Mount Ascension Transitional Care Of Cascadia

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many

FORM CMS-2567 (02/99) Previous Versions Obsolete

and takes appropriate corrective action if the alleged violation is confirmed by the facility. [sic]9. The facility ensures that all written grievance decisions include:a. The date the grievance was received,b. A summary statement of the resident's grievance,c. The steps taken to investigate the grievance,d. A summary of the pertinent findings or conclusions regarding the resident's concerns(s),e. A statement as to whether the grievance was confirmed or not confirmed,f. Any corrective action taken or to be taken by the facility because of the grievance, andg. The date the written decision was issued.10. The facility reports any alleged violations involving neglect, abuse, including injuries of unknown source, and/or misappropriation of resident property .13. The evidence demonstrating the result of any grievance is maintained for a period of no less than 3 years from the issuance of the grievance decision.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/23/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Mount Ascension Transitional Care of Cascadia

2475 Winne Ave Helena, MT 59601

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

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

Based on interviews and record reviews, the facility failed to identify and report accusations of abuse and/or neglect by staff to The State Survey Agency for 3 (#s 1, 4, and 5) of 7 sampled residents. This deficient practice increased the risk of harm to residents by the accused staff. Findings include:1. Review of resident #1's Progress notes, dated 6/4/25, reflected resident #1 complained about not being repositioned all night, from the time he was put in bed until morning. Review of resident #1, physician note, dated 6/16/25, reflected resident #1's family member voiced a complaint about the lack of medication administration of vaginal cream, which was not being used, and questioned if catheter care was being completed. During an

interview on 9/22/25 at 2:01 p.m., staff member A stated there was no State Survey Agency report for the neglect of care, which was related to the lack of assisting a resident with repositioning, the lack of catheter care, or the lack of the use of the vaginal cream, per the reported concerns by resident #1 and a family member on 6/4/25 or 6/16/25.2. Review of a Grievance, dated 8/3/25, reflected resident #4 stated he had trouble with a night CNA who hurt him during care while being changed. The allegation of potential abuse was not reported to the State Survey Agency. 3. Review of a Grievance, dated 6/16/25, reflected resident #5 stated a staff member came in to help with a stand transfer and pulled his left arm, which hurt, and he yelled in pain. Resident #5 was being treated for a recently fractured left arm. The allegation of potential abuse or neglect was not reported to the State Survey Agency. During an interview on 9/23/25 at 11:40 a.m., staff member A stated the abuse and/or neglect of care accusations for residents #s 1, 4, and 5 should have been reported the State Survey Agency and investigated. Review of the facility policy, Identification and Investigation of Abuse, Neglect, Misappropriation, and Injuries of Unknown Origin, dated 8/1/23, reflected:- . 1. Review reports of grievances, complaints, and allegations of abuse, neglect, injuries of unknown injury, and misappropriation for patterns or isolated incidents of unexplained functional regression, or other evidence of physical, verbal, sexual or psychological abuse or punishment posing a serious and immediate threat to individuals.- . All other allegations involving Neglect, Exploitation, Mistreatment, Misappropriation of resident property, and injuries of Unknown Source will be reported to State (Survey) Agency immediately, but no later than 24 hours from the time the incident/allegation was made known to the staff member.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/23/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Mount Ascension Transitional Care of Cascadia

2475 Winne Ave Helena, MT 59601

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0610

Respond appropriately to all alleged violations.

Level of Harm - Minimal harm or potential for actual harm

Based on interviews and record reviews, the facility failed to thoroughly investigate alleged violations of abuse or neglect by staff, to prevent further abuse, neglect, or mistreatment from occurring, and take appropriate corrective action, as a result of investigation findings for 3 (#s 1, 4, and 5) of 7 sampled residents. This deficient practice placed residents at risk of harm from further abuse, neglect or mistreatment by staff members accused. Findings include:1. Review of a Grievance, dated 8/3/25, reflected resident #4 voiced a complaint that a staff member hurt him while he was being assisted during care.2.

Review of a Grievance, dated 6/16/25, reflected resident #5 complained that a staff member hurt his arm when he was being assisted during a transfer. The resident had a fractured left arm. Record reviews of the grievances for resident #4 or #5 failed to show the events are investigated or reported to the State Survey Agency as potential alleged abuse or neglect. 3. Review of resident #1's Progress notes, dated 6/4/25, reflected resident #1 complained about not being repositioned all night. Review of resident #1's, Care Plan, dated 6/4/25, reflected resident #1 had pressure ulcers on her sacrum and right heel, with an intervention requiring assistance to turn and position every two to three hours. Review of resident #1, physician note, dated 6/16/25, reflected resident #1's family member voiced a complaint about a vaginal cream not being administered and was concerned that catheter care was not done. Review of resident #1's, physician Order Summary, dated 9/22/25, reflected an order dated 5/22/25 for catheter care, including cleaning the catheter every shift. The Order Summary also included an order for Estrace Vaginal Cream to be inserted once daily.During an interview on 9/22/25 at 2:01 p.m., staff member A stated there was no State Survey Agency report for the neglect of care complaints for resident #1. During an interview on 9/23/25 at 11:40 a.m., staff member A stated the abuse and/or neglect of care accusations for resident #s 1, 4 and 5 should have been reported the State Survey Agency and investigated. SReview of the facility policy, Identification and Investigation of Abuse, Neglect, Misappropriation, and Injuries of Unknown Origin, dated 8/1/23, reflected:. 1. Review reports of grievances, complaints, and allegations of abuse, neglect, injuries of unknown injury, and misappropriation for patterns or isolated incidents . - . Investigate 1. Once the incident is reported, an investigation of the allegation [sic] violation will be conducted following CMS Facility Reported Incident criteria.

Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet