F0684

D

Failure to Provide Ordered Skin Care, Positioning, and Meal Assistance for Two Residents

Stanwood, Washington Survey Completed on 01-22-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide appropriate skin care and treatment according to physician orders and resident needs for a resident with Parkinson’s disease, cerebellar ataxia, dementia, and muscle weakness. The resident, who had no documented cognitive impairment on a recent MDS, reported to a collateral contact that a rash on their toes and feet had worsened and was painful, and that staff did not clean their feet before applying prescribed ointment. The collateral contact observed the resident’s toes and feet as red, discolored, and with skin breakdown. The resident’s care plan documented chronic dermatitis to the lower extremities and later a fungal rash to both toes, and there was a long-standing order for Triamcinolone 0.1% ointment to be applied twice daily for rash, but the order lacked a specific application site and end date. Review of the MAR and TAR over several months showed no documentation of monitoring the skin condition of the feet/toes or cleaning the skin prior to ointment application. Nursing staff confirmed the ointment was applied to both feet and that the feet had not been cleaned prior to application until a specific date, and the DON acknowledged the order lacked a specific site and end date and could not clearly describe expectations for documenting and monitoring skin issues.

The deficiency also involves the facility’s failure to follow care plan interventions for positioning and pressure injury prevention for a resident with a history of stroke, right-sided hemiplegia/hemiparesis, and existing pressure injuries to the right outer ankle and left heel. The resident’s MDS documented moderate cognitive impairment, a need for substantial/maximal assistance with bed mobility, supervision or touching assistance with meals, and risk for pressure ulcers. The care plan directed staff to provide substantial/maximal assistance with two staff for bed mobility and to float the resident’s heels when in bed as they allowed. Multiple observations showed the resident in bed with heels and feet lying directly on the mattress surface, including times when the lower legs were uncovered and when a pillow under the calves still left one heel resting directly on the bed. At another time, the resident was positioned on their side with their torso leaning toward the edge of the bed, knees hanging over the mattress edge, and the right outer ankle lying directly on the mattress.

In addition, the facility failed to ensure appropriate assistance with meals for this same resident, who required supervision or touching assistance and only occasional monitoring and cueing after setup. Surveyors observed an untouched lunch tray on the overbed table within reach of the resident on multiple occasions over several hours, with no staff present to assist or supervise. Later observations showed the resident in the same position with the lunch tray still untouched, and when asked, the resident inaccurately reported having eaten lunch. Nursing assistants interviewed described relying on Kardex information in the closet or EMR and communication from licensed nurses or nurse managers for care directions, but the observed lack of meal assistance and positioning did not align with the resident’s documented needs and care plan requirements.