bowel movement)

3. Fleet Enema (for day six of no bowel movement)

Review of the bowel record showed Resident 1 had no documented bowel movements from 02/07/2025 - 02/10/2025 (four days).

The February 2025 MAR showed facility nurses did not offer/administer Resident 1 any as needed bowel medications.

On 02/28/2025 at 10:36 AM, Staff C, RCM, said facility nurses failed to administer Resident 1's as needed Milk of Magnesia on 02/10/2025 (the fourth day without a bowel movement) as ordered.

Reference WAC 388-97-1060(1)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 24 505210 Department of Health & Human Services Printed: 09/07/2025 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 505210 B. Wing 02/28/2025

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

Life Care Center of Port Orchard 2031 Pottery Avenue Port Orchard, WA 98366

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 Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 50945 potential for actual harm Based on observation, interview and record review, the facility failed to appropriately monitor pressure ulcers Residents Affected - Few in a manner consistent with professional standards of practice for 2 of 5 sampled residents (Residents 59 and 44) reviewed for pressure ulcers. This failure placed residents at risk of worsening conditions, unnecessary treatment, pain, and a diminished quality of life.

Findings included .

Review of the facility's policy titled, Documentation & Assessment of Wounds, dated with a review date of 07/09/2024, showed the Overall Wound Impression is documented based on the clinical impression of the overall wound bed, peri wound, and wound healing outcome as expected wound decline/worsening may not be acknowledged by just and increase in wound measurement [ .].

1) Resident 59 was admitted to the facility on [DATE REDACTED] and had diagnoses of chronic venous insufficiency (a disease that damages leg veins, can cause blood to pool in legs), malnutrition, and unstageable pressure ulcer of the left heel. Review of the Admission MDS, dated [DATE REDACTED], showed Resident 59 had severe cognitive impairment.

Review of the Electronic Health Record (EHR) showed Resident 59's skin assessments were as follows:

- On 01/21/2025, on the Admission Assessment, it was documented that Resident 59 had a left heel 1x1 scab inside a 2x2 red non-blanchable area.

- On 01/21/2025, a braden scale (assessment that determines risk of a pressure ulcer) was done that selected that the resident had an existing pressure ulcer. Under the section that asked for location of blanchable redness, it said sacrum//left heel around scab. This assessment tool did not provide measurements or staging.

- On 01/28/2025, it was documented Resident 59 had left heel 2 scabbed area, new order for skin prep - no measurement or staging were done (Such as: Stage I, Stage II, Stage III, Stage IV, deep tissue injury, unstageable)

- On 02/04/2025, it was documented Resident 59 had left heel 2 scabbed area, new order for skin prep - no measurement or staging were done.

- On 02/11/2025, it was documented Resident 59 had left heel 2 scabbed area, new order for skin prep- no measurement or staging done.

- On 02/19/2025, there was no note of skin issue to the heels, only that heels floated.

- On 02/21/2025, a provider progress note showed, She is complaining of pain to left heel and she is found to have a pressure ulcer and RN and DON [Director of Nursing Services] notified. A diagnosis was added to Resident 59's EHR, of an unstageable pressure ulcer.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 24 505210 Department of Health & Human Services Printed: 09/07/2025 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 505210 B. Wing 02/28/2025

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

Life Care Center of Port Orchard 2031 Pottery Avenue Port Orchard, WA 98366

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 - On 02/21/2025, no skin assessment of the left heel by nursing was documented.

Level of Harm - Minimal harm or Review of Resident 59's orders showed an order for skin prep (a topical skin protection), initiated 01/28/2025 potential for actual harm to be applied twice a day.

Residents Affected - Few On 02/21/2025, an additional order was placed for skin prep application and off-loading of the heel with monitoring for every shift.

During an interview and observation on 02/27/2025 at 10:41 AM, when asked what was involved in a skin assessment, Staff O, Registered Nurse, said they looked at all of the resident's kin to assess for breakdown. For Resident 59, after looking in the EHR, Staff O said for Resident 59 they had responded about a different skin issue, and that the document they were looking at said the heels were floated, Probably redness to heels, I saw something before. During observation of Resident 59's left heel with Staff O, Resident 59 was observed with the scab on their left heel, flakey skin to the right side of the foot that was peeling off, and there was generalized redness to the heel.

During an interview on 02/27/2025 at 11:13 AM, Staff C, Resident Care Manager (RCM), when asked what their expectation was for documentation related to pressure ulcers, said they expected staff to document weekly, if there were signs or symptoms of infection, and if there was any changes in status. Staff C said if

the wound care team was following the pressure ulcer, then weekly measurements were done. For Resident 59, Staff C said they were not being followed by the wound care team and there were not weekly measurements or staging. Regarding the 02/21/2025 provider note, Staff C said their expectation was for the licensed nurse to have put risk management in the EHR, to have written a progress note, to have filled out a braden scale, to have filled out a pain assessment, to have done a pain assessment, and to have notified family.

During an interview on 02/28/2025 at 12:55 PM, Staff B, Director of Nursing Services (DNS), said for pressure ulcers, measurements were usually done in the wound observation tool, not all nurses knew how to stage a wound, and if the wound care team was not following the pressure ulcer, then it might not have been measured. When asked about Resident 59, Staff B said on admission the scabbed skin had come off and

the heel was blanching, but this was not documented. Regarding the 02/21/2025 provider note, Staff B said

the nurse who was notified by the provider should have notified risk management. Staff B said they did not have documentation of weekly measurements or wound assessment to include wound bed tissue type, any drainage, or response to treatment, for Resident 59 and that they should have had.

2) Resident 44 was admitted to the facility on [DATE REDACTED]. The Admission MDS, dated [DATE REDACTED], showed Resident 44 was moderately cognitively impaired and at risk for a pressure ulcer.

Review of the EHR showed Resident 44 acquired a pressure ulcer on 02/07/2025 on their left ear from their nasal cannula straps (from oxygen administration).

Review of Resident 44's orders showed an order for skin prep three times a day until resolved, initiated on 02/07/2025.

Review of Resident 44's skin assessments/wound observations showed:

On 02/07/2025: Stage 2 acquired pressure ulcer with measurements of 0.5 x0.5 x0.1 cm

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 24 505210 Department of Health & Human Services Printed: 09/07/2025 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 505210 B. Wing 02/28/2025

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

Life Care Center of Port Orchard 2031 Pottery Avenue Port Orchard, WA 98366

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 On 02/10/2025: No wound listed

Level of Harm - Minimal harm or On 02/19/2025: No wound listed potential for actual harm

Review of a progress note from 02/13/2024, showed pressure area noted on top of resident's left ear from Residents Affected - Few oxygen tubing. New order to apply skin prep to area BID [twice a day] until resolved. Placed new order to ensure padding is around oxygen tubing Q [every] shift for protection. Will continue to monitor.

Review of Resident 44's orders showed an additional skin prep order was added on 02/13/2025, but the previous skin prep was never discontinued.

Review of Resident 44's Medication Administration Record showed that Resident 44 had skin prep signed off five times a day, with documentation on multiple occasions within an hour of the previous administration. For example, on 02/20/2025 at 9:36 PM and 10 PM (24 minutes apart), and 02/22/2025 at 9:43 PM and 10:00 PM (17 minutes apart). Although the order was for their left ear, staff on multiple occasions signed off administration of skin prep on both ears.

Review of a progress note from 02/20/2024 showed Resident 44 did not have oxygen or a nasal cannula on.

Observation on 02/23/2025 at 1:47 PM, showed Resident 44 was not on oxygen and was not using a nasal cannula.

During an interview on 02/25/2025 at 12:24 PM, Resident 44 said they had not had skin prep for a couple days and was able to correctly identify where staff had been putting skin prep on them.

During an observation on 02/25/2025 at 12:28 PM, Staff J, Licensed Practical Nurse (LPN), entered Resident 44's room to apply skin prep. Resident 44 stated, There's nothing on my ear. Staff J said they could see a little bit of pinkness, and the pressure ulcer was mostly resolved. Staff J said they remembered seeing the pressure ulcer the previous week.

During an interview on 02/27/2025 at 9:19 AM, Staff G, LPN, when asked what was included in a weekly skin assessment, said, head to toe, top to bottom, all of the resident's skin. When asked about one of the skin assessments they had filled out, Staff G said the pressure ulcer should have been on their documented assessment and was not. Staff G said they remembered seeing the pressure ulcer on Resident 44 on 02/24/2025.

During an interview on 02/27/2025 at 10:22 AM, Staff I, RCM, when asked about the additional order for skin prep, said their understanding was that Resident 44's pressure ulcer was improving/resolving, that they only needed skin prep twice a day, and that the old order should have been discontinued. Staff I said their expectation for skin assessments was that they should have mentioned the pressure ulcer until resolved, and then still monitored for three weeks after resolution. Staff I confirmed the skin prep orders listed the left ear for location, and said the administration record should not show bilateral ears as being charted.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 24 505210 Department of Health & Human Services Printed: 09/07/2025 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 505210 B. Wing 02/28/2025

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

Life Care Center of Port Orchard 2031 Pottery Avenue Port Orchard, WA 98366

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 During an interview on 02/28/2025 at 12:55 PM, Staff B, DNS, when asked if residents not followed by wound care were still getting measurements of their wounds, said that for residents not followed by wound Level of Harm - Minimal harm or team, if nursing did not obtain a measurement, then yes it would not have been done. When asked about potential for actual harm Resident 44, Staff B said it did not meet expectations that they did not mention the pressure ulcer, and if staff did not see it then they should have documented it was resolved. When asked about the two separate skin Residents Affected - Few prep orders, said it did not meet expectations.

Reference