Mountain View Of Cascadia

Based on interview and record review, the facility failed to ensure they employed qualified and competent staff to provide social work services. This deficient practice had the potential to affect all residents in need of social services. Findings include: During an interview on 6/4/25 at 10:05 a.m., staff member A stated NF3 was originally hired as a business office assistant. She was later promoted to social service director. He stated she had some on-the-job training when she first assumed the role. Stating she went to another corporate facility and received on-site training there with the social worker at that facility. A request submitted on 6/4/25 at 10:30 a.m., for additional training/education for NF3, for acting as a social work director, was submitted. No additional training or education for NF3, related to social work services, was provided by the end of the survey. During an interview on 6/4/25 at 2:40 p.m., NF3 stated she was not originally hired as the facility's social worker. She stated she was later promoted into the position. NF3 stated she did not have a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to ensure safeguards to prevent unauthorized use of electronic signatures for residents Medicare Secondary Payer (MSP) Form for 3 (#s 9, 31, and 40) of 15 sampled residents. This deficient practice had the potential to affect all residents with the need to sign MSP forms. Findings include: During an interview on 6/4/25 at 10:05 a.m., staff member A stated it was brought to his attention that NF3 was electronically signing resident and/or resident's representative names on documents for MSP forms. He stated staff member G noticed a bunch of MSP forms being printed back-to-back for several residents. Staff member A stated when staff member G brought the concern to his attention it was noted that the documents, which had an electronic signature, were not actually signed by the residents or their representatives. During an interview on 6/4/25 at 2:46 p.m., staff member G stated NF3 was behind on getting the MSP forms signed by the residents or their representatives. She stated one morning she noticed there were several MSP forms…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews, and record review, the facility failed to ensure a resident was served a meal when tablemate's were served, and the resident had to wait 20 minutes while the other residents at the table finished their meals, for 1 (#43); and failed to ensure catheter bags were covered with a dignity bag in public areas for 1 (#15) of 15 sampled residents. Findings include: 1. During an observation on 6/3/25 at 8:21 a.m., resident #43 was seated at the dining table across from another resident. This resident had his plate and was eating breakfast. Resident #43 did not have her food. Residents at nearby tables were served their plates in no particular order. During an observation on 6/3/25 at 8:37 a.m., resident #43's tablemate had finished his breakfast. Resident #43 was still waiting for her plate. She wondered out loud if she could leave. During an observation on 6/3/25 at 8:44 a.m., resident #43 was served her breakfast. Resident #43 waited 23 minutes for her plate while those at her table and surrounding tables ate their meals. During an interview on 6/4/25 at…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to inform and include the residents' guardian in the decision-making process for initiating physical and occupational therapy services, for 3 (#s 15, 19, and 44) of 15 sampled residents. This deficient practice caused the representative frustration and limited their ability to participate in resident care. Findings include: 1. During an interview on 6/4/25 at 3:36 p.m., NF2 stated she was concerned she was not informed by the facility that resident #19 was receiving therapy services. She stated she only became aware the resident was receiving therapy services when she was contacted about needing to sign a form to discontinue physical therapy. NF2 stated she was the legal guardian for resident #19, and the resident was not capable of making informed decisions for her own care. She stated she would have liked to be part of the decision-making process for resident #19, regarding her therapy services, so she could have attended the evaluation to discuss therapy goals for the resident. Review of resident #19's Physical Therapy…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews, and record review, the facility failed to implement care planned fall interventions contributing to falls for 2 (#s 6 and 12) of 15 sampled residents. This deficient practice increased the risk for falls. Findings include: 1. Resident #6 Review of resident #6's Care Plan Report, date initiated 12/1/23, reflected the following: .Goal: She will be free of fall related injuries . Environmental: Provide non-skid strips on floor next to bed on both sides of bed . [sic] During an observation on 6/2/25 at 1:25 p.m., non-skid strips were not visible on the floor of resident #6's room. During an observation on 6/4/25 at 8:44 a.m., non-skid strips were not visible on the floor of resident #6's room. During an interview on 6/4/25 at 11:52 a.m., staff member K stated resident #6 did not routinely call for help and stated, I think there are strips on the floor by her bed, but no fall mat. During an observation on 6/5/25 at 8:36 a.m., non-skid strips were noted on the floor of resident #6's room. The bed was positioned near the window thus revealing non-skid…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to change oxygen tubing as ordered and keep oxygen tubing off the floor for 1 (#6) of 15 sampled residents. This deficient practice increased the risk for a respiratory infection. Findings include: During an observation on 6/2/25 at 1:25 p.m., oxygen tubing was at resident #6's bedside, and it was not dated. During an observation on 6/3/25 at 11:45 a.m., oxygen tubing was at resident #6's bedside; it was not dated, and the portion of the tubing that connects to the resident's face/nose was sitting on the floor. During an interview on 6/4/25 at 11:52 a.m., staff member K stated oxygen tubing should be changed every Tuesday or Wednesday by staff member I. During an interview on 6/4/25 at 11:57 a.m., staff member E stated oxygen tubing should be changed every Monday. During an interview on 6/4/25 at 12:02 p.m., staff member I stated she changed oxygen tubing every Monday afternoon for residents, unless she was not working, and in that case a nurse would change the tubing. During an interview on 6/4/25 at 2:39 p.m.,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to provide an end date for an as needed anti-anxiety medication order, for 2 (#s 1 and 4) of 14 sampled residents. Findings include: A review of resident #1's physician orders, dated 12/5/23, 3/5/24, and 3/7/24, showed, Lorazepam 1 mg. Give 1 tablet orally once a day as needed for anxiety. The orders did not include a duration. Lorazepam is the generic name for Ativan, an anti-anxiety medication. Review of resident #1's physician progress note, dated 12/5/24, showed, Patient had single episode . feeling very claustrophobic and anxious . Will write prescription for LORAZEPAM to have on hand just as needed . There was no duration noted. During an interview on 6/5/24 at 8:47 a.m., staff member F stated they did the 14-day limit for antipsychotic medications, but she was not aware of a duration requirement on PRN psychotropic medication orders. During an interview on 6/5/24 at 10:50 a.m., staff member F was not aware of needing to have a specified duration or stop date for continued PRN psychotropics. Staff member F stated she…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a staff member that was hired as a medication aide was certified or licensed. This deficient practice had the potential to affect all residents in the facility receiving medications, to include 1 (#2) resident. Findings include: During an interview on [DATE] at 2:46 p.m., staff member C stated during the time when staff member E was hired the previous DON had checked licensing and certifications for new hires. Staff member E had a certified medical assistant certificate but not a medication aide license. During an interview on [DATE] at 2:57 p.m., staff member B stated she audited nursing staff licensing in February 2024 and discovered staff member E did not have a medication technician license or certificate. During an interview on [DATE] at 9:54 a.m., staff member A stated the previous DON confused medication aide with medical assistant certification when staff member E was hired. A review of an Offer of employment, document dated [DATE],…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to ensure the residents' medical record included documentation the resident, or resident representative, was provided education regarding the benefits/side effects of pneumococcal and influenza vaccinations for 4 (#s 1, 4, 21, and 182) of 5 sampled residents. Findings include: During an interview on 5/22/23 at 1:52 p.m., staff member B stated they did not have signed vaccine declinations with education about risks/benefits for resident #s 1, 4, 21, and 182. Review of resident #s 1, 4, 21, and 182's electronic medical records accessed 5/20/23 - 5/22/23, showed a lack a documentation regarding education being provided to residents, or their representatives, on influenza and pneumococcal vaccinations. Review of resident #1's immunizations showed she refused the influenza vaccine. Review of resident #4's immunizations showed she refused the influenza vaccine. Review of resident #21's immunizations showed she refused the influenza and pneumococcal vaccines. Review of resident #182's immunizations showed he refused the influenza…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to ensure the residents' medical record included documentation the resident, or resident representative, was provided education regarding the benefits/side effects of Covid-19 vaccinations for 5 (#s 1, 4, 5, 21, and 182) of 5 sampled residents. Findings include: During an interview on 5/22/23 at 1:52 p.m., staff member B stated the facility did not have signed vaccine declinations with education about risks/benefits for resident #s 1, 4, 5, 21, and 182. Review of resident #s 1, 4, 5, 21, and 182's electronic medical records, accessed 5/20/23 - 5/22/23, showed a lack a documentation regarding education being provided to residents, or their representatives, on Covid-19 vaccinations. Review of resident #1's immunizations showed she refused the Covid-19 vaccine. Review of resident #4's immunizations showed she refused the Covid-19 vaccine. Review of resident #5's immunizations showed she refused the Covid-19 vaccine. Review of resident #21's immunizations showed she refused the Covid-19 vaccine. Review of resident #182's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to notify the physician of resident concerns, including a significant weight loss for 1 (# 4); and missed doses of medications for 1 (#6) of 2 sampled residents. Findings include: 1. Review of resident #4's documented weights showed: - 1/15/23 the resident weighed 124.2 lbs. - 2/12/23 the resident weighed 116 lbs. This represented a 6.6% weight loss in one month. There was no documentation stating the physician was aware of the significant weight loss. During an interview on 5/22/23 at 3:15 p.m., staff member F stated they would notify the doctor of resident changes by fax, versus a phone call, as long as there was no injury. During an interview on 5/22/23 at 3:30 p.m., staff member D stated physician notification done by fax would be saved and scanned into the chart. Documentation of physician notification of resident #4's weight loss was requested on 5/22/23. It was not provided by the end of the survey. 2. Review of resident #6's nursing progress notes, dated 2/15/23, showed the resident did not receive two of her…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure care plans were updated after falls for 2 (#1 and #26) of 2 sampled residents. Findings include: 1. During an interview on 5/20/23 at 3:31 p.m., resident #1 stated she had falls in the past at the facility, once at her toilet, and a few times near her bed. Resident #1 stated the fall on 2/5/23 involved her air mattress sliding out from under her while she was transferring, using a sit to stand with one staff member, resulting in her falling to the floor. Resident #1 stated she was to have at least two staff helping with her sit to stand transfers. During an interview on 5/21/23 at 1:39 p.m., staff member C stated resident #1 had a history of falls at the facility. Staff member C stated he, staff member B, or staff member F, updated the resident's care plan after fall investigations were completed by the management team. During an interview on 5/21/23 at 1:56 p.m., staff member B stated after a fall, the care plans were updated with interventions…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to ensure a staff member adjusted the bed height, to prevent a fall during a transfer, for 1 (#1) of 2 sampled residents. Findings include: During an interview on 5/20/23 at 3:31 p.m., resident #1 stated she had fallen in the past at the facility, once at the toilet, and a few times near her bed. Resident #1 stated the fall on 2/5/23 involved her air mattress sliding out from under her while she was transferring, using a sit to stand with one staff member, resulting in her falling to the floor. Resident #1 stated she was to have at least two staff helping with her sit to stand transfers. During an interview on 5/21/23 at 1:19 p.m., staff member I stated resident #1 had fallen in the facility and had always been a resident who required a two-person physical assist with the resident's transfers. During an interview on 5/21/23 at 1:56 p.m., staff member B stated post fall investigations were documented in PCC, and staff involved in the falls would be educated. During an interview on 5/22/23 at 2:38 p.m., staff member B stated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.