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🔎 Mount Ascension Transitional Care Of Cascadia

Inspection Results


Inspection Overview

Mount Ascension Transitional Care Of Cascadia has been cited for a total of 57 deficiencies since we began saving each survey.

In Montana, the average facility has **36.01 deficiencies** in our database. This profile shows the longer-term view.

Tip: Surveys happen throughout the year. Always check the official Medicare Care Compare site for the most recent data.



Understanding Deficiency Severity (A-L Scale)

The farther along in the alphabet (A through L) the Scope value is, the more severe the deficiency. **A through F means no actual harm has happened.**

Severity (Harm)Scope (Widespread?)Code Range
No Actual HarmIsolated to PatternA - C
No Actual HarmWidespreadD - F
**Actual Harm**IsolatedG
**Actual Harm**PatternH
**Actual Harm**WidespreadI
**Immediate Jeopardy**IsolatedJ
**Immediate Jeopardy**PatternK
**Immediate Jeopardy**WidespreadL


Detailed Deficiency List (Most Recent First)

Scope/Severity: F

Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.

Survey Date: 2025-01-16
Correction Date: 2025-02-24
Category: Nursing and Physician Services Deficiencies
From Complaint: N

Scope/Severity: E

Provide and implement an infection prevention and control program.

Survey Date: 2025-01-16
Correction Date: 2025-02-24
Category: Infection Control Deficiencies
From Complaint: N

Scope/Severity: E

Implement a program that monitors antibiotic use.

Survey Date: 2025-01-16
Correction Date: 2025-02-24
Category: Infection Control Deficiencies
From Complaint: N

Scope/Severity: E

Develop and implement policies and procedures for flu and pneumonia vaccinations.

Survey Date: 2025-01-16
Correction Date: 2025-02-24
Category: Infection Control Deficiencies
From Complaint: N

Scope/Severity: D

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Survey Date: 2025-01-16
Correction Date: 2025-02-24
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: D

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Survey Date: 2025-01-16
Correction Date: 2025-02-24
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: D

Ensure services provided by the nursing facility meet professional standards of quality.

Survey Date: 2025-01-16
Correction Date: 2025-02-24
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: Y

Scope/Severity: E

Provide safe and appropriate respiratory care for a resident when needed.

Survey Date: 2024-12-17
Correction Date: 2025-01-21
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: D

Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.

Survey Date: 2024-12-17
Correction Date: 2025-01-21
Category: Nutrition and Dietary Deficiencies
From Complaint: Y

Scope/Severity: D

Provide and implement an infection prevention and control program.

Survey Date: 2024-12-17
Correction Date: 2025-01-21
Category: Infection Control Deficiencies
From Complaint: Y

Scope/Severity: F

Allow resident to participate in the development and implementation of his or her person-centered plan of care.

Survey Date: 2024-10-16
Correction Date: 2024-11-08
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: E

Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.

Survey Date: 2024-10-16
Correction Date: 2024-11-08
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: D

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Survey Date: 2024-10-16
Correction Date: 2024-11-08
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: D

Respond appropriately to all alleged violations.

Survey Date: 2024-10-16
Correction Date: 2024-11-08
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: G

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Survey Date: 2024-10-16
Correction Date: 2024-11-08
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: D

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Survey Date: 2024-05-21
Correction Date: 2024-06-19
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: Y

Scope/Severity: E

Ensure services provided by the nursing facility meet professional standards of quality.

Survey Date: 2024-05-21
Correction Date: 2024-06-19
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: Y

Scope/Severity: G

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Survey Date: 2024-05-21
Correction Date: 2024-06-19
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: D

Provide safe, appropriate pain management for a resident who requires such services.

Survey Date: 2024-05-21
Correction Date: 2024-06-19
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: B

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

Survey Date: 2023-12-21
Correction Date: 2024-01-27
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: B

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.

Survey Date: 2023-12-21
Correction Date: 2024-01-27
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

Survey Date: 2023-12-21
Correction Date: 2024-01-27
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Survey Date: 2023-12-21
Correction Date: 2024-01-27
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

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.

Survey Date: 2023-12-21
Correction Date: 2024-02-02
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

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.

Survey Date: 2023-12-21
Correction Date: 2024-01-27
Category: Nursing and Physician Services Deficiencies
From Complaint: N

Scope/Severity: D

Ensure medication error rates are not 5 percent or greater.

Survey Date: 2023-12-21
Correction Date: 2024-01-27
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: D

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Survey Date: 2023-11-08
Correction Date: 2023-12-06
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: E

Develop, implement, and/or maintain an effective training program for all new and existing staff members.

Survey Date: 2023-11-08
Correction Date: 2023-12-06
Category: Administration Deficiencies
From Complaint: Y

Scope/Severity: D

Reasonably accommodate the needs and preferences of each resident.

Survey Date: 2023-01-05
Correction Date: 2023-02-19
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

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.

Survey Date: 2023-01-05
Correction Date: 2023-02-19
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

Ensure each resident receives an accurate assessment.

Survey Date: 2023-01-05
Correction Date: 2023-02-19
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

Survey Date: 2023-01-05
Correction Date: 2023-02-19
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Survey Date: 2023-01-05
Correction Date: 2023-02-19
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: G

Ensure services provided by the nursing facility meet professional standards of quality.

Survey Date: 2023-01-05
Correction Date: 2023-02-19
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: E

Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.

Survey Date: 2023-01-05
Correction Date: 2023-02-19
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: G

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Survey Date: 2023-01-05
Correction Date: 2023-02-19
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Survey Date: 2023-01-05
Correction Date: 2023-02-19
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: H

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

Survey Date: 2023-01-05
Correction Date: 2023-02-19
Category: Nursing and Physician Services Deficiencies
From Complaint: N

Scope/Severity: D

Ensure each resident must receive and the facility must provide necessary behavioral health care and services.

Survey Date: 2023-01-05
Correction Date: 2023-02-19
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Survey Date: 2023-01-05
Correction Date: 2023-02-19
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: E

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.

Survey Date: 2023-01-05
Correction Date: 2023-02-19
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: D

Provide or obtain dental services for each resident.

Survey Date: 2023-01-05
Correction Date: 2023-02-19
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Provide or get specialized rehabilitative services as required for a resident.

Survey Date: 2023-01-05
Correction Date: 2023-02-19
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: L

Provide and implement an infection prevention and control program.

Survey Date: 2023-01-05
Correction Date: 2023-02-19
Category: Infection Control Deficiencies
From Complaint: N

Scope/Severity: E

Ensure staff are vaccinated for COVID-19

Survey Date: 2023-01-05
Correction Date: 2023-02-19
Category: Infection Control Deficiencies
From Complaint: N

Scope/Severity: C

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.

Survey Date: 2021-12-22
Correction Date: 2022-01-15
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

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.

Survey Date: 2021-12-22
Correction Date: 2022-01-15
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

Provide and implement an infection prevention and control program.

Survey Date: 2021-12-22
Correction Date: 2022-01-15
Category: Infection Control Deficiencies
From Complaint: N

Scope/Severity: D

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Survey Date: 2021-12-22
Correction Date: 2021-12-30
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: D

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Survey Date: 2021-12-22
Correction Date: 2022-01-15
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: E

Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.

Survey Date: 2020-03-05
Correction Date: 2020-08-21
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

Survey Date: 2020-03-05
Correction Date: 2020-08-21
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

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.

Survey Date: 2020-03-05
Correction Date: 2020-08-21
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

Provide care and assistance to perform activities of daily living for any resident who is unable.

Survey Date: 2020-03-05
Correction Date: 2020-08-21
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: G

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Survey Date: 2020-03-05
Correction Date: 2020-08-21
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Provide enough food/fluids to maintain a resident's health.

Survey Date: 2020-03-05
Correction Date: 2020-08-21
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.

Survey Date: 2020-03-05
Correction Date: 2020-08-21
Category: Nursing and Physician Services Deficiencies
From Complaint: N


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All deficiency data is sourced directly from the **Centers for Medicare & Medicaid Services (CMS)**.
Data Aggregation and Review provided by **The Nursing Home Site.**