Health Inspection - PROVIDENCE MOUNT ST VINCENT

F-Tag F550

Harm Level: Minimal harm or locked, compartments for controlled drugs.

Residents Affected: Few

F-F550 Resident Rights

Refer to F 600 Free from Abuse and Neglect

Refer to F 880 Infection Prevention and Control

REFERENCE: WAC 388-97-1080(1).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 49 of 61 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 0761 Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately Level of Harm - Minimal harm or locked, compartments for controlled drugs. potential for actual harm 42203 Residents Affected - Few Based on observation, interview, and record review the facility failed to ensure medications and biologicals were secured for 1 of 7 units (300 S/Resident 89), and expired medications and biologicals were disposed of for 1 of 6 medication carts (5 South Medication Cart 1), and 4 of 4 medication rooms (5 North, 5 South, 4 South, and 3 South) reviewed for medication storage and labeling. These failures to ensure medication rooms and carts were secured and free from expired medications and ensure medications were not left unattended in common areas placed residents at risk for receiving the wrong medications, expired medications, and other negative health outcomes.

Findings included .

According to the 06/2022 revised Medication Storage and Disposal facility policy, facility would provide proper disposal of medications.

<300 South/Resident 89>

According to the 11/05/2024 Quarterly Minimum Data Set (MDS - an assessment tool) Resident 89 was assessed with severely impaired memory. The MDS showed Resident 89 had a chronic respiratory disease.

Observation on 01/02/2025 at 11:24 AM in the 300 South dining room showed three residents seated at a table. One resident pointed at a respiratory inhaler placed on the table, pointed at Resident 89, and stated that's her medicine. The inhaler was not in a box or labeled in anyway. At 11:34 AM a nurse's aide served water to the residents at the table and did not identify the unsecured inhaler

On 01/02/2025 at 11:54 AM Staff QQ (License Practical Nurse - LPN) appeared on the unit. Staff QQ stated

they were the nurse on duty, and just returned from a break. Staff QQ stated they gave Resident 89 the inhaler. Staff QQ stated they did not know if Resident 89 had intact memory or was assessed to able to administer their own medications prior to giving it to them. Staff QQ stated they should have but did not verify if Resident 89 was able to administer their inhaler before leaving it with the resident unsupervised. Staff QQ stated it was their first day working that unit.

47836

<5 North Medication Room>

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 50 of 61 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 0761 Observation on 01/06/2025 at 1:54 PM showed four urinary catheter kits expired on 09/28/2024, a sputum sample kit expired 10/2024, three wound dressings expired 10/31/2023, a specimen collection kit expired Level of Harm - Minimal harm or 01/31/2021, an injectable medication expired 12/30/2024, a QFT (brand name) specimen kit expired potential for actual harm 09/30/2024, a bottle of hemoccult developer and hemoccult sensa developer with the expiration dates illegible/worn off, and a gallon bottle of antibacterial and antimicrobial skin cleanser solution expired on Residents Affected - Few 07/2023.

In an interview on 01/06/2025 at 2:00 PM Staff RR (Registered Nurse - RN) stated the expired medications and supplies should have been disposed of upon expiration.

In an interview on 01/09/2025 at 10:01 AM Staff B (Director of Nursing) stated they expected staff to monitor expiration dates, dispose of all expired medications and supplies immediately, and reorder as needed. Staff B stated it was important to dispose of expired medications and supplies to ensure they were viable for the residents.

45941

<5 South Medication Cart 1>

Observation on 01/06/2025 at 1:50 PM showed one bottle of over-the-counter medication was expired on 11/2024.

<5 South Medication Room>

Observation on 01/06/2025 at 1:57 PM showed Intravenous (IV- needle inserted into a vein to give drug or fluid) start kit was expired on 11/06/2024, safety Huber needle (a special needle used to administer medications in ports) set expired on 09/30/2021, suction Yanker (tube to suction fluids from the body) expired on 09/28/2024, and four subcutaneous starter kits expired on 05/01/2023.

In an interview on 01/06/2025 at 2:07 PM, Staff R Stated they checked the medication cart periodically but missed the opportunity to remove the expired medication from the medication cart. Staff R stated they should check the IV supply in the medication room and should remove the expired ones, but they did not.

In an interview on 01/09/2025 at 12:20 PM, Staff B stated nurses should check the med carts and med rooms and dispose of the expired medications.

50511

<4 South Medication Room>

Observation on 01/07/2025 at 08:40 AM observed one immunization vaccine vial labeled with an expiration date of 12/18/2023 and three bottles of ostomy care powder with an expiration date on the bottle of 10/5/2024.

In an interview on 01/07/2025 at 8:46 AM Staff Z (LPN) stated the expired vaccine and ostomy supplies should not have been in the medication room as it could cause harm to a resident and would not be as effective.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 51 of 61 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 0761 <3 South Medication Room>

Level of Harm - Minimal harm or Observation on 01/10/2025 at 12:15 PM observed one bag full of unused nebulizer ampules with an potential for actual harm expiration date on the bag of 09/05/2024 and one bottle of a liquid laxative with an expiration date of 07/24/2024. Residents Affected - Few

In an interview on 01/10/2025 at 12:15 PM Staff ZZ (RN) confirmed expired medications and stated they should not be in the medication room and should be disposed of immediately.

In an interview on 01/10/2025 at 10:31 AM Staff K (Manager Long Term Care Registered Nurse) stated all nurses were responsible for checking medication storage for expired medication, this did not happen but should have.

REFERENCE: WAC 388-97-1300(2).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 52 of 61 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 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 42203

Residents Affected - Many Based on observation, interview, and record review the facility failed to ensure food and drinks served to residents were prepared and distributed under sanitary conditions for 1 of 1 facility kitchens, and 2 of 6 unit kitchenettes. The failure to maintain kitchen equipment in a sanitary manner, complete Hand Hygiene (HH - washing or sanitizing hands) as required, sanitize kitchen thermometers appropriately, and ensure Certified Nursing Assistant's (CNA's) hair was secured when preparing meals in unit kitchenettes placed residents at risk for contaminated/spoiled food, foodborne illness, and other negative health outcomes.

Findings included .

According to the facility's 04/2023 Neighborhood Food Service policy, staff must wash their hands prior to food preparation. The policy showed hair must be restrained.

Observation on 01/02/2025 of the facility's main kitchen from 8:45 AM through 8:50 AM showed: an uncovered meat slicer with nothing preventing dust or other contaminants from building up on its surfaces; a stand mixer bowl not in use, right side up on a shelf next to the mixer on with nothing preventing dust or other contaminants from building up inside; two food processor bases with a substantial amount of dried-up food splatter of different colors and consistencies; the counter-mounted can opener had a dried buildup of food on the blade.

In an interview at that time Staff GG (Dining Service Supervisor) stated they expected kitchen equipment including mixers, meat slicers and grinders, and food processors to be maintained in a manner that prevented unnecessary exposure to dust and contaminants. Staff GG stated the can opener should have been cleaned after use.

Observation of lunch preparation in the facility's main kitchen on 01/08/2025 at 10:40 AM showed Staff VV (Cook) frying shrimp in a deep fryer with disposable gloves on. Staff VV removed their gloves to answer the phone. Without washing their hands, Staff VV put on a new pair of gloves and returned to frying shrimp. At 10:48 AM Staff VV emptied the fry basket into three stainless steel pans with aluminum foil wearing the same gloves they put on without HH after answering the phone. At 10:58 AM Staff VV removed the pair of gloves and put on a new pair. Staff VV did not wash their hands before replacing the gloves. At 11:13 AM an unidentified cook was observed to smooth the outside of their surgical mask, then without washing their hands flipped some sauteing chicken, opened the freezer by the handle and retrieving a package of shrimp, handled two fryer baskets, fetched another shrimp package, and placed shrimp in the two fryer baskets, and pressed the empty shrimp containers in the garbage can before washing their hands at 11:16 AM.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 53 of 61 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 0812 <4th Floor North>

Level of Harm - Minimal harm or Observations of meal services on the 4th floor North Unit on 01/02/2025 at 12:10 PM, showed Staff MM potential for actual harm (Nutrition Attendant) wearing a hairnet that only covered the top half of their hair, the lower half of their hair was loose and uncovered. Staff MM had uncovered steam table pans containing dishes they were preparing Residents Affected - Many to check the temperatures of prior to meal service. Staff MM placed their thermometer probe into a pan of shrimp and then wiped the probe with a paper towel. Staff MM then put the thermometer probe into a second pan and then wiped the probe with a paper towel. Next, Staff MM put the same probe, without sanitization, into a pan of carrots. Staff MM then checked the temperatures of mashed potatoes, gravy, pureed carrots, ground meat, and pureed chicken stew while only wiping the thermometer probe with a paper towel, rather than sanitizing with an alcohol swab.

On 01/08/2025 at 12:29 PM, during meal services, Staff MM was observed using a thermometer to check the food temperatures prior to meal service. Staff MM sanitized the thermometer probe prior to starting, then proceeded to check the couscous (a type of pasta), beets, and cabbage while only using a paper towel to wipe the probe, Staff MM then checked the temperature of the shrimp and wiped the probe with a paper towel. Staff XX (Supervisor - Food Services) approached Staff MM, gave them a sanitizer wipe, and encouraged them to use it between dishes. Staff XX then left the area. Staff MM used the sanitizer wipe once, then proceeded to check the black bean soup, mashed potato, minced, and pureed food product temperatures, using a paper towel to wipe the probe between the bins instead of swabs.

In an interview on 01/09/2025 at 12:55 PM Staff GG stated they expected dietary staff to disinfect thermometers with alcohol swabs when taking temperatures of different dishes prior to serving food.

<4th Floor South>

Observations on 01/02/2025 PM at 12:03 PM showed Staff CC (CNA) and Staff DD (CNA) were serving food onto lunch plates. Staff DD did not have a hairnet or other means to secure their hair. At 12:05 PM Staff CC delivered a tray to a resident's room, then returned to serving food from the steam table without washing their hands or putting on gloves. At 12:06 PM Staff DD served dessert from the steam table without a means to secure their hair. At 12:09 PM Staff CC returned from delivering a tray from a designated Enhanced Barrier Precaution (EBP) room and returned to serving lunches without washing their hands. At 12:13 PM Staff CC delivered a tray to room [ROOM NUMBER]. A housekeeping cart was blocking the doorway and Staff CC moved the housekeeping cart with a bare hand and delivered the tray to the room. Staff CC returned from room [ROOM NUMBER] and did not wash hands before pouring coffee for another resident.

In an interview on 01/02/2025 at 12:31 PM Staff GG stated the facility followed the food code for hand hygiene. Staff GG stated staff should wash their hands before, after, during and throughout a meal service.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 54 of 61 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 0812 Observation of the 400 South dining room on 01/08/2025 at 12:10 PM showed Staff EE (CNA) serving lunch to residents. With gloved hands, Staff EE touched a table where a resident sat then served a plate without Level of Harm - Minimal harm or changing gloves or doing HH. Staff EE then brought some cocktail sauce to a resident, and an iced tea to a potential for actual harm different resident, all with the same gloves on. At 12:15 PM Staff EE now with bare hands, entered room [ROOM NUMBER] which had a sign outside indicating a resident in the room was on Enhanced Barrier Residents Affected - Many Precautions, which required staff to don gloves and a gown if there was any resident contact. Without donning gown and gloves, Staff EE fully entered the room with the door ajar, discussed food choices with the resident before leaving at 12:18 PM. Upon leaving the room without performing HH, Staff EE touched the door, donned gloves and began preparing more plates. AT 12:19 PM, Staff EE placed straws in three drink and placed two trays on a cart, still with no HH. At 12:21 PM Staff EE with the assistance of a second CNA repositioned a resident and then performed HH.

In an interview on 01/09/2025 at 12:55 PM Staff GG stated they expected all staff assisting with meal service

in unit dining rooms to perform HH when required, including after answering the phone in the main kitchen. Staff GG stated they expected CNAs to restrain their hair if serving food from a steam table in a unit dining room.

REFERENCE WAC 388-97-1100 (3).

43642

50511

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 55 of 61 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 0842 Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Level of Harm - Minimal harm or potential for actual harm 47836

Residents Affected - Few Based on observation and interview the facility failed to keep all protected health information in the residents' records confidential and out of view from unauthorized individuals on 1 of 7 (5 North) units reviewed. This failure placed all former and current residents at risk for a violation of their right to privacy.

Findings included .

Review of the 08/2017 Facility Admission Agreement showed residents had a right to secure and confidential personal and medical records.

<5 North>

Observation and interview on 01/06/2025 at 8:52 AM showed a paper copy of an interdisciplinary team progress note in the grievance file folder on the wall by the elevator on the fifth floor. Staff E (Resident Care Manager) stated the paper copy of the progress note should not be in the grievance wall folder as anyone had access to that file folder. Staff E stated it was important to maintain resident record confidentiality for resident rights.

Observation and interview on 01/06/2025 at 10:41 AM showed a 5 North resident roster/report sheet lying on top of cart 1 in view for anyone to see. Staff UU Licensed Practical Nurse) stated they should have covered

the sensitive resident information on the report sheet before walking away from their cart but forgot. Staff UU stated it was important to protect resident information for resident's rights.

In an interview on 01/09/2025 at 10:01 AM Staff B (Director of Nursing) stated staff were expected to keep resident information covered and out of site from others. Staff B stated it was important to maintain resident confidentiality for their rights.

REFERENCE: WAC 388-97-1720(1)(c).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 56 of 61 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 0849 Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. Level of Harm - Minimal harm or potential for actual harm 43642

Residents Affected - Few Based on observation, interview, and record review the facility failed to ensure effective coordination of care between the facility and hospice staff, for 1 of 2 residents (Resident 170) reviewed for hospice services. Additionally, the facility failed to update the resident's Care Plan (CP) to show which agency was responsible for the hospice care. These failures prevented implementation of a system by which consistent communication between the facility and hospice staff occurred, and placed residents at risk for not for receiving necessary care and services.

Findings included .

According to facility's revised 04/2023 Hospice Coordination policy, the facility and hospice would: establish

a regular communication schedule and determine the appropriate method(s) for communication .; exchange all relevant resident information, including the resident's CP .; would ensure their staff were knowledgeable about the communication protocols and were trained to effectively communicate with each other.

According to a 12/11/2024 Admission Minimum Data Set (MDS - an assessment tool), Resident 170 had multiple medically complex diagnoses including cancer. This MDS indicated Resident 170 did not have a life expectancy of less than six months and was not on hospice.

Observations on 01/07/2025 at 1:35 PM showed Resident 170's hard chart at the nurse's station had stickers

on the front indicating the resident was on hospice services. In the chart was a 12/06/2024 hospice election statement form indicating Resident 170 was started on hospice services on 12/06/2024.

Review of the 12/06/2024 Hospice Facility Collaboration Notes form from Resident 170's chart showed this form was used on that occasion to document the resident's admission to hospice. The form showed pain was identified as a concern for Resident 170. There was a section to document interventions/comments/instructions but was left blank with a line across the section diagonally and a signature from the hospice nurse underneath. The second page of the form was left blank, including a Collaboration section, which included a spot to document the date of the next visit, information on who received the provided communication at the facility, to the provider, and the resident and/or representative.

Review of Resident 170's physician's orders showed no order for hospice services, only a 12/21/2024 order for an antianxiety medication to be administered as needed for anxiety as part of the hospice comfort kit.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 57 of 61 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 0849 Review of Resident 170's 12/17/2024 Comfort Care CP showed the resident's goal was for comfort care per

the hospice plan of care. Only three interventions were listed: pain management per hospice intervention, Level of Harm - Minimal harm or follow the physician's order form for advance directives, and involve the family with the resident's care with a potential for actual harm comfort focused goal.

Residents Affected - Few A 12/23/2024 Self-Care deficit CP gave directions to staff to assist Resident 170 with all activities of daily living and to see the Kardex (directions to staff regarding how to provide care) for the level of assistance needed.

Review of Resident 170's Kardex as of 01/06/2025 did not show any indication the resident was on hospice or what care was to be provided by the facility or hospice.

In an interview on 01/08/2025 at 9:17 AM, Staff WW (Certified Nursing Assistant) stated they were responsible for Resident 170's bathing and they utilized the Kardex for the resident's care need instructions. Staff WW was unsure what care was given by the hospice providers.

Review of Resident 170's progress notes showed no hospice visit notes were uploaded into Resident 170's records until 01/03/2025, at which time a late entry note was added from a 12/09/2024 and a 12/17/2024 hospice visit. On 01/06/2025 late entry notes were added from a 12/09/2024 and a 12/11/2024 hospice visit.

In an interview on 01/10/2025 at 12:25 PM, Staff K (Manager Long Term Care - Registered Nurse) stated it was their expectation there be adequate collaboration between the facility and hospice, the hospice records would be readily available in the resident records, a hospice order obtained and in place, and a detailed CP developed identifying what care the resident would receive from the facility and from hospice. Staff K stated good collaboration was important so the facility could assure everything was coordinated and the resident was receiving the care required. Staff K reviewed Resident 170's records and stated the records were, unfortunately lacking.

In an interview on 01/10/2025 at 4:07 PM, Staff A (Administrator) stated it was their expectation hospice services were coordinated with the facility, including ensuring orders, CPs, and progress/visit notes were readily available in the resident's records.

REFERENCE: WAC 388-97-1060(1).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 58 of 61 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 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** 45941 potential for actual harm Based on observation, interview, and record review the facility failed to maintain an infection prevention and Residents Affected - Some control program designed to provide a sanitary environment to help prevent the transmission of communicable diseases. The facility failed to implement and/or follow isolation precautions for 3 of 7 residents (Resident 14, 85, and 15) reviewed for Enhanced Barrier Precautions (EBP) , and failed to follow Transmission Based Precaution (TBP) for 1 of 2 rooms (room [ROOM NUMBER]) reviewed for TBP. These failures placed the residents at risk for facility acquired or healthcare-associated infections and related complications.

Findings included .

The facility's 08/2024 Transmission-Based Precautions (TBP) policy showed the facility used different kinds of precautions to protect residents and staff from different kinds of communicable diseases. The policy showed the appropriate precautions would be implemented when residents were diagnosed with or suspected to have infections or communicable diseases that could be spread by contact or droplets. This policy showed EBP precautions were implemented for residents with open wounds, central line, urinary catheter, feeding tube, and tracheostomy. Facility would place an EBP sign on resident's door to instruct staff and visitors to follow the precautions.

The facility's 10/2023 revised Enteral Nutrition policy showed the staff would use clean techniques at all times when opening the feeding system to prevent contamination.

According to the 12/19/2024 Admission Minimum data Set (MDS - an assessment tool), Resident 14 had intravenous (IV- into a vein) access and received an IV medication for an infection. The MDS showed Resident 14 was dependent on staff for transfers and personal hygiene.

Observation on 01/03/2025 at 8:26 AM showed Resident 14's door had an EBP sign, and instructed staff to wear a gown and gloves during direct care. Observation showed Staff KK (Certified Nursing Assistant- CNA) providing care to Resident 14, Staff KK was not wearing an isolation gown.

In an interview on 01/03/2025 at 9:11 AM, Staff KK stated they should wear isolation gown, but they forgot to put the gown on.

According to the 11/07/2024 Admission MDS, Resident 85 had greater than 51% of their intake through Tube Feeding (TF- a tube into the stomach into which liquid nutrition was instilled). This assessment showed Resident 85 had severely impaired vision.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 59 of 61 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 0880 Observation on 01/07/2025 at 9:07 AM showed Resident 85's door had an EBP sign that instructed staff to wear a gown and gloves when providing care to Resident 85. Observation at that time showed Staff V Level of Harm - Minimal harm or (Licensed Practical Nurse) without a gown while administering nutritional liquid via the TF to Resident 85. potential for actual harm

Observation on 01/07/2025 at 9:29 AM showed the TF tubing fell on the floor while Staff V administered Residents Affected - Some liquid nutrition to Resident 85. Staff V grabbed the same tubing from the floor and attached the tubing to the resident. Staff V did not obtain clean tubing.

In an interview on 01/07/2025 at 10:16 AM, Staff V stated they should wear an isolation gown while providing care to the resident and should not use the tubing from the floor because that tubing was not clean anymore. Staff V stated they were nervous and forgot to grab new tubing.

In an interview on 01/08/2025 at 12:20 PM, Staff B (Director of Nursing) stated they expected staff to follow

the facility infection control policy but they did not.

50511

According to a 11/1/2024 Quarterly MDS, Resident 15 had a pressure ulcer and required skin treatments

during the assessment period.

Review of Resident 15's Treatment Administration Record for December 2024 showed an order for EBP for

an open wound and to ensure correct signage, personal protection equipment, and supplies were available and were in use on every shift.

Observations on 01/08/2025 at 2:48 PM Staff PP (Licensed Practical Nurse - LPN) provided wound care to Resident 15's left foot. Staff PP was not wearing a gown per EBP sign that was posted on Resident 15's room door.

Observation showed Staff PP did not remove their gloves and did not wash hands when leaving the resident's room to get a smaller bandage. After completion of wound care treatment, Staff PP used ungloved hands to pull up prep sheet that had used wound supplies on it and did not sanitize hands before putting on new gloves.

In an interview on 01/08/2025 at 3:00 PM Staff PP read the EBP on door and stated the sign read staff should use a gown and sanitize their hands while providing direct care to Resident 15. Staff PP stated they should have used a gown while providing wound care for infection control but did not. Staff PP stated they should have washed hands before, during and after wound care.

In an interview on 01/09/2025 at 2:16 PM Staff K (Manager Long Term Care Registered Nurse) stated for rooms with EBP, it would be used for close personal contact. Staff K stated staff should be putting on a gown, washing their hands and washing hands before they go out of a room.

In an interview on 01/10/2025 at 12:52 PM Staff B stated they would expect staff to follow EBP protocols and use gowns, use proper hand hygiene and use gloves when providing direct care. Staff B stated their expectation would be for staff to follow EBP protocols but they did not.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 60 of 61 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 0880 47836

Level of Harm - Minimal harm or <Transmission Based Precautions> potential for actual harm <room [ROOM NUMBER]> Residents Affected - Some

Observation and interview on 01/02/2025 at 8:19 AM showed room [ROOM NUMBER] with a contact precaution sign and an EBP sign posted on the door. Staff UU (LPN) stated the resident in room [ROOM NUMBER] bed 1 had a contagious infection in their wounds and was on contact precautions to prevent the spread of the infection and the resident in 501 bed 2 was on EBP to protect them from contracting an infection because they had a chest port, a dialysis access to their left arm, and open wounds.

Observation on 01/03/2025 at 8:34 AM showed room [ROOM NUMBER] with the contact precaution and EBP signs posted on the door.

In an interview on 01/09/2025 at 9:40 AM Staff C (Infection Preventionist) stated EBP were to protect fragile residents with indwelling medical devices or wounds from contracting an infection. Staff C stated residents

on Transmission-Based Precautions (Contact, Droplet, and Airborne Precautions) should not be placed in

the same room as residents on EBP for their health and safety.

Refer to

F-Tag F610

Harm Level: TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 42203

Residents Affected: Few prohibition and prevention of abuse for 2 of 5 residents (Residents 110 and 95) reviewed for abuse and one

F-F610.

REFERENCE: WAC 388-97 -0640(2).

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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 .

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.

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 15 of 61 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.

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 16 of 61 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.

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 17 of 61 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 18 of 61 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 0623 Provide timely notification to the resident, and if applicable to the resident representative and ombudsman,

before transfer or discharge, including appeal rights. Level of Harm - Minimal harm or potential for actual harm 45941

Residents Affected - Few Based on interview and record review, the facility failed to ensure a system by which residents/representatives received required written notices at the time of transfer/discharge, or as soon as practicable for 2 of 7 residents (Residents 14 and 120) reviewed for hospitalization s. Failure to ensure written notification to the resident and/or the resident's representative of the reasons for the discharge in writing and in a language and manner they understood, placed residents at risk for a discharge that was not

in alignment with the resident's stated goals for care and preferences.

Findings included .

Review of a 02/2022 facility's Bed Hold and Return to Facility policy, showed for the planned transfers, the facility would provide the transfer/discharge information before or at the time of the transfer. The policy showed for emergency transfers, the facility would contact residents or representatives to offer information within 24 hours.

Review of Resident 14's 11/14/2024 Discharge Return Anticipated Minimum Data Set (MDS - an assessment tool)showed Resident 14 discharged to an acute care hospital on 11/14/2024.

Review of Resident 14's health records on 01/02/2025 showed no documentation staff provided the required written transfer notification within 24 hours to Resident 14 and/or their representative regarding their transfer to hospital.

In an interview on 01/06/2025 at 12:12 PM, Staff D (Social Services Director) Stated their process was to provide a written notification to residents or their representatives the same day the residents go to the hospital, or the notification is emailed to them the next day. Staff D reviewed Resident 14's record and was unable to locate a written notification copy provided to Resident 14 during transferred to the hospital.

In an interview on 01/10/2025 at 12:35 PM, Staff A (Administrator) stated they expected staff to provide written notification to residents/representatives in a timely manner during hospitalization .

47836

According to a 08/15/2024 Discharge MDS Resident 120 discharged to an acute care hospital on 08/15/2024.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 61 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 0623 Review of Resident 120's health records on 01/03/2025 showed no documentation staff provided the required written transfer notification to Resident 120 and/or their representative regarding their transfer to the Level of Harm - Minimal harm or hospital. potential for actual harm

In an interview on 01/07/2025 at 12:55 PM Staff D reviewed Resident 120's records and stated there was no Residents Affected - Few documentation that showed the written transfer notification was provided as required to Resident 120 or their representative.

In an interview on 01/10/2025 at 12:35 PM Staff A stated they expected staff to provided written transfer notifications as soon as possible after the transfer and in a timely manner.

REFERENCE: WAC 388-97-0120 (2)(a-d).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 61 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 0625 Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 45941

Residents Affected - Few Based on interview and record review, the facility failed to provide the resident and/or the resident's representative with a written notice of the facility's bed-hold policy, at the time of transfer or within 24 hours, for 2 of 7 sample residents (Resident 14 & 120) reviewed for hospitalization . This failure placed the residents and their representatives at risk of not being informed of their right to, and the cost of, holding the resident's bed while hospitalized that was necessary for decision-making.

Findings included .

Review of a 02/2022 facility's Bed Hold and Return to Facility policy, showed facility would provide residents and their representatives bed hold and return information at admission and before a hospital transfer or therapeutic leave. For the planned transfers, the facility would provide the bed hold information before or at

the time of the transfer. The policy showed for emergency transfers, the facility would contact residents or representatives to offer bed hold within 24 hours.

Review of Resident 14's 11/14/2024 Discharge Return Anticipated MDS showed Resident 14 discharged to

an acute care hospital on 11/14/2024.

Review of Resident 14's health record showed Resident 14 was sent to the hospital on 11/14/2024 and readmitted to the facility on [DATE REDACTED].

Review of Resident 14's health record showed no documentation that indicated a bed hold notification was provided to Resident 14 when they discharged to the hospital on 11/14/2024 as required.

In an interview on 01/06/2025 at 12:12 PM, Staff N (Social Services Assistant) stated facility's bed hold process was to offer bed hold information to residents/representatives' same day when residents were sent out to a hospital.

In an interview on 01/10/2025 at 12:35 PM, Staff A (Administrator) they expected staff to offer bed hold to residents/representatives in a timely manner when residents were sent out to a hospital.

47836

According to a 08/15/2024 Discharge MDS Resident 120 discharged to an acute care hospital on 08/15/2024.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 61 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 0625 Review of Resident 120's health records showed they were transferred to an acute care hospital on 0815/2024 and returned to the facility on [DATE REDACTED]. Review of Resident 120's health records showed no Level of Harm - Minimal harm or documentation that indicated staff provided a bed hold notification to Resident 120 when they discharged potential for actual harm [DATE REDACTED] as required.

Residents Affected - Few In an interview on 01/07/2025 at 12:55 PM Staff D (Social Service Director) reviewed Resident 120's records and stated there was no documentation staff provided the bed hold notification to Resident 120, or their representative as required.

In an interview on 01/10/2025 at 12:35 PM Staff A stated they expected staff to provide a bed hold notification at time of transfer to the hospital or as soon as possible after the transfer.

REFERENCE: WAC 388-97-0120 (4).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 61 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 0641 Ensure each resident receives an accurate assessment.

Level of Harm - Minimal harm or 43642 potential for actual harm Based on observations, interview, and record review the facility failed to ensure 1 (Resident 170) of 35 Residents Affected - Few residents Minimum Data Set (MDS- an assessment tool) were completed accurately to reflect the resident's condition. This failure placed residents at risk for unidentified and/or unmet needs.

Findings included .

According to a 12/11/2024 Admission MDS, Resident 170 had multiple medically complex diagnoses including cancer. This MDS indicated Resident 170 did not have a life expectancy of less than six months and was not on hospice.

Review of Resident 170's physician orders showed the resident was receiving an antianxiety medication for anxiety as part of a hospice comfort kit.

Observations on 01/07/2025 at 1:35 PM showed Resident 170's hard chart at the nurse's station had stickers

on the front indicating the resident was on hospice services.

According to a 12/06/2024 hospice election statement form, Resident 170 was started on hospice services

on 12/06/2024.

In an interview on 01/10/2025 at 2:31 PM, Staff SS (Care Manager - Registered Nurse) stated the completion of an accurate MDS was how they identify resident problems/issues that needed to be addressed. Staff SS reviewed Resident 170's 12/11/2024 Admission MDS and stated it was inaccurate as hospice should have been coded, but was not. Staff SS stated capturing hospice care in the MDS was important because the goal was comfort-focused and they needed to ensure Resident 170's care plan aligned with the resident's wishes.

Refer to

F-Tag F686

F-F686-Treatment to Prevent Pressure Ulcer

REFERENCE: WAC 388-97-1320(1)(c), (2)(b).

.

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F-Tag F849

Harm Level: Minimal harm or

Residents Affected: Few Based on observation, interview, and record review the facility failed to develop and/or implement

F-F849 - Hospice Services.

REFERENCE: WAC 388-97-1000(1)(b).

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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 0656 Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 47836

Residents Affected - Few Based on observation, interview, and record review the facility failed to develop and/or implement comprehensive Care Plans (CPs) for 2 (Residents 428 & 93) of 35 sample residents whose CPs were reviewed. This failure placed residents at risk for unmet care needs, inappropriate care, and frustration.

Findings included .

According to a 12/30/2024 Admission Minimum Data Set (MDS - an assessment tool) Resident 428 admitted to the facility on [DATE REDACTED]. The MDS showed Resident 428 was frequently incontinent of bowels.

Review of Resident 428's 12/30/2024 9:10 AM Infection Prevention & Control progress note Resident 428 admitted on [DATE REDACTED] and was on enteric precautions (infection control measure designed to prevent transmission of pathogens through the fecal-oral route) at the hospital for diarrhea their entire hospital stay.

The note showed the hospital ruled out any infectious origin, but Resident 428 was still experiencing diarrhea since admission to the facility.

In an interview on 01/03/2025 at 8:55 AM Resident 428 stated they had frequent diarrhea which required an antidiarrheal medication for management. Resident 428 stated they were normally continent of bowels but were now frequently incontinent of stool since this hospitalization due to the diarrhea coming on quickly and without warning. During this interview Resident 428 pressed the call light to call for toileting assistance but in less than a minute was unable to wait and was incontinent of diarrhea.

Review of Resident 428's CP showed no documentation of the unmanaged diarrhea.

In an interview on 01/09/2025 at 9:40 AM Staff C (Infection Preventionist) stated Resident 428 was on enteric precautions their entire stay at the hospital but was ruled out as infectious so was removed from the precautions. Staff C stated Resident 428 still had issues with diarrhea but did not have a CP developed directing staff on how to care for this issue but should have. Staff C stated it was important to develop a CP for the frequent diarrhea to ensure Resident 428 stayed hydrated and to avoid skin breakdown.

43642

According to a 12/26/2024 Annual MDS, Resident 93 was at risk for pressure ulcers and had no rejection of care. This MDS showed staff assessed Resident 93 used a walker for mobility, required supervision for transfers from bed, and was dependent on staff for dressing, putting on/taking off footwear, and personal hygiene.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 61 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 0656 Observations on 01/03/2025 at 9:27 AM and 01/06/2025 at 9:49 AM showed edema to both Resident 93's lower legs. Level of Harm - Minimal harm or potential for actual harm Review of Resident 93's 12/26/2024 progress note showed edema was identified during an assessment and weights were being monitored. Residents Affected - Few

Review of Resident 93's comprehensive CP showed no problem was developed regarding the resident's lower leg edema.

In an interview on 01/10/2025 at 12:25 PM, Staff K (Manager Long Term Care - Registered Nurse) stated it was their expectation staff address current resident conditions on a CP so staff are aware of interventions that should be in place for a resident.

In an interview on 01/10/2025 at 1:43 PM, Staff B (Director of Nursing) stated it was their expectation staff develop a CP, implement interventions to monitor identified edema, and document findings on the weekly skin assessments.

REFERENCE: WAC 388-97-1020(1), (2)(a)(b).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of 61 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 0657 Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 47836

Residents Affected - Some Based on observation, interview, and record review the facility failed to provide care conferences as required for 2 (Residents 427 & 28) of 35 sample residents whose Care Plans (CPs) were reviewed, and failed to ensure CPs were updated as needed to reflect changes in resident's care needs for 4 (Residents 22, 142, 170, & 7) of 35 sample residents whose CPs were reviewed. The failure to provide care conferences and to update CPs with changes in residents' health status placed residents at risk for unmet care needs, unnecessary care, and frustration.

Findings included .

According to a facility policy titled, Resident Care Plan Reviews and Care Conferences, revised 04/2023, showed the facility would hold care conferences in accordance with regulatory requirements and as needed.

According to 01/01/2025 Admission Minimum data Set (MDS - an assessment tool) Resident 427 admitted to

the facility on [DATE REDACTED] without memory impairment.

In an interview on 01/02/2025 at 12:14 PM Resident 427 stated they did not have a care conference yet. Resident 427 stated staff did not schedule a care conference with them since admitting to the facility but they wanted one so they could understand their plan of care for their stay at the facility and get some questions answered.

In an interview on 01/08/2025 at 12:30 PM Staff M (Social Worker) stated the facility expected care conferences to be scheduled as needed or when the residents requested. Staff M stated Resident 427 did not request a care conference, so they did not schedule one for them.

50511

According to the Annual 11/20/2024 MDS, Resident 28 had medically complex conditions. Resident 28 could make themselves self-understood, could understand others, and did not have memory impairment.

According to the 02/19/2021 Communication Risk CP, Resident 28 had a communications deficit due to hearing loss. The CP showed a goal for Resident 28's care needs would be satisfactorily met through effective communication during their long-term care stay. The CP included interventions for staff to provide verbal communication with visual cues and to verify understanding with Resident 28.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of 61 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 0657 Record review showed a 09/12/2024 Care Conference form. The form had a section showing who participated. This section did not indicate Resident 28 or their family member was invited to the 09/12/2024 Level of Harm - Minimal harm or care conference. potential for actual harm

Record review showed a 06/26/2024 Care Conference form for Resident 28. The form had a section showing Residents Affected - Some who participated. This section did not indicate Resident 28 or their family member was invited to the 06/26/2024 care conference.

In an interview on 01/03/2025 at 9:50 AM Resident 28 stated staff occasionally included them and talked about their care, but this was rare.

In an interview on 01/09/2025 at 2:25 PM Staff K (Manager Long Term Care Registered Nurse) stated the facility offered quarterly and yearly care conferences, or more often if a resident requested one. Staff K stated the facility used the care conference form to invite residents and family members to their care conferences. Staff K stated the form should be used to invite Resident 28 to their care conferences but did not.

In an interview on 01/09/2025 at 10:21 AM Staff D (Social Service Director) stated they expected care conferences to be done with the resident and/or representative, and interdisciplinary team including, but not limited to, a social worker, nursing, the provider, and the director of rehabilitation. Staff D stated they expected care conferences to be offered and held within five days of admission, quarterly, and as needed/requested.

43642

According to a 12/12/2024 Quarterly MDS, Resident 22 had multiple medically complex diagnoses including stroke, had clear speech, was able to understand, and be understood by others. This MDS showed Resident 22 was assessed with a functional limitation in range of motion to one side of their arms and legs. The MDS showed Resident 22 required set up assistance for eating, was dependent on staff for daily hygiene.

According to the 12/29/2022 potential for oral health issues . CP, Resident 22 had no natural teeth and used upper dentures only. The CP directed staff to ensure Resident 22 wore their upper dentures.

Review of the Kardex (care instructions for nurse's aides) as of 01/06/2025 showed Resident 22 used their lower dentures, rather the upper dentures identified on the CP.

In an interview on 01/10/2025 at 12:25 PM, Staff K (Manager Long Term Care - Registered Nurse) stated the Kardex was inaccurate and needed to be updated to ensure Resident 22 received the assistance they needed with their dentures.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 27 of 61 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 0657 According to the 11/14/2024 Quarterly MDS, Resident 141 had intact memory. The MDS showed Resident 142 had diagnoses including malnutrition. Level of Harm - Minimal harm or potential for actual harm In an interview on 01/03/2025 at 8:51 AM Resident 142 stated they recently had all their teeth extracted and now used upper and lower dentures. Observations at this time showed Resident 142 had both upper and Residents Affected - Some lower dentures in their mouth.

According to a 11/06/2024 progress note, Resident 141 had a dental appointment on that date. The note showed this appointment was for an extraction.

According to the 07/15/2024 at risk for nutritional status . CP, Resident 142 was at risk related to poor oral/dental status with broken teeth. Resident 142's goal was to be free of infection, pain, and bleeding in their oral cavity. This CP did not address Resident 142's denture use.

Review of the Kardex as of 01/07/2024 showed Resident 142's denture status was not addressed.

In an interview on 01/10/2025 at 12:25 PM, Staff K stated that Resident 142 required dentures. Staff K stated

the resident's CP and Kardex should be updated to address the resident's dentures.

According to a 12/11/2024 Admission MDS, Resident 170 had multiple medically complex diagnoses including cancer. This MDS indicated Resident 170 required an indwelling catheter (tubing to assist with bladder drainage).

According to a progress note Resident 170's catheter was removed on 12/27/2024.

According to the 12/17/2024 at risk for complications related to use of an indwelling catheter . CP Resident 170 still required an indwelling catheter. The CP directed staff to provide catheter care as needed. There was no CP to show what, if any, assistance Resident 170 needed to urinate.

Review of the Kardex as of 01/06/2025 showed Resident 170 still needed a catheter.

In an interview on 01/10/2025 at 12:25 PM, Staff K stated that Resident 170 no longer had a catheter. Staff K stated the resident's CP and Kardex should be updated to address their current toileting status.

42203

According to the 10/07/2024 Quarterly MDS, Resident 7 had diagnoses including stroke history, and one-sided limitations to their Range of Motion (ROM). The MDS showed Resident 7 received a bed mobility restorative nursing program but no ROM programs.

Record review showed a 02/03/2022 impaired mobility . CP was developed for Resident 7. This CP included

an intervention for staff to provide a Passive ROM (PROM) program to Resident 7's left side to prevent contractures (permanent tightening of the tendons and muscles).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 28 of 61 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 0657 In an interview on 01/10/2025 at 10:59 AM Staff B stated Resident 7 no longer required a PROM program. Staff B stated the CP was not up to date. Level of Harm - Minimal harm or potential for actual harm REFERENCE: WAC 388-97-1020(2)(c)(d).

Residents Affected - Some

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 29 of 61 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 0658 Ensure services provided by the nursing facility meet professional standards of quality.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 43642 potential for actual harm Based on observation, interview, and record review the facility failed to ensure: physician's orders were Residents Affected - Few followed for 2 (Resident 22 & 85) and medications were administered for 1 (Resident 28) of 35 sample residents reviewed. These failures placed residents at risk for medication errors, delayed treatment, and adverse outcomes.

Findings included .

According to a 12/12/2024 Quarterly Minimum Data Set (MDS - an assessment tool), Resident 22 had multiple medically complex diagnoses including neurogenic bladder (a condition where the nerves that control the bladder are damaged) and required the use of an indwelling catheter (a tube inserted into the bladder to collect and drain urine).

Observations on 01/06/2025 at 8:55 AM, and 01/07/2025 at 1:31 PM showed Resident 22 with a catheter bag hanging from the bottom of the bed frame.

Review of Resident 22's physician orders showed a 12/21/2024 order to remove the indwelling catheter for a trial and to replace with a size 16 FR [French] catheter if the resident was unable to urinate. A second 12/21/2024 order showed staff were to scan the resident's bladder each shift and to place the size 16 FR indwelling catheter if the bladder had greater than 500 cubic centimeters (cc).

Review of a 12/23/2024 nursing alert charting progress note showed staff documented Resident 22 had 698 cc of urine and a size 14 FR indwelling catheter was inserted. There was no physician's order directing staff to change the size of the indwelling catheter to a 14 FR or directions to staff on the duration of the newly placed catheter.

In an interview on 01/10/2025 at 12:25 PM, Staff K (Manager Long Term Care - Registered Nurse) stated Resident 22 should have routine physician orders in place for the continued use of the indwelling catheter. Staff K stated it was their expectation staff should have, but did not follow the physician orders when the new catheter was implemented on 12/23/2024.

45941

According to the 11/07/2024 Admission MDS, Resident 85 was readmitted to the facility on [DATE REDACTED] with weakness on one side of the body and had severe cognitive impairment. This assessment showed Resident 85 was dependent on staff with toileting, feeding, personal hygiene, and repositioning. The assessment showed Resident 85 was at risk for pressure ulcers.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 30 of 61 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 0658 Review of Resident 85's January 2025 physician orders on 01/06/2025 showed a 10/29/2024 order directing staff to apply a dressing to Resident 85's sacral wound and change every three days. Level of Harm - Minimal harm or potential for actual harm Review of Resident 85's January 2025 Treatment Administration Record (TAR) showed the facility nursing staff documented Resident 85 refused treatment on 01/03/2025 and on 01/06/2025 documented they applied Residents Affected - Few the dressing to Resident 85's sacral wound as ordered.

Observation on 01/06/2025 at 1:33 PM and on 01/07/2025 at 10:24 AM showed Resident 85 had no dressing

on their sacral area.

In an interview on 01/07/2025 at 1:00 PM, Staff Q (Certified Nursing Assistant) stated they did not see a dressing to Resident 85's sacral area recently.

Observation and interview on 01/08/2025 at 11:34 AM showed Staff S (Licensed Practical Nurse - LPN) assess Resident 85's sacral area and stated Resident 85 did not have a wound on their sacral area and there was no dressing.

In an interview on 01/09/2025 at 9:41 AM, Staff E (Director Long Term Care Registered Nurse) stated they expected staff to follow the physician orders. Staff E stated if there was any change, staff should clarify the orders with provider, but they did not.

50511

According to the 11/20/2024 Annual MDS, Resident 28 was assessed to have medically complex conditions including unstable blood sugars, high blood pressure and heart failure. The MDS showed Resident 28 took a diuretic medication (expels excess water fluid from the body to lower blood pressure) and a medication to lower blood sugar levels.

Review of the January 2025 Medication Administration Record (MAR) showed Resident 28 had a 11/04/2024 physician's order for a blood sugar lowering medication and to give 1 tablet twice a day.

Review of the January 2025 MAR showed Resident 28 had a 01/16/2024 physician's order for a supplemental medication to be given two tablets every other day.

In an interview on 01/08/2025 at 9:09 AM Resident 28 stated they were told by the nurse that two of their medications were not given this morning and was told the pharmacy needed to be called. Resident 28 stated

they thought the supplemental pill was not given and was not sure of the other one that was missed. Resident 28 stated the nurse was aware of the missing medications and was going to check why it was missing. Resident 28 stated they were very upset about not receiving their medications due to pharmacy issues. Resident 28 stated they called their family to tell them how upset they were with frequently missing medications and they might need to move out because of this.

Review of Resident 28's January 2025 MAR showed supplemental medication and blood sugar lowering medication was not given in the AM on 01/08/2025.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 31 of 61 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 0658 In an interview on 01/08/2025 at 12:40 PM Staff J (LPN) stated Resident 28's medications were not available when they were passing out medications this morning. Staff J stated they did not have time to call the doctor Level of Harm - Minimal harm or or pharmacy regarding the missing medications for Resident 28 and could not recall what the medications potential for actual harm were that were missing for Resident 28.

Residents Affected - Few In an interview on 01/10/2025 at 10:30 AM, Staff K stated the nurse should have notified the provider for further instructions on what to do about Resident 28 missing their medications, but did not. Staff K stated the nurse should have documented in the progress notes that Resident 28 was missing their medications and documented the provider instructions on what to do because of missing their medications, but did not.

REFERENCE: WAC 388-97-1620(2)(b)(i)(ii).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 32 of 61 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 45941 potential for actual harm Based on observation, interview, and record review the facility failed to provide assistance with Activities of Residents Affected - Some Daily Living (ADL), related to cleanliness and grooming for 8 of 35 residents (Resident 14, 22, 170, 93, 112, 120, 126, & 82) reviewed for ADLs. Facility failure to provide residents who were dependent on staff for assistance with nail care, dentures, dressing, shaving, and bathing placed the residents at risk for poor hygiene, long facial hair, embarrassment, and a diminished quality of life.

Findings included .

According to the 12/19/2024 Admission Minimum Data Set (MDS - an assessment tool), Resident 14 readmitted to the facility on [DATE REDACTED] with weakness on the left side of their body. The assessment showed Resident 14 was dependent on staff for personal hygiene, showers, and toileting needs.

Observations on 01/03/2025 at 11:31 AM and on 01/06/2025 at 8:23 AM showed Resident 14 was in bed. Resident 14 had long fingernails with black debris under their fingernails.

Observation and interview on 01/07/2025 at 10:07 AM showed Resident 14 was up in a wheelchair in their room. Resident 14 had long fingernails with black residue under their nails. Resident 14 stated they needed staff assistance to clip their fingernails.

According to the 01/02/2025 ADL self-care performance deficit Care Plan (CP), Resident 14 required one-person extensive assistance with personal hygiene and toileting

In an interview on 01/09/2025 at 10:36 AM, Staff E (Director Long Term Care Registered Nurse) stated they expected staff to check the resident's preferences related to ADLs and provide assistance as needed. If the resident refused, staff should document the refusals.

In an interview on 01/10/2025 at 11:10 AM, Staff A (Administrator) stated staff should provide ADLs to all residents daily and as needed.

43642

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 33 of 61 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 0677 According to a 12/12/2024 Quarterly MDS, Resident 22 had multiple medically complex diagnoses including stroke, had clear speech, was able to understand, and be understood by others. This MDS showed Resident Level of Harm - Minimal harm or 22 was assessed with a functional limitation in range of motion to one side of their arms and legs. The MDS potential for actual harm showed Resident 22 required set up assistance for eating, was dependent on staff for upper and lower body dressing and had no rejection of care. Residents Affected - Some

Review of a revised 12/29/2022 potential oral health CP showed directions to staff to ensure Resident 22 wears upper dentures.

Observations on 01/06/2025 at 9:00 AM showed staff deliver Resident 22's breakfast tray and place it on the resident's overbed table. Staff set up the tray and left the room. Resident 22 was not wearing any dentures.

In an interview on 01/06/2025 at 10:03 AM, Resident 22 stated they had dentures and would wear the dentures if they had them. Resident 22 stated, they keep forgetting to bring them to me, it does not look good when I do not wear them. In an observation at this time, Resident 22's dentures were in a denture cup across

the room next to the sink.

Observations on 01/08/2025 at 8:57 AM showed Resident 22 eating breakfast without wearing dentures. On 01/09/2025 at 12:36 PM, when asked why Resident 22 was not wearing their dentures, the resident indicated

the staff had not brought them over yet, and stated, I will remind them.

In an interview on 01/10/2025 at 12:25 PM, Staff K (Manager Long Term Care - Registered Nurse) stated it was their expectation for staff to assist residents with their dentures every day during routine morning care and prior to meals to assist with eating.

According to a 12/11/2024 Admission MDS, Resident 170 had intact memory, clear speech, was understood, and able to understand others. This MDS showed staff assessed Resident 170 required substantial assistance to roll from side to side in bed, was dependent on staff for lower body dressing and transfers, and had no rejection of care.

Observations on 01/02/2025 at 9:03 AM showed Resident 170 lying in bed wearing a hospital gown. In an

interview at this time, Resident 170 stated the staff did not offer to get them up and stated they liked to get up and dressed in clothes. Similar observations of Resident 170 lying in bed with a hospital gown on were observed on 01/03/2025 at 11:00 AM, 01/06/2025 at 8:54 AM, and on 01/07/2025 at 1:31 PM.

In an interview on 01/10/2025 at 12:25 PM, Staff K stated it was their expectation staff get residents up and dressed in the morning if they are willing. Staff K stated staff should notify the nurse and document in the records if a resident refuses.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 34 of 61 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 0677 According to a 12/26/2024 Annual MDS, Resident 93 had multiple medically complex diagnoses including dementia. This MDS showed staff assessed Resident 93 to be dependent on staff for personal hygiene, and Level of Harm - Minimal harm or had no rejection of care. potential for actual harm

Review of a 12/31/2024 ADL CP showed staff identified a goal Resident 93 would receive the appropriate Residents Affected - Some level of assistance for their ADLs and mobility and gave directions to staff to see the Kardex (directions to care staff) for ADLs and mobility assistance needs. Review of Resident 93's Kardex on 01/06/2025 showed

the resident was dependent on staff for bathing and hygiene.

Observations on 01/03/2025 at 9:31 AM showed Resident 93 with long chin hairs and being taken into the shower room by staff. On 01/06/2025 at 9:46 AM, observations showed Resident 93 with the same long chin hairs as previously observed on 01/03/2025, three days later.

According to a 12/01/2024 Quarterly MDS, Resident 112 had multiple medically complex diagnoses including dementia. This MDS showed staff assessed Resident 112 to be dependent on staff for personal hygiene and had no rejection of care.

Review of a 12/02/2024 ADL CP showed staff identified a goal Resident 112 would receive the appropriate level of assistance for their ADLs and mobility and gave directions to staff to see the Kardex for ADLs and mobility assistance needs. Review of Resident 112's Kardex on 01/06/2025 showed the resident was dependent on staff for bathing and required supervision with one assist for hygiene. This Kardex gave instructions to staff to shave Resident 112's facial hair as needed after shower per the resident's preference.

Observations on 01/02/2025 at 10:01 AM, 01/03/2025 at 9:22 AM, and on 01/06/2025 at 9:54 AM showed Resident 112 with long chin hairs.

In an interview and observations on 01/07/2025 at 3:25 PM, Staff W (RN) confirmed the long chin hairs for Resident 93 and Resident 112. Staff W stated it was their expectation staff assist residents to shave on shower days and as needed between shower days.

47836

According to a 09/25/2024 Quarterly MDS, Resident 120 had no cognitive impairment. The MDS showed Resident 120 required assistance with bathing.

Review of Resident 120's ADL CP showed they preferred bed baths and staff would offer and assist them weekly on Thursdays.

Review of Resident 120's bathing history report on 01/06/2025 showed no bathing offered on 12/26/2024 and 01/02/2025 per resident bathing schedule. Resident 120's bathing history report showed the last bed bath offered and received was on 12/19/2024.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 35 of 61 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 0677 In an interview on 01/06/2025 at 10:28 AM Resident 120 stated staff had not offered them a bed bath since

the Thursday before Christmas 2024, 12/19/2024. Resident 120 was upset and stated the staff often would Level of Harm - Minimal harm or not offer them bathing. potential for actual harm

In an interview on 01/07/2025 at 1:12 PM Staff K stated their expectations were staff offer residents bathing Residents Affected - Some weekly per preference and schedule and as requested. Staff K stated Resident 120 preferred bed baths and was to have them every Thursday per their CP. Staff K reviewed Resident 120's health records and stated Resident 120 had not had bathing since 12/19/2024 but should have every Thursday. Staff K stated there were no refusals documented in Resident 120's health records and staff knew they needed to document if a resident refused.

In an interview on 01/09/2025 at 10:01 AM Staff B (Director of Nursing) stated they expected staff to offer bathing per the residents' schedule and preferences. Staff B stated it was important to provide bathing to residents for infection prevention and to prevent skin breakdown.

46479

According to the 10/04/2024 Annual MDS, Resident 126 had clear speech, was able to understand others, and was understood by others in conversation. The assessment showed it was very important for Resident 126 to choose between a tub bath, shower, bed bath, or sponge bath and the resident had no rejection of care during the assessment period.

In an interview on 01/02/2025, Resident 126 stated they only received one shower per week and that they would like more showers.

Review of Resident 126's Kardex (directions to care staff) on 01/06/2025 showed the resident preferred to be showered in the morning on Tuesdays. The Kardex showed Resident 126 was dependent on staff for bathing. Review of the 2 North unit bath schedule provided by staff, showed Resident 126 was scheduled for showers on Tuesdays during the day shift.

Review of Resident 126's November 2024 Certified Nursing Assistant (CNA) documentation showed Resident 126 received a shower on 11/05/2024 and refused a shower on Wednesday, 11/13/2024. There was no documentation that showed Resident 126 was offered a shower on Tuesday 11/12/2024, their preferred shower day. Their next shower was not documented until 11/19/2024, 13 days after the 11/05/2024 shower. There was no documentation that showed the resident was offered a shower the next shift or next day after their declination of the shower on 11/13/2024.

Review of Resident 126's December 2024 CNA documentation showed the resident received a shower on 12/03/2024, declined a shower on 12/06/2024, and was not showered again until 12/17/2024, 13 days after

the shower on 12/03/2024. There was no documentation showing the resident was offered a shower the next shift or next day after their declination of the shower on 12/06/2024. Resident 126 received a shower on 12/17/2024 and 13 days later, on 12/31/2024. There was no documentation the resident was offered and declined a shower between 12/17/2024 and 12/31/2024.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 36 of 61 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 0677 In an interview on 01/10/2025 at 12:34 PM, Staff B stated they expected resident refusals to be documented. Staff B stated if a resident wanted more than one shower per week, the facility could try and accommodate Level of Harm - Minimal harm or them. Staff B stated they would inform the family of the resident that the family could hire a private care giver potential for actual harm for the resident if the facility could not accommodate the resident's request.

Residents Affected - Some <Resident 82>

According to the 12/23/2024 Significant Change in Status MDS, Resident 82 was sometimes understood and could sometimes understand others in conversation. The MDS showed Resident 82 had severe impairment with their ability to think, remember, and make decisions. Resident 82 did not reject care during the assessment period, and it was very important to them to chose between a tub bath, shower, bed bath, or sponge bath. The MDS showed Resident 82 was not showered/bathed during the assessment period and their ability to perform shower/bathing was not assessed.

Review of Resident 82's Kardex on 01/06/2025 showed the resident was dependent on staff for assistance with bathing. The Kardex showed Resident 82 preferred a tub bath on Wednesday mornings. Review of the 2 North unit bath schedule provided by staff, showed Resident 82 was scheduled to be bathed on Tuesdays

during the day shift.

Observation on 01/08/2024 showed Resident 82 lying in bed. The resident had hair stubble on their chin and their hair appeared stringy and greasy.

Review of Resident 82's October 2024 CNA documentation showed the resident received two showers

during the month of October. This documentation showed staff did not provide Resident 82 with bathing once per week as the resident was assessed to require. There was no documentation that showed Resident 82 was offered and refused bathing opportunities.

Review of Resident 82's November 2024 CNA documentation showed Resident 82 received three showers for the month of November. This documentation showed Resident 82 refused two showers. There was no documentation that showed the resident was offered bathing assistance the next shift or the next day.

Review of Resident 82's December 2024 CNA documentation showed Resident 82 received three bathing opportunities during the month of December. There were no bathing opportunities documented from 12/18/2024 to 12/31/2024 showing Resident 82 went 14 days without a shower or bed bath. There were no documented refusals for the month of December.

In an interview on 01/10/2025 at 12:39 PM, Staff B stated the facility did not have specific CNAs assigned to bathing residents. Staff B stated the CNA assigned to the resident, was responsible for providing bathing assistance for residents scheduled for bathing on the shift. Staff B stated staff should document refusals for bathing and staff should reattempt later in the shift, the next shift, and next day. Staff B stated they expected staff on the next shift or the next day should document the resident's acceptance of or declined bathing assistance.

REFERENCE: WAC 388-97-1060(2)(c).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 37 of 61 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 0679 Provide activities to meet all resident's needs.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 42203 potential for actual harm Based on observation, interview, and record review the facility failed to ensure activity programs met the Residents Affected - Some needs of each resident for 3 of 5 sampled residents (Resident 110, 170, & 171) reviewed for activities. Failure to provide meaningful activities left residents at risk for boredom, frustration, and a diminished quality of life.

Findings included .

According to the facility's 07/2024 Activities policy, each resident should be provided the opportunity to participate in activities that reflected their interests and lifestyle. The policy showed the activities offered should help meet residents' physical, mental, and psychosocial wellbeing.

According to the 11/14/2024 Admission Minimum Data Set (MDS - an assessment tool) Resident 110 had intact memory, and sometimes experienced social isolation. The MDS showed it was extremely important to Resident 110 to get outside when the weather was suitable. The MDS showed all activity preferences were extremely important for Resident 110, except participating in group activities, which was not very important to

the resident.

According to the 11/29/2024 Little or no activity involvement related to mobility status . Care Plan (CP) Resident 110's goal was to participate in activities of their choice per the facility's activities calendar. The CP included interventions to provide and orient Resident 110 to the facility's activity calendar and to refer to Activity assessment .

In an interview and observation on 01/03/2025 at 12:46 PM Resident 110 was looking out of their window when a surveyor entered their room. Resident 110 stated they were not bored while a resident at the facility but wanted to go outside. Resident 110 stated facility staff did not offer to take them outside since admitting

in November 2024.

Review of the November 2024 activities flow sheets showed Resident 110 was not offered to go outside that month.

Review of the December 2024 activities flow sheets showed Resident 110 was offered one on one activity on 13 of 29 days when the resident was available, and participated in the book cart and movies/sit com activities

on 12/30/2024 only. The flowsheet showed from 12/19/2024 through 12/29/2024, no activities provided.

The January 2025 activities flowsheet showed on four of eight days no activity participation was documented and showed no offers to go outside for Resident 110.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 38 of 61 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 0679 In an interview on 01/08/2025 at 1:44 PM, Staff NN (Recreation Therapist) stated it was important to provide residents meaningful activities. Staff NN stated all activities provided were documented in the electronic chart Level of Harm - Minimal harm or and would appear on the activities flow sheets. Staff NN stated they did not offer to take Resident 110 for potential for actual harm some fresh air since the resident moved to the unit and if this occurred when Resident 110 was on their prior unit, it would be documented. Residents Affected - Some 43642

According to a 12/11/2024 Admission MDS, Resident 170 had intact memory, clear speech, was understood, and able to understand others. This MDS showed staff assessed Resident 170 required substantial assistance to roll from side to side in bed, was dependent on staff for transfers, had no rejection of care, and indicated activity preferences were very important to them.

In an interview on 01/03/2025 at 8:35 AM, when Resident 170 was asked about activities, the resident stated

they would, absolutely go to activities, and stated, I would love that. Resident 170 stated they have not gone to any activities since being admitted to the facility and felt it was because they were unable to walk to get to them.

Observations on 01/06/2025 at 8:54 AM and 10:10 AM, and on 01/07/2025 at 1:31 PM showed Resident 170 lying in bed wearing a hospital gown. Activities were observed being set up and occurring in the activity room

on 01/06/2025 and 01/07/2025 while Resident 170 was in bed in their room.

Review of a 01/02/2025 Activity CP showed directions for staff to encourage activity attendance with Resident 170 and identified the resident was interested in bingo.

Review of the December 2024 activities flow sheets showed documentation Resident 170 was only offered:

a one to one activity, a movie/sit com activity, and sensory activity on 3 of 26 days; and a book cart and an independent leisure project on 2 of 26 days in December 2024. No refusals were documented on the flow sheets.

Review of the January 2025 activities flow sheets showed documentation Resident 170 was offered a one to one activity, book cart, independent leisure project, movies/sit com, and a sensory activity on 1 of 5 days in January on 01/03/2025. No refusals were documented on the flow sheets.

In an interview on 01/10/2025 at 1:02 PM, Staff AAA (Recreational Therapist) stated they worked on two units and had about 40 residents to work with for activities. Staff AAA stated if a resident refused an activity or if an activity was provided, it should be documented in the resident records. Staff AAA stated any offers or refusals for Resident 170 should be documented.

45941

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 39 of 61 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 0679 According to the 12/08/2024 Admission MDS Resident 171 admitted to the facility on [DATE REDACTED]. The MDS showed Resident 171 made their own decisions and had no behavior of rejecting care during this Level of Harm - Minimal harm or assessment period. The MDS showed it was very important to Resident 171 to have things to read, music to potential for actual harm listen to, engage with groups of people, participate in their favorite activities, and to join religious services.

Residents Affected - Some According to the 12/09/2024 potential for leisure activity deficit due to hard of hearing CP Resident 171's goal was to participate in activities per their preferences and choices. The CP included interventions to provide the weekly activity and movie calendar in Resident 171's room.

According to the 12/26/2024 COVID 19 (viral respiratory infection) CP, staff were instructed to provide in room activities of Resident 171's interest and opportunities for the resident to express their feelings related to

the situational stressor of their respiratory infection.

Observation and interview on 01/03/2025 at 9:43 AM showed Resident 171's door was closed and an Aerosol precaution sign was on the door. Resident 171 was sitting on the edge of their and was looking out of their window. Resident 171 stated they had COVID, and no one came to their room.

Similar observations on 01/06/2025 at 8:06 AM and 12:21 PM, and on 01/07/2025 at 9:18 AM and 12:35 PM showed no reading material, no music playing, and no religious services available for Resident 171 in their room.

In an interview on 01/07/2025 at 12:50 PM, Staff R (Licensed Practical Nurse) stated Resident 171 tested negative for COVID on 01/04/2025 and was not on isolation precautions anymore.

In an interview on 01/07/2025 at 1:16 PM, Staff TT (Recreation Therapist Assistant) stated they had to take care of two floors for activities and had to complete admission activity assessments for the new admissions. Staff TT stated they did not provide in-room activities to Resident 171 because they had COVID, and staff did not want to spread the infection to other residents.

In an interview on 01/10/2025 at 11:14 AM, Staff A (Administrator) stated it was important to provide activities to all residents according to their choices. Staff A stated staff should provide in-room activities to Resident 171 with COVID per their preferences, but they did not.

REFERENCE: WAC 388-97-0940(1).

51791

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 40 of 61 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Level of Harm - Minimal harm or 50511 potential for actual harm Based on observation, interview, and record review the facility failed to ensure 1 of 5 residents (Resident 15) Residents Affected - Few reviewed for Pressure Ulcers (PU- injury to the skin and underlying tissue due to prolonged pressure), received necessary care and services, consistent with professional standards of practice, to promote healing, and prevent new ulcers from developing. Failure to implement wound prevention interventions, report on worsening conditions and to use appropriate hand hygiene practices and personal protective equipment (gloves, masks and gowns) when providing wound care and provide proper infection control practices, placed residents at risk for deterioration in skin condition(s) pressure ulcers and a diminished quality of life.

Review of the revised 01/2023 Pressure Ulcer Prevention and Treatment policy, showed the facility would evaluate the resident's clinical condition and pressure ulcer risk factors and implement interventions that were consistent with resident needs, goals and recognized standards of practice.

According to the 11/15/2024 Quarterly Minimum Data Set (MDS - an assessment tool), Resident 15 had impairments to both sides of their lower body and was dependent on staff for activities of daily living, mobility, and used a wheelchair. The MDS showed Resident 15 was at risk for pressure ulcers and needed pressure reducing devices for their chair and bed.

Review of the revised 11/19/2024 Impairment to Skin Integrity Care Plan (CP) showed Resident 15 had the potential for impairment to skin integrity due to impaired mobility and a history of pressure ulcers. Interventions on the CP instructed staff to provide a cushion while the resident was in their wheelchair and to wear foot cradles or to elevate their feet while the resident was up in their wheelchair.

Review of the physician orders showed an order to float Resident 15's left foot. Physician orders showed staff were to monitor wounds for signs and symptoms of infection and worsening condition during each shift and to document and notify the provider.

Review of Kardex (caregiver information sheet) showed staff were to float heels with pressure mat or boots.

Observation on 01/08/2025 at 08:53 AM showed Resident 15 sitting in the dining room, with slippers on. The left foot was hanging to the floor while the resident was sitting in the wheelchair.

Observation on 01/08/2025 at 12:35 PM showed Resident 15 was sitting in the dining room in a wheelchair. Resident 15 had slipper shoes on and the left foot heel was hanging down.

In an interview on 01/09/2025 at 1:42 PM Staff EE (Certified Nursing Aid) stated Resident 15 wore a boot on their foot while in bed but did not use anything while they were sitting up in their wheelchair.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 41 of 61 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 0686 In an interview on 01/09/2025 at 2:40 PM Staff K (Manager Long Term Care Registered Nurse) stated staff should always float Resident 15's heel and needed to check with Staff B on what this meant for Resident Level of Harm - Minimal harm or 15's care. potential for actual harm

In an interview on 01/10/2025 at 10:34 AM, Staff K stated after checking with Staff B, Resident 15 should be Residents Affected - Few using boots but was not.

Review of Treatment Records for December 2024 showed staff were to monitor wounds from a left lateral diabetic foot ulcer for signs or symptoms of infection or worsening during each shift, to write in the progress notes the appearance of the wound and to notify the provider.

Observation on 01/07/2025 at 1:43 PM, while Staff Z (Licensed Nurse) was applying a dressing cover to Resident 15's lower back area, another dressing on Resident 15's left foot was observed to be saturated with blood and the bandage had come off from the left side of the foot. Staff Z stated the contracted wound care service provided wound care the day before and stated they were not told by any other staff that the wound was bleeding.

Review of progress notes showed a progress note dated 01/07/2025 by Staff Z showing that Resident 15 had drainage to right heel and had a non-open diabetic ulcer to left foot. Staff Z noted that they notified the provider and was waiting for a response. No other progress notes located in the medical record showed that

a wound was bleeding on the left foot.

In an interview on 01/09/2025 at 2:43 PM, Staff K stated they were not made aware Resident 15 had a bleeding wound. Staff K stated it was not uncommon for bandages to fall off as they have as needed orders to replace bandages. Staff K stated the care staff should have reported the bed sheets being bloody and should have notified the nurse so the nurse could address why Resident 15 was bleeding. Staff K stated there should be a new skin assessment report made by the nurse and the nurse should notify the provider of

the issue. If a skin assessment report was completed by the nurse the unit manager would be notified about Resident 15's wound issue.

In an interview on 01/10/2025 at 12:49 PM Staff B stated their expectation was for nurses to follow physician orders. Staff K stated if there was a change in appearance of Resident 15's skin, this should be documented

on the skin assessment form and reported to the unit manager and the provider.

Refer to

F-Tag F880

Harm Level: Minimal harm or

Residents Affected: Some Based on observation, interview, and record review the facility failed to ensure the environment was free of

F-F880 Infection Prevention and Control

REFERENCE: WAC 388-97-1060 (3)(b).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 42 of 61 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 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Minimal harm or potential for actual harm 46479

Residents Affected - Some Based on observation, interview, and record review the facility failed to ensure the environment was free of accident hazards for 4 of 9 (2 North, 4 South, St Joseph's Residence (SJR), & 5 North) units reviewed. The failure to ensure sharps (syringe needles, razors etc.) and chemicals were stored safely placed residents at risk for injury, unsafe chemicals, and accident hazards.

Findings included .

According to the revised 01/2025 Cleaning and Disinfection of Environment Surfaces policy, all chemicals would remain out of reach of residents and stored behind locked doors to ensure safety.

<2 North Unit>

Observation on 01/02/2025 at 8:43 AM showed the clean utility room on the 2 North unit was unlocked. Eight blood collection kits with needles were observed uncontained on a shelf at waist height. A towel warmer device was present and in use in the utility room. The towel warmer was easily opened and not secured/locked.

In an interview on 01/02/2025 at 9:44 AM, Staff V (Licensed Practical Nurse - LPN) confirmed the eight blood collection kits in the unlocked utility room and stated they should be secured from residents. Staff V observed

the utility room door and confirmed there was no locking mechanism on the utility room door. Staff V stated

they did not have a key to lock the utility room.

In an interview on 01/10/2025 at 12:42 PM, Staff B (Director of Nursing) stated it was their expectation that needles/sharps be secured and out of resident reach.

50511

<4 South Unit>

Observation on 01/02/2025 at 9:39 AM showed the door to clean utility room was unlocked on the 4 South unit. The door opened freely and allowed access to bottles of shaving cream, body wash, and barrier incontinent creams stocked in utility room.

Observation on 01/02/2025 at 9:43 AM showed the spa room door was propped open on the 4 South unit. One bottle of disinfectant cleaner deodorant with warning label on bottle of disinfectant to keep out of reach of children and a caution warning to avoid contact with eyes and skin was observed in the spa.

In an interview on 01/10/2025 at 10:42 AM Staff K (Manager, Long Term Care Registered Nurse) stated the spa/tub room should be locked for safety reasons but was not.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 43 of 61 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 0689 43642

Level of Harm - Minimal harm or <Unsecured chemicals> potential for actual harm <SJR Unit> Residents Affected - Some

Observations 01/02/2025 at 10:03 AM on the SJR unit showed a laundry door open with a sign on the door that said, please keep door closed. There were no staff nearby the room. Inside the room was an unlocked cabinet that contained a bottle of disinfectant. On the bottle was a label that said, Danger, keep out of the reach of children. A bottle of laundry detergent was also in the unlocked cabinet. On top of the counter, in a basket with other items, was an aerosol spray can of a disinfectant and sanitizer. This can had a label which said, keep out of the reach of children. Observations on 01/02/2025 at 10:34 AM showed the door was closed but remained unlocked, there was no lockable mechanism on the door. The chemicals were still inside the room in an unlocked cabinet and on the counter.

In an interview on 01/10/2025 at 1:31 PM, Staff OO (Director of Operations) stated the door to the laundry room should remain closed and the chemicals should be locked and inaccessible to the residents.

47836

<5 North Unit>

Observation on 01/02/2025 at 9:23 AM showed the spa room and clean utility room on 5 North unit unlocked. One gallon bottle of a skin disinfectant/antiseptic solution, a spray bottle of a facility disinfectant cleaning solution were observed uncontained on a shelf in an open cabinet at knee height, and razors in an unlocked drawer in the spa room. The unlocked clean utility room on 5 North unit was observed to have razors and resident hygiene supplies uncontained.

In an interview on 01/02/2025 at 9:54 AM Staff HH (LPN) stated the spa and clean utility room were always left unlocked. Staff HH stated it could be dangerous for residents to leave the spa and clean utility room unlocked.

In an interview on 01/02/2025 at 9:54 AM Staff E (Resident Care Manager) stated both doors should remain locked, and staff should have keys, but the spa room lock was broken. Staff E acknowledged the chemicals and razors should be behind locked doors.

In an interview on 01/10/2025 at 12:35 PM Staff A (Administrator) stated their expectations were for chemicals to be behind locked containment and out of reach from residents. Staff A stated it was important to properly store chemicals and razors to ensure resident safety.

REFERENCE: WAC 388-97-1060(3)(g).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 44 of 61 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 0692 Provide enough food/fluids to maintain a resident's health.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 45941 potential for actual harm Based on observation, interview, and record review the facility failed to ensure residents weights were Residents Affected - Few accurately monitored for 1 of 7 residents (Resident 14) reviewed for nutrition. The failure to ensure resident weights were rechecked when appropriate and the physician notified as required placed residents at risk for weight loss, weight gain, and other negative health outcomes.

Findings included .

According to the facility's 10/2023 Weight and Nutrition Monitoring Policy, the facility would strive to prevent significant weight loss in residents. The policy showed changes in the residents' nutritional status and weight would be discussed routinely by clinical staff and the Registered Dietician (RD).

According to the 12/19/2024 Admission Minimum Data Set (MDS - an assessment tool) Resident 14 readmitted to the facility on [DATE REDACTED] and had diagnoses including anemia and malnutrition. The MDS showed Resident 14 was dependent on staff for transfers, personal hygiene, showers, toileting needs, and needed one-person set-up assistance for meals. The MDS showed Resident 14 weighed 151 pounds (lbs.) and had no significant weight loss during the assessment period.

Review of Resident 14's nutritional assessment completed on 12/19/2024 by Staff II showed Resident 14 was at risk for weight loss due to poor appetite. Staff II's assessment of Resident 14 instructed staff to notify them of any significant change in Resident 14's weight.

Review of Resident 14's weight record showed Resident 14's weight on 11/10/2024 was 155 lbs., on 12/13/2024 was 151.2 lbs., and on 01/03/2025 was 119.8 lbs.

Review of Resident 14's health record on 01/08/2025 showed no documentation staff reweighed Resident 14 to verify if the 01/03/2025 weight of 119.8 lbs. was accurate. There was no documentation showing nurses notified the physician or Staff II about Resident 14's potential 30 lbs. weight loss in three weeks.

In an interview on 01/09/2025 at 9:26 AM, Staff E (Director - Long Term Care, Registered Nurse) stated Resident 14's health record showed the resident lost over 30 lbs. weight since 12/13/2024. Staff E stated the facility process was to weigh residents weekly unless there was specific order by the provider. Staff E stated staff should have reweighed Resident 14 on 01/03/2025 as it was improbable they lost that much weight. Staff E stated the facility should have notified the provider but did not.

REFERENCE: WAC 388-97-1060 (3)(h).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 45 of 61 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 0697 Provide safe, appropriate pain management for a resident who requires such services.

Level of Harm - Minimal harm or 47836 potential for actual harm Based on observation, interview, and record review the facility failed to ensure pain management was Residents Affected - Few provided to residents consistent with professional standards of practice including the failure to complete a thorough pain assessment prior to as needed (PRN) pain medication administration and have pain medications readily available for 2 of 7 residents (Resident 120 & 28) reviewed for pain management. These failures placed residents at risk for experiencing untreated pain and a decreased quality of life.

Findings included .

According to a 09/25/2024 Annual Minimum Data Set (MDS - an assessment tool) Resident 120 had no cognitive impairment. The MDS showed Resident 120 had a diagnosis of chronic pain and received routine and PRN pain medications without any nonpharmacological pain interventions implemented. The MDS showed Resident 120 experienced pain more than five days during the assessment period and their pain occasionally affected their sleep and day to day activities.

Review of a 09/27/2024 Altered Comfort related to Chronic Pain and Muscle Spasm Care Plan (CP) showed staff would assess pain routinely and collaborate with Resident 120 to ensure pain relief.

Review of Resident 120's physician orders showed a 11/12/2024 narcotic pain medication to be administered every eight hours PRN.

Review of Resident 120's November 2024, December 2024, and January 2025 Medication Administration Records (MAR) showed a PRN narcotic pain medication with pain level, location, interventions, and amount as areas to document as part of the pain assessment prior to administration. These MARs showed inaccurate, and incomplete pain assessments prior to administration of the PRN narcotic pain medication for Resident 120.

In an interview on 01/03/2025 at 1:35 PM Resident 120 stated the staff did not administer their pain medications timely and did not assess their pain prior to administration. Resident 120 stated they requested

the provider schedule the pain medication routinely to ensure timely administration.

In an interview on 01/07/2025 at 1:21 PM Staff K (Manager Long Term Care Registered Nurse) stated they expected staff to complete the pain assessment including documentation of Resident 120's pain level, pain location, dosing amount, and non-pharmacologic interventions prior to PRN pain medication administration. Staff K stated staff did not consistently document Resident 120's pain level, pain location, correct dose administered, or offered nonpharmacological pain interventions prior to administration, but should have.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 46 of 61 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 0697 In an interview on 01/09/2025 at 10:01 AM Staff B (Director of Nursing) stated they expected staff to document an accurate and thorough pain assessment prior to all PRN pain medication administration. Staff Level of Harm - Minimal harm or B stated as part of the pain assessment they expected staff to document the residents pain level per the 1-10 potential for actual harm pain scale, the location of the pain, nonpharmacological pain interventions provided, and the effectiveness of

the pain medication. Staff B stated it was important to complete pain assessments to ensure good pain Residents Affected - Few management and quality of life for residents.

50511

According to the facility's 12/2024 Pain Management policy, a resident who had a major change in pain regimen was put on alert charting and pain was assessed every shift while on alert. The policy showed current pain medications, and their effectiveness were reviewed in collaboration with the provider as indicated and documented in progress notes every shift when on alert for pain-related issues.

According to a 11/20/2024 Annual MDS, Resident 28 had chronic pain and was taking pain medications for their condition without nonpharmacological pain interventions implemented.

Review of a 02/19/2021 Altered Comfort CP showed Resident 28 was in constant pain and received pain medication to relieve pain related to chronic wounds.

In an interview on 01/03/2025 at 10:03 AM Resident 28 stated they had pain to their right thigh, and they took pain medications several times a day because of their chronic wounds.

In an interview on 01/06/2025 at 9:39 AM Resident 28 stated the night nurse informed them the facility did not have their PRN pain medication. The medication did not arrive from the pharmacy. Resident 28 stated staff gave them an over-the-counter pain medication for their breakthrough pain but was frustrated because

the facility ran out of their medications before, and they didn't understand how this kept happening.

Review of a progress note entry on 01/06/2025 at 10:45 PM showed the nurse called the pharmacy on 01/05/2025 and again on 01/06/2025 to reorder Resident 28's pain medication. The pharmacy responded the pain medication was to be delivered. The progress note showed the nurse was not able to obtain the medication from the emergency medication supply kit because the pain medication was not in the kit.

Review of a progress note entry on 01/07/2025 at 1:30 AM showed the nurse wrote that they did not receive

a medication delivery for Resident 28's pain medication. Review of the progress notes showed Resident 28 was not on alert charting for pain while the facility was awaiting delivery of the pain medication.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 47 of 61 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 0697 In an interview on 01/09/2025 at 2:02 PM Staff K stated the facility switched to another pharmacy recently which may have contributed to the delay. Staff K stated the pharmacy reported they would refill the Level of Harm - Minimal harm or medication on 01/05/2025, but they did not. Staff K stated the nurses should have pulled the pain medication potential for actual harm from the facility emergency supply kit, notify nursing management, notify the provider, and document in the progress notes. Staff K stated the nurses did not follow the facility protocol but should have. Residents Affected - Few REFERENCE: WAC 388-97-1060(1).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 48 of 61 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 0726 Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. Level of Harm - Minimal harm or potential for actual harm 45941

Residents Affected - Some Based on interview and record review the facility failed to ensure nursing staff had the appropriate competencies and skill sets to provide nursing and related services, to assure resident safety, and attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident according to resident assessments and plans of care for 4 of 4 facility staff (Staff Q - Certified Nursing Assistant), Staff W Registered Nurse (RN), Staff X - (RN), and Staff Y - (RN)) randomly selected and reviewed for competency. Additionally, the facility failed to ensure proficiency of nursing staff. The failure of nursing and nurse aide staff, to demonstrate a measurable pattern of knowledge, skills, abilities, behaviors that nurses need to perform work roles successfully, resulted in deficiencies related to the competency of nursing staff.

Findings included .

The 2024 Facility Assessment review date 10/14/2024 showed training, education and competencies of nurses and nurse aides were necessary to provide support and care to the residents of the facility. The Facility Assessment showed nurses and nursing assistants would complete a skills assessment upon hire and competency-based skills assessments annually. The Facility Assessment showed the facility would provide education and verify competency of nursing staff in the areas of abuse and neglect, resident rights, dementia care, infection control, communication, and specific resident needs based on the person-centered care plans. The Facility Assessment showed the facility would also provide Nurse Assistant training, education, and verify competency in the areas of personal care skills, vital sign monitoring, safety and mobility, communication and empathy, infection control, emergency protocols, and cultural competency.

In an interview on 01/08/2025 at 12:20 PM, Staff B (Director of Nursing) stated they were responsible for nursing staff's competency and oversight, completed staff evaluations to assess staff competencies, skills, and knowledge upon hiring and annually. Staff B was asked to provide verification of competency documentation for Staff Q, Staff W, Staff X, and Staff Yand Staff B could not provide competency performance evaluations as requested.

In an interview on 01/10/2025 at 9:23 AM, Staff A (Administrator) stated the facility should complete nursing staff evaluation to assess their competencies, skills, and knowledge to provide safe care to residents, but the facility did not assess the nursing staff's competency as required.

Refer to

Providence Mount St Vincent

Inspection Findings

F-Tag F550

F-Tag F610

F-Tag F686

F-Tag F849

F-Tag F880

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