Providence Mount St Vincent

F-F610.

REFERENCE: WAC 388-97-0640(5)(a).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 12 505182 Department of Health & Human Services Printed: 09/11/2025 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 505182 B. Wing 01/10/2025

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

Providence Mount St Vincent 4831 35th Avenue Southwest Seattle, WA 98126

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 0610 Respond appropriately to all alleged violations.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 42203 potential for actual harm Based on interview and record review, the facility failed to thoroughly investigate reportable incidents for 2 of Residents Affected - Some 5 sample residents (Residents 110 & 95) reviewed for abuse, and one supplemental resident (Resident 124).

The failure to thoroughly investigate allegation of abuse placed residents at risk of verbal and mental abuse, psychosocial harm, and diminished quality of life.

Findings included .

<Facility Policy>

The facility's Abuse Prohibition and Prevention policy dated 01/2024, defined sexual abuse as non-consensual sexual contact of any kind. The policy showed when a resident made an allegation of suspected or alleged abuse, a thorough investigation would be completed. The policy showed a thorough investigation would include interviews with any witnesses and document details of the alleged event. The policy showed the facility would document the details of the occurrence in the record of all affected residents, including immediate interventions.

<Resident 110>

According to the Admission Minimum Data Set (MDS - an assessment tool) dated 11/14/2024, Resident 110 had intact memory and experienced social isolation on rare occasions. The assessment showed Resident 110 required partial to moderate assistance with transferring from a chair to a bed and supervision/touching assistance for moving in bed. The MDS showed Resident 110 had a fractured right hip.

In an interview on 01/02/2025 at 9:41 AM, Resident 110 was asked if they had any concerns with their care at the facility. Resident 110 immediately directed the conversation to a specific incident that occurred before Christmas the prior month (10 days prior). Resident 110 stated a facility caregiver kissed them and tried to climb into their bed.

Review of the facility's investigation into this allegation showed the incident was reported to the facility on [DATE REDACTED] and took place on 12/24/2024. The investigation substantiated Resident 110's allegation that they were touched inappropriately by Staff I (Certified Nursing Assistant) who was immediately dismissed. The investigation included Staff I's CNA credentials but did not include a background check to show if Staff I had any disqualifying history that should have prevented them from working at the facility. The investigation showed Staff B (Director of Nursing) interviewed Staff I via telephone and included a statement from Staff D (Social Services Director). The investigation did not include any interviews with any other potential witnesses or victims, neither facility staff nor residents. The investigation did not show if Staff I had worked on any other units and did not include a screening of other potentially affected residents. The investigation showed it was completed by Staff T (Unit Manager, Registered Nurse) who worked at a sister facility but was acting as interim unit manager, and signed off by Staff B.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 12 505182 Department of Health & Human Services Printed: 09/11/2025 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 505182 B. Wing 01/10/2025

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

Providence Mount St Vincent 4831 35th Avenue Southwest Seattle, WA 98126

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 0610 In an interview at 01/08/2025 at 3:12 PM with Staff B, Staff F (Director of Clinical Operations), and Staff A (Administrator), Staff F stated they provided the copy of the investigation to Staff A to give to surveyors. Staff Level of Harm - Minimal harm or F stated Staff T did the investigation on site and Staff F retrieved the investigation from a digital folder and potential for actual harm provided all the investigative materials available. Staff A stated they would verify if any witness/potential victim interviews were completed but believed Staff D (Social Services Director) did so and provided Residents Affected - Some whatever documentation they could locate. Staff A stated they did not know if other staff were interviewed as potential witnesses. Staff A stated they would verify what assignments Staff I received when they worked at

the facility. Staff A stated they would locate Staff I's background check.

On 01/08/2025 at 3:29 PM Staff A called Staff T who stated they spoke with the nurse on duty on the unit, and Staff D, but no CNAs. Staff D stated they wrote a progress note to document they interviewed the residents with intact memories on Resident 110's unit (300 North).

On 01/09/2025 at 10:29 AM Staff A provided documentation of Staff I's assignments. This documentation showed between 10/23/2024 through 12/27/2024 Staff I worked on seven of the facility's nine units. Staff A provided a printout of the email showing Staff D attempted to interview five residents, all on the 300 North unit. Of those five residents, Staff D documented two residents were unable to be interviewed, one of which was due to the resident's advanced dementia. Staff A also provided Staff I's background inquiry and stated

they reached out to Staff I's staffing agency to obtain the background information. Staff A stated residents on

the six other units should have been, but were not, interviewed to determine if they were witness to, or negatively impacted by Staff I's conduct. Staff A stated the background inquiry, unit assignments, and resident interviews should have been included in the investigation.

<Resident 95>

According to the 11/06/2024 Quarterly MDS, Resident 95 had intact memory and impaired vision. The MDS showed Resident 95 had no delusions or hallucinations and exhibited no behavioral symptoms. The MDS showed Resident 95 used a cane and a walker to assist their ambulation. The MDS showed Resident 95 had no falls since the prior assessment.

In an interview on 01/02/2025 at 9:28 AM Resident 95 described that on Christmas Eve, 2024 at dinner time

they intervened when a resident threw a hot beverage at Resident 124. Resident 95 stated they slipped on

the spilled beverage, fell and banged their head on the edge of a table. Resident 95 stated they experienced no negative outcomes from the fall and head bump. Resident 95 was unsure of the exact name of the resident who threw the beverage but could provide identifying details.

According to a 12/24/2024 progress note Resident 95 had an unwitnessed fall on 12/2024 after slipping and bumping their head.

Review of the facility's December 2024 Incident Log showed a 12/24/2024 entry for Resident 95 that indicated the resident had a fall. There was nothing logged showing a resident-to-resident interaction occurred.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 12 505182 Department of Health & Human Services Printed: 09/11/2025 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 505182 B. Wing 01/10/2025

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

Providence Mount St Vincent 4831 35th Avenue Southwest Seattle, WA 98126

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 0610 Review of the facility's investigation into the 12/24/2024 incident showed the incident occurred at 4:30 PM and was categorized as a non-injury fall. The investigation showed Staff U (Long Term Care Registered Level of Harm - Minimal harm or Nurse) found Resident 95 on the dining room floor near the television. The investigation showed Resident 95 potential for actual harm stated they tripped on themselves and bumped their head. The investigation included no witness interviews from other staff or residents. The investigation was completed by Staff T but was not signed by either Staff T Residents Affected - Some or Staff B.

In an interview on 01/09/2025 at 10:57 AM Resident 124 corroborated Resident 95's recollection of the incident. Resident 124 stated a resident threw a hot beverage at them after they sat in the resident's favorite chair, and Resident 95 slipped on the spilled drink while trying to intervene. Resident 124 stated Staff U was

the nurse on duty at the time. Resident 124 stated Staff U patted them on the head and told them to avoid

the resident.

In an interview on 01/09/2025 at 11:07 AM Resident 95 stated Staff U was working that shift, but their head was turned away, but came to assist the resident within a minute. Resident 95 stated a dietary aide or CNA was also present but could not recall whom as they were shaken up in that moment. Resident 95 stated they did not recall facility staff interviewing them as to what happened. Resident 95 reaffirmed they slipped and did not trip. Resident 95 expressed frustration that the facility's characterization of the incident could negatively impact their independence, which was important to them.

In an interview with Staff A and Staff B on 01/10/2025 at 10:45 AM Staff A stated the investigation did not but should have included statements from potential witnesses. Staff A stated the dining room where the incident occurred was typically occupied throughout the day. Staff B stated that Resident 95 gave a very different description of what happened when originally interviewed, and there was no way to prove what happened. Staff B was unsure why Resident 95 changed their story. When asked if there would be clearer understanding of what happened if other residents and staff were interviewed, Staff B said witness interviews would be helpful to determine what happened. Staff B stated that in their role as Director of Nursing, they were ultimately responsible for ensuring investigations were thorough.

<Resident 124>

According to the 01/04/2024 Quarterly MDS, Resident 124 had adequate speech and vision and moderate memory impairment. The MDS showed Resident 124 exhibited no behavioral symptoms and did not experience hallucinations or delusions.

In an interview on 01/03/2025 at 12:37 PM Resident 124 reported to a surveyor that in the morning of the prior day (01/02/2024) in the 300 North dining room they backed their wheelchair into someone who cussed at them loudly and walked away. Resident 124 stated Staff U witnessed the incident, patted them on the head and told them to calm down. The allegation was immediately reported to Staff A who stated the facility would investigate the incident and provide the investigation once complete.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 12 505182 Department of Health & Human Services Printed: 09/11/2025 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 505182 B. Wing 01/10/2025

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

Providence Mount St Vincent 4831 35th Avenue Southwest Seattle, WA 98126

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 0610 Review of the 01/02/2025 investigation showed Resident 124 backed their wheelchair into another resident

on the unit who blurted a common expletive. The investigation showed Staff B interviewed Staff U via Level of Harm - Minimal harm or telephone. Staff U stated to Staff A who stated the incident occurred when the second resident was trying to potential for actual harm pass behind Resident 124. Staff U denied any physical contact between the two residents. Staff B also called Staff BB (RN) who interviewed the other resident. The investigation did not indicate Staff BB was present at Residents Affected - Some the time. The investigation included a statement from Staff D who interviewed Resident 124 who stated the other resident bumped into them and cussed at them. Staff D's statement showed Resident 124 informed them Staff T comforted them and patted them on the shoulder rather than their head. Staff D stated they interviewed the other resident who could not recall the incident. The investigation ruled out abuse as the incident was witnessed and Resident 124 made differing statements. The investigation did not include witness statements from other staff or residents in the area at the time who may have been able to confirm or refute Resident 124's experience of the incident. The investigation showed it was completed by Staff F, Staff B, Staff A, and Staff T. No staff signed off on the investigation as complete.

In an interview with Staff A and Staff B on 01/10/2025 at 10:45 AM Staff A stated the investigation should have included witness statements from other potential staff and resident witnesses.

REFERENCE: WAC 388-97-0640 (6)(a)(b).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 12 505182