Deficiency Records for Mount Ascension Transitional Care of Cascadia
Updated as of March 01, 2024
A list of the most recent deficiencies for Mount Ascension Transitional Care of Cascadia. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Establish policies and procedures for volunteers. | Fire Safety | 2024-01-03 | 2024-02-05 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2024-01-03 | 2024-02-05 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2024-01-03 | 2024-02-05 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-01-03 | 2024-02-05 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-01-03 | 2024-02-05 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2024-01-03 | 2024-02-05 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2024-01-03 | 2024-02-05 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2023-12-21 | 2024-02-02 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-12-21 | 2024-01-27 | N |
| 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. | Health | 2023-12-21 | 2024-01-27 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-12-21 | 2024-01-27 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-12-21 | 2024-01-27 | N |
| Ensure that nurse aides who have worked more than 4 months, are trained and competent; and nurse aides who have worked less than 4 months are enrolled in appropriate training. | Health | 2023-12-21 | 2024-01-27 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-12-21 | 2024-01-27 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-11-08 | 2023-12-06 | Y |
| Develop, implement, and/or maintain an effective training program for all new and existing staff members. | Health | 2023-11-08 | 2023-12-06 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-01-05 | 2023-02-19 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2023-01-05 | 2023-02-19 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-01-05 | 2023-02-19 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-01-05 | 2023-02-19 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-01-05 | 2023-02-19 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-01-05 | 2023-02-19 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2023-01-05 | 2023-02-19 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-01-05 | 2023-02-19 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2023-01-05 | 2023-02-19 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-01-05 | 2023-02-19 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2023-01-05 | 2023-02-19 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-01-05 | 2023-02-19 | N |
| 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 locked, compartments for controlled drugs. | Health | 2023-01-05 | 2023-02-19 | N |
| Provide or obtain dental services for each resident. | Health | 2023-01-05 | 2023-02-19 | N |
| Provide or get specialized rehabilitative services as required for a resident. | Health | 2023-01-05 | 2023-02-19 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-01-05 | 2023-02-19 | N |
| Ensure staff are vaccinated for COVID-19 | Health | 2023-01-05 | 2023-02-19 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2023-01-09 | 2023-02-17 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-01-09 | 2023-02-17 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-01-09 | 2023-02-17 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-01-09 | 2023-02-17 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2023-01-09 | 2023-02-17 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-01-09 | 2023-02-17 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2021-12-27 | 2022-02-01 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2021-12-27 | 2022-02-01 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2021-12-27 | 2022-02-01 | N |
| Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2021-12-27 | 2022-02-01 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2021-12-27 | 2022-02-01 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-12-27 | 2022-02-01 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-12-27 | 2022-02-01 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2021-12-27 | 2022-02-01 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-12-27 | 2022-02-01 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2021-12-27 | 2022-02-01 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2021-12-27 | 2022-02-01 | N |
| Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency. | Health | 2021-12-22 | 2022-01-15 | N |
| 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. | Health | 2021-12-22 | 2022-01-15 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-12-22 | 2022-01-15 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-12-22 | 2022-01-15 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-12-22 | 2021-12-30 | Y |
