Mount Ascension Transitional Care of Cascadia

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement and operationalize an effective grievance process and failed to thoroughly investigate, document, track, and resolve grievances, including failing to provide a written grievance decision upon request, for 1 (#10) of 11 sampled residents. The facility also failed to prominently post and include within the facility grievance policy the required contact information for the designated grievance official (name, business mailing address, business email, and business telephone number), which may affect any resident wishing to file a grievance at the facility. These failures resulted in a family member not receiving a timely written resolution to four grievances submitted to the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the provision of pharmaceutical services to ensure ordered medications were available which resulted in missed doses of prescribed pain medications, interruption in pain management, and delayed care, and resident medications were not acquired, received, dispensed and or administered as needed or ordered by the physician, for 2 (#s 2 and 3) of 11 sampled residents. This failure contributed to the ongoing risk for resident #2, who had a diagnosis of Stage IV cancer and required high-dose pain medication(s) for pain relief, and this increased the risk for uncontrolled symptoms of pain.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents received showers and assistance for their assessed needs and physician orders for 2 (#s 8 and 9) of 11 sampled residents. The deficient practice resulted in both residents going approximately 12 to 13 days without a shower. Resident #9 had a physician's order requiring a minimum of four showers per week due to colostomy care needs, and the lack of showering increased the risk of compromised personal hygiene and skin integrity concerns.

Inspectors wroteBased on interview and record review, the facility failed to ensure nursing aides received performance evaluations that were completed and maintained, at least annually for 3 staff members (C, D, and E) of 3 employee files sampled. This resulted in the absence of documented assessments of employee performance, feedback, and opportunities to identify education or performance improvement needs. The deficient practice increased the risk that all residents receiving care from nurse aides could be affected by unrecognized performance deficits.

Inspectors wroteBased on interview and record review, the facility failed to ensure a timely, comprehensive interdisciplinary team (IDT) post-fall assessment, including root cause analysis, implementation of effective interventions, and care plan updates, was completed for avoidable falls, for 1 (#19) of 9 sampled residents. The failure resulted in the resident experiencing additional falls, and the resident had a major injury and was hospitalized .

Inspectors wroteBased on interview and record review, the facility failed to develop and implement an effective, comprehensive, data-driven Quality Assurance and Performance Improvement (QAPI) program. The facility identified multiple Performance Improvement Projects (PIPs); however, failed to implement, monitor, and sustain effective corrective actions. The failure resulted in ongoing quality of care and service concerns without resolution and placed all residents at risk for continued substandard care and negative outcomes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a clean, sanitary, and homelike environment for 2 (#s 1 and 13) of 9 sampled residents. The failure placed residents at risk for exposure to unsanitary environmental conditions and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement appropriate infection prevention and control practices, including hand hygiene, transmission-based precautions, and personal protective equipment (PPE), for 1 (#42) of 9 sampled residents. The failure placed residents, staff, and visitors at risk for transmission of COVID-19 and other infectious diseases.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were not left at the bedside for resident self-administration without a physician order and safety assessment for 1 (#42) of 9 sampled residents. The failure placed the resident at risk for choking, aspiration, and medication errors.

Inspectors wroteBased on interview and record review, the facility failed to ensure physician ordered services were provided in accordance with professional standards for 1 (#99) of 9 sampled residents. The failure resulted in the resident not receiving ordered physical therapy services and placed the resident at risk for decline in mobility, strength, and functional status.

Inspectors wroteBased on observation, interview, and record review, the facility's kitchen staff failed to handle food in a clean and sanitary manner during meal service to prevent potential contamination. These deficient practices were observed in the food preparation area during meal service and resulted in unsanitary conditions in the kitchen. These failures may affect any resident who received food from the kitchen when sanitation practices were not upheld.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure staff utilized personal protective equipment properly during care of residents who were positive with COVID-19, and for a resident who was on droplet precautions, for 3 (#s 7, 10, and 32) of 18 sampled and supplemental residents; and failed to maintain a system of communicable disease surveillance for tracking of active infections in the facility. The deficient practices placed residents, staff, and visitors at risk for the transmission of infections.

Inspectors wroteBased on interview and record review, the facility failed to maintain an infection surveillance and antibiotic stewardship program to ensure tracking of effective and efficient antibiotic therapies for residents residing in the facility.

Inspectors wroteBased on observation and interview, the facility staff failed to ensure a resident was assisted with maintaining a dignified existence when the staff did not identify and provide personal care to a female resident who had dark facial hair that she wanted shaved off, and the facial hair bothered the resident, for 1 (#71) of 15 sampled residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure an investigation of a facility reported incident was completed with thorough documentation of the findings for 1 (#70) of 15 sampled residents.

Inspectors wroteBased on interview and record review, the facility failed to provide a written notice of the reason for a facility-initiated transfer or bed hold to the resident or the resident's representative, for 1 (#74) of 15 sampled residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure a baseline care plan was developed within 48 hours after a resident's admission, to reflect monitoring of high-risk medications used by the resident, for 1 (#79) of 15 sampled residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement a care plan for individualized shower preferences to maintain resident cleanliness and ensure the resident felt their hygiene needs were met, for 1 (#42) of 15 sampled residents.

Inspectors wroteBased on interview and record review, the facility failed to update a resident care plan based on an individual resident's care needs related to behaviors exhibited, for 1 (#70) of 15 sampled residents. This deficient practice placed resident #70 at risk for unmet needs and or the lack of behavior monitoring to identify changes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide ADL assistance to a resident who required staff assistance with bathing, for 1 (#42) of 15 sampled residents. The deficient practice resulted in a resident feeling unclean.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide necessary care and services to promote the highest practicable well-being for range of motion for 1 (#71) of 15 sampled residents. The resident's range of motion limitations affected her ability to complete or participate in ADL care and increased the risk of continued deterioration in range of motion.

Inspectors wroteBased on observation, interview, and record review, the facility failed to review the risks and benefits of using a mobility bar and failed to obtain safety measurements for mobility bars attached to the bed, for 2 (#s 1 and 71) and failed to obtain informed consent prior to the installation of the mobility bar for 1 (#71) of 15 sampled residents. The failure placed the residents at risk for entrapment.

Inspectors wroteBased on interview and record review the facility failed to provide a medication to meet the needs of 1 (#60) of 15 sampled residents. The failure to provide medication in a timely manner could prolong illness of Covid-19. Review of resident #60's physician note, dated 2/9/26, showed resident #60 had a chronic illness and was being treated with chemotherapy for metastatic cancer. Review of resident #60's nursing progress note, dated 2/21/26, at 5:04 p.m., showed that resident #60 tested positive for COVID-19. The physician ordered Molnupiravir (an oral antiviral medication for treating mild-to-moderate Covid-19 in high-risk, non-hospitalized patients) to treat resident #60's COVID-19. Review of resident #60's nursing progress note, dated 2/22/26, at 5:51 p.m., showed that Molnupiravir (medication) to treat COVID-19 was supposed to be delivered on Monday (2/23/26), in the morning. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to label a medication with an open date and failed to dispose of an expired vaccine. This deficient practice had the potential to affect any resident using the identified medications/supplies.

Inspectors wroteBased on interview and record review, the facility failed to ensure documentation for the education, and the signed consent or declination of the influenza or pneumococcal immunizations by the resident or their responsible party, for 1 (#5) of 5 residents sampled for vaccinations.

Inspectors wroteBased on interview and record review, the facility failed to ensure documentation was completed and maintained to show education was provided to the resident or their representative related to the risks and benefits of the COVID-19 vaccination, for 1 (#5) of 5 sampled residents for vaccinations.

Inspectors wroteBased on interview, and record review, the facility failed to ensure staff received facility specific restraint and abuse prevention training prior to providing resident care to keep a resident free from a physical restraints for 1 (#3) of 9 sampled residents. This deficient practice resulted in the resident biting at the placed hand restraints causing their tooth to break. The deficient practice increased the risk of imminent harm related to restraints. The facility identified the failure of staff utilizing physical restraints and addressed and corrected the deficient practice before the survey, resulting in the findings of past non-compliance.

Inspectors wroteBased on interview and record review, the facility failed to complete a thorough investigation, take corrective action to ensure the safety of a resident with a known elopement attempt, and maintain documentation of the investigation involving the resident who left the protective oversight of the facility when transported to a dental visit, and he was left unattended, and then left the dental office alone and traveled to a relative's house, approximately two miles away. The resident's location was unknown for approximately one hour, for 1 (#2) of 3 sampled residents for wandering and elopement risk. The facility's failure to address these concerns placed this resident at continued risk of harm.

Inspectors wroteBased on interview, and record review, the facility failed to modify care plan interventions to reduce the risk of elopement, failed to provide routine behavioral monitoring for a resident with a known elopement risk, failed to provide supervision of a resident with a known elopement risk during transport to a medical appointment which resulted in the resident leaving unsupervised, failed to conduct an interdisciplinary investigation of an elopement, and failed to ensure a resident's care plan interventions were updated to prevent the reoccurrence of an elopement for 1 (#2) of 9 sampled residents. The facility's failure to address these concerns placed this resident at a continued risk of elopement and or harm.

Inspectors wroteBased on interviews and record reviews, the facility failed to uphold and operationalize policies and procedures related to grievances and take immediate action to prevent further grievances or address abuse and neglect included in grievances. Due to the lack of follow-up, those residents or individuals submitting the grievances had no resolution to their identified concerns, and there was no documentation of facility efforts to resolve the grievances. This deficient practice resulted in many residents or individuals not having concerns addressed, and increased the risk of ongoing nursing care or abuse and neglect concerns. For those grievances submitted, which were not investigated, 4 (#s 1, 2, 4, and 5) of 7 sampled residents were affected, and this was a system breakdown.

Inspectors wroteBased on interviews and record reviews, the facility failed to identify and report accusations of abuse and/or neglect by staff to The State Survey Agency for 3 (#s 1, 4, and 5) of 7 sampled residents. This deficient practice increased the risk of harm to residents by the accused staff.

Inspectors wroteBased on interviews and record reviews, the facility failed to thoroughly investigate alleged violations of abuse or neglect by staff, to prevent further abuse, neglect, or mistreatment from occurring, and take appropriate corrective action, as a result of investigation findings for 3 (#s 1, 4, and 5) of 7 sampled residents. This deficient practice placed residents at risk of harm from further abuse, neglect or mistreatment by staff members accused.

Inspectors wroteBased on interview and record review, the facility failed to evaluate and revise a care plan after a resident's elopement for 1 (#8) of 17 sampled residents, and ensure the staff were educated on the care plan. This deficient practice increases the risk for additional elopements as well as injury.

Inspectors wroteBased on interview and record review, the licensed nurse failed to follow a provider's order and process it timely for a resident's urine analysis (UA) with reflex culture for 1 (#12) of 17 sampled residents. This deficient practice resulted in a five-day delay in diagnosing a UTI.

Inspectors wroteBased on interview and record review, facility nursing staff failed to identify a change in condition of a resident for 1 (#5) of 17 sampled residents. This deficient practice resulted in an 11-day delay of testing and treatment for a resident who had a UTI.

Inspectors wroteBased on interviews and record reviews, the facility failed to have a registered nurse working at least eight consecutive hours a day, seven days a week. This deficient practice increased the risk to all residents at the facility, in the event RN services were required, but an RN was not scheduled and on shift to provide RN services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff practiced appropriate use of personal protective equipment (PPE), during care of residents on enhanced barrier precautions (EBP) on 100 north hall, for 5 (#s 42, 49, 51, 56, and 232) of 30 sampled residents.

Inspectors wroteBased on interview and record review, the facility failed to maintain the antibiotic stewardship program to include infection surveillance and monitoring of antibiotic use. This deficient practice increased the risk of a negative outcome for all residents receiving prescribed antibiotics who were at an elevated risk for multi drug-resistant infections.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were screened for influenza, pneumonia, and COVID-19 immunizations; and failed to offer or obtain a signed declination for pneumococcal vaccines, for 3 (#s 28, 45 and 232) of 5 residents sampled for immunizations.

Inspectors wroteBased on interview and record review, the facility staff failed to respect a resident's rights by not following up with a request's request to be sent to the emergency room when the resident was not feeling well, and a visitor called the ambulance for the transfer to the acute care setting, for 1 (#11) of 30 sampled residents.

Inspectors wroteBased on interview and record review, the facility failed to identify and report an allegation of neglect to the State Survey Agency, within 24 hours of the incident, for 1 (#11) of 30 sampled residents.

Inspectors wroteBased on interviews and record reviews, a facility licensed staff member failed to provide services that met professional standards, by failing to monitor a resident's need for oxygen, and monitor the resident's need to transition to an acute care facility, for further assessment, for 1 (#11) of 30 sampled residents. The resident was treated for an illness at the acute care hospital.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure physician orders were present in the EHR for 2 (#s 2 and 5) residents; and failed to ensure oxygen supplies/equipment were labeled consistently to show the date the supplies were cleaned or changed, for 5 (#s 1, 4, 5, 6, and 7) sampled residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to encourage and properly implement resident dietary preferences for 1 (#10); and failed to have a consistent process in place to address therapeutic diets over the weekend, when a new diet was ordered/modified, to ensure the change was addressed timely for safety, for 1 (#10) of 10 sampled residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain water temperatures that were within the CDC's recommended temperatures to prevent the growth of legionella; and obtain water temperatures in resident areas for 4 (#s 1, 4, 5, and 8) of 10 sampled residents; failed to ensure temperatures were completed frequently enough to follow the facility policy; failed to provide staff with adequate Legionella education; and failed to properly clean areas where legionella could be found (such as the eyewash stations, an ice machine, and sinks/toilets specifically, for 1 (#9) of 10 sampled residents; and failed to ensure oversight or intervention was completed from the infection preventionist when a resident was recently diagnosed with legionella.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide adequate assistance to prevent injury for 1 (#1); and ensure the residents' environment was free from smoking and vapes creating accident hazards for 3 (#s 1, 2, and 3) of 10 sampled residents investigated regarding smoking and falls. This deficient practice resulted in a fractured hip for resident #1, and created an accident hazard for the residents.

Inspectors wroteBased on interviews and record reviews, the facility failed to conduct quarterly and annual care conferences and include residents and their representatives to facilitate ongoing participation in the plan of care and goals, for 7 (#s 1, 9, 10, 11, 12, 13, and 14) of 7 sampled residents investigated regarding care conferences.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure residents knew how to file a grievance, resolve resident grievances promptly, and maintain evidence demonstrating the result of all grievances for a period of no less than 3 years from the issuance of the grievance decision, for 8 (#s 1, 4, 5, 6, 7, 8, 9, and 15) of 15 sampled residents investigated regarding grievances. Failure to thoroughly investigate grievances had the potential to result in failure to recognize and address potential resident abuse, neglect, or other care and service concerns that needed to be addressed.

Inspectors wroteBased on interviews and record review, the facility failed to report to the State Survey Agency and Adult Protective Services, allegations of abuse by staff for 1 (#15); and report findings for one investigation to the State Survey Agency, for 1 (#16) of 16 sampled residents.

Inspectors wroteBased on interviews and record review, the facility failed to thoroughly investigate and prevent further potential abuse while the investigation was in progress for allegations of abuse by staff for 1 (#15) of 16 sampled residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 2 (#s 6 and 15) of 4 sampled residents did not develop a new pressure ulcer or have worsening of pressure ulcers. Outcomes included: Resident #6 developed a sacral pressure ulcer in eight days, which worsened to a Stage IV, the pressure ulcer was avoidable, and the resident had pain from the wound. The staff failed to identify, report, and assess the skin as necessary, failed to develop and implement interventions to reduce skin pressure timely, and failed to complete dressing changes as ordered once the wound developed, for #6. For resident #15, the resident developed a Stage III pressure ulcer resulting from a skin tear caused during the provision of care. The facility failed to develop and implement pressure ulcer prevention strategies staff failed to follow physician orders for wound care.

Inspectors wroteBased on interview and record review, licensed nursing and certified staff failed to follow standards of practice for wound care, for 1 (#6) of 5 sampled residents; Resident #6 developed a pressure ulcer which deteriorated to a Stage IV. It was identified physician orders for treatments were not followed multiple times, over multiple shifts, and on multiple days.

Inspectors wroteBased on interview and record review, it was identified the facility staff were aware of a resident's wound status, and use of a mechanical lift, but failed to develop a care plan problem, goals, or interventions for the prevention of the pressure ulcer to her right heel and back, for 1 (#15); and failed to develop a care plan for pain management for a resident who had pain during wound care, for 1 (#6) out of 5 sampled residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure 1 (#6) of 3 sampled residents was medicated for pain 30 minutes prior to pressure ulcer dressing changes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a baseline care plan, and provide the resident or their representative with a written summary of the resident's baseline care plan, for 1 (#114) of 16 sampled residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the established care plan, evaluate the effectiveness of interventions, or revise the comprehensive care plan for 1 (#1) of 16 sampled residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the care and services necessary for contractures and the ROM for residents admitted with limited range of motion, for 2 (#s 1 and 39) of 2 sampled residents with contractures.

Inspectors wroteBased on interview and record review the facility failed to ensure a nurse aide completed a NATCEP program within four months of full-time employment at the facility, for 1 (staff member K) of 3 sampled staff members.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the medication error rate was less than five percent affecting 2 (#s 3 and 17) of 4 sampled residents. The calculated error rate was 8.11 percent.

Inspectors wroteBased on interview and record review, facility staff failed to provide a Notice of Transfer/Discharge to the resident or resident's representative, for 1 (#34) of 16 sampled residents.

Inspectors wroteBased on interview and record review, facility staff failed to provide a Notice of Bed Hold to a resident or resident's representative, for 1 (#34) of 16 sampled residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure they maintained an effective training program for all newly hired and existing staff and staff providing services under contractual agreement, ensuring staff received training during orientation regarding prohibiting and prevention of abuse, neglect, misappropriation of resident property and exploitation for 4 (staff members C, D, G, and H) of 10 staff members. This deficient practice had the potential to affect residents provided services by the staff who had not recieved the abuse prevention training.

Inspectors wroteBased on interview and record review, the facility failed to ensure hired personnel had a completed criminal background check prior to working at the facility for 1 (Staff member I) of 10 staff members. This deficient practice had the potential to affect all residents of the facility.