Mount Ascension Transitional Care of Cascadia

In the surveyor’s words

From the most serious findings on record at Mount Ascension Transitional Care of Cascadia, in the surveyor’s own words.

• Immediate jeopardy, widespreadF880Jan 5, 2023

  Based on observation, interview, and record review it was determined there was a system failure for the prevention of infections. The facility failed to identify and protect residents from infection of Influenza A. There were 13 residents in transmission-based precautions for positive or presumed positive Influenza A (#s 10, 15, 17, 21, 22, 29, 32, 33, 34, 42, 53, 66, and 68) during the survey. The first resident was positive for Influenza A on 12/22/22, and within one week, there were 13 residents positive for Influenza A. Resident #10 was admitted to the hospital. This failure had the potential to cause a widespread Influenza outbreak throughout the facility. […]

• Actual harm, patternF725Jan 5, 2023

  Based on observation, interview, and record review, the facility failed to maintain enough staff to effectively manage the care needs of the residents, which lead to a delay in response for resident call lights for 8 (#s 10, 12, 25, 36, 41, 42, 44, and 52) of 8 sampled residents; failed to provide adequate wound care for 1 (#68) of 6 sampled residents; failed to provide physical therapy as ordered for 2 (#s 37 and 52 ) of 5 sampled residents; failed to weigh residents as ordered to monitor for weight loss for 2 (#s 9 and 52) of 5 sampled residents; and failed to provide showers as scheduled for 1 (#23) of 5 sampled residents. These failures had residents feeling mad, frustrated, stranded and unworthy, and for some, they struggled with incontinence due to long wait times. […]

• Actual harm, isolatedF689Mar 24, 2026

  Based 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 . Findings include:During a telephone interview on 3/23/26 at 1:40 p.m., NF4 stated resident #19 had been declining for the past couple of months, with increased confusion, weight loss, agitation, and right hip and leg pain. […]

• Actual harm, isolatedF689Oct 16, 2024

  Based 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. Findings include: 1. During an interview on 10/15/24 at 9:25 a.m., resident #1 stated he had a broken hip because a CNA dropped him when transferring him on the toilet. Resident #1 stated he was supposed to have two people for transfers but only one person the night he fell . […]

• Actual harm, isolatedF686May 21, 2024

  Based 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. […]