The facility also failed to report two other accusations of neglect and abuse involving staff members, federal inspectors found during a September complaint investigation. The violations increased risks to residents by allowing accused staff to continue working without proper scrutiny.
Resident 1 complained on June 4 that staff had not repositioned him all night, from the time he was put to bed until morning. Twelve days later, his family member raised additional concerns during a physician visit about medication administration failures. The vaginal cream prescribed for the resident was not being used, and the family questioned whether catheter care was being completed properly.
Staff member A acknowledged during a September 22 interview that none of these neglect allegations had been reported to the state survey agency, as required by federal regulations.
The most serious incident involved resident 4, who filed a formal grievance on August 3 describing how a night shift certified nursing assistant had hurt him during care. The resident specifically stated the CNA caused pain while changing him, but facility administrators never forwarded the abuse allegation to state authorities.
Resident 5 experienced a different type of harmful treatment that also went unreported. According to a June 16 grievance, a staff member came to help with a standing transfer and pulled the resident's left arm, causing him to yell in pain. The incident was particularly concerning because resident 5 was being treated for a recently fractured left arm at the time.
The staff member who pulled his injured arm knew about the fracture, making the rough handling especially problematic for someone in a vulnerable healing period.
During interviews, facility staff acknowledged the reporting failures. Staff member A admitted on September 23 that the abuse and neglect accusations for all three residents should have been reported to the state survey agency and investigated according to protocol.
The facility's own policies required these reports. Mount Ascension's written procedures, dated August 1, 2023, specifically mandate that staff "review reports of grievances, complaints, and allegations of abuse, neglect, injuries of unknown injury, and misappropriation for patterns or isolated incidents."
The policy also states that "all other allegations involving Neglect, Exploitation, Mistreatment, Misappropriation of resident property, and injuries of Unknown Source will be reported to State Agency immediately, but no later than 24 hours from the time the incident/allegation was made known to the staff member."
None of the three incidents were reported within the required 24-hour window. In fact, they were never reported at all until federal inspectors discovered them during their investigation.
The pattern of concealment spanned nearly three months, from June 16 through August 3. During this period, residents continued to experience concerning interactions with staff while administrators failed to trigger the protective investigations that state reporting requirements are designed to ensure.
Resident 1's case involved multiple types of neglect. The failure to reposition him overnight violated basic care standards designed to prevent pressure sores and maintain circulation. The medication administration problems with vaginal cream suggested broader issues with following prescribed treatment plans. Questions about catheter care raised infection control concerns for a particularly vulnerable medical device.
His family's decision to raise these issues during a physician visit on June 16 indicated their growing frustration with the quality of care. The physician documented their complaints in medical records, creating an official trail that facility administrators should have recognized as requiring state notification.
The resident 4 situation involved direct physical harm during intimate care. Certified nursing assistants handle some of the most personal and vulnerable moments in residents' lives. When a CNA causes pain during changing, it represents a fundamental breach of trust and professional duty.
The formal grievance process exists partly to capture these serious allegations. By filing written complaints, residents create documentation that facilities cannot easily dismiss or ignore. The August 3 grievance about the night CNA should have triggered immediate reporting and investigation protocols.
Resident 5's experience highlighted how staff actions can compound existing medical vulnerabilities. A fractured left arm requires careful handling during any movement or transfer. When staff members pull on injured limbs hard enough to cause residents to yell in pain, they risk further injury and demonstrate dangerous carelessness.
The timing of his June 16 grievance, filed the same day as resident 1's family complaints, suggests a broader pattern of problematic care during that period. Multiple residents were experiencing concerning treatment from different staff members across different shifts.
Staff member A's acknowledgment that all three cases should have been reported and investigated reveals awareness of proper procedures. The facility knew what it was supposed to do but chose not to do it for months while residents remained at risk.
The inspection findings covered incidents involving at least three different types of staff members: certified nursing assistants, medication administration personnel, and transfer assistance workers. The reporting failures affected multiple departments and shifts, indicating systemic problems with recognizing and responding to abuse allegations.
Federal inspectors classified the violations as causing minimal harm or potential for actual harm to some residents. However, the failure to report suspected abuse and neglect creates ongoing risks that extend far beyond the initial incidents.
When facilities conceal abuse allegations, they prevent state investigators from determining whether staff members should be removed from patient care. They also miss opportunities to identify patterns that might reveal more widespread problems requiring immediate intervention.
The three residents who filed complaints or whose families raised concerns trusted the facility to take their allegations seriously. Instead, Mount Ascension administrators allowed accused staff members to continue working with vulnerable residents while keeping state authorities in the dark about potential safety threats.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Mount Ascension Transitional Care of Cascadia from 2025-09-23 including all violations, facility responses, and corrective action plans.
Additional Resources
- View all inspection reports for Mount Ascension Transitional Care of Cascadia
- Browse all MT nursing home inspections