Above average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Mountain View Of Cascadia during CMS and state inspections, most recent first.
Lack of Qualified Dietary Oversight: The facility did not employ a qualified CDM or full-time dietitian to direct dietary services. The consultant dietitian provided services remotely and had not been to the kitchen, while the staff member being trained for the dietary manager role had only front-of-house and general kitchen experience, no LTC dietary management experience, and only ServSafe certification. The facility could not provide the dietary manager's certification, and staff later confirmed the person did not meet CDM criteria. This lack of oversight was linked to failures with food temperatures, temp logs, sanitation schedules, and keeping the dietary area clean and sanitary.
A facility failed to consistently serve meals at a palatable temperature and within posted meal times. Residents reported cold trays, cold eggs, half-cooked hashbrowns, and repeated delays, and during an observation many residents were still waiting for breakfast well after service had started, with some stating they were hungry and frustrated by the late meal delivery.
Food was not consistently stored, monitored, prepared, and served under sanitary conditions. Staff did not reliably document refrigerator and freezer temps, and food holding temps were not routinely recorded; during observation, breakfast food on the serving line was checked but not documented, and cream of wheat measured below the recommended hot-holding temp. Surveyors also observed heavy dust, grease, and debris on kitchen vents, a wall fan, light fixtures, and stained ceiling tiles, while staff acknowledged the cleaning and documentation gaps.
Menu substitutions were served without prior RD approval and the approved menu was not followed. A chef’s salad dinner was converted for residents on minced and moist and pureed diets without a posted therapeutic menu extension, and residents needing altered textures were served thickened tomato soup, pureed roast beef, and butterscotch pudding instead of the approved meal. The next morning, staff served waffles and sausage patties from the prior week’s menu even though the new menu cycle had started, while items listed on the menu were unavailable.
A staff member was promoted to Social Services Manager without the required background or education in social work or a related field. The only training provided was a single day at another facility, with no further education or supervised experience documented. Facility records and training transcripts confirmed the lack of relevant qualifications or training for the role.
A staff member electronically signed MSP forms for multiple residents and their representatives without proper authorization, bypassing required safeguards for electronic signatures and protected health information. The issue was identified when another staff member noticed an unusual pattern in form printing and confirmed with residents and representatives that they had not signed or authorized the forms.
A resident was left waiting for her meal for over 20 minutes while others at her table ate, due to inconsistent meal service practices, despite her care plan noting nutritional risks. Another resident with a suprapubic catheter was observed multiple times in public areas with her catheter bag uncovered, contrary to her care plan and available privacy covers, compromising her dignity.
Staff did not consistently change oxygen tubing as ordered and failed to keep the tubing off the floor for a resident, with observations showing undated tubing and part of the tubing in contact with the floor. Staff interviews revealed inconsistent knowledge of the tubing change schedule, and facility policy requirements for safe handling and infection control were not followed.
The facility did not inform or involve legal guardians in the initiation of physical and occupational therapy services for three residents who were unable to make their own care decisions. Guardians expressed frustration at not being notified or included in therapy planning, and staff confirmed that required notifications and consents were not obtained prior to starting therapy, contrary to facility policy.
The facility did not consistently implement care planned fall prevention interventions for two residents, including failure to ensure non-skid strips, fall mats, accessible call bells, and signage were in place as required. Staff interviews revealed a lack of awareness of the specific interventions, and observations confirmed that these measures were not consistently provided, despite documented falls and injuries.
A facility failed to ensure a staff member hired as a medication aide was certified or licensed, affecting all residents receiving medications. The previous DON mistakenly verified a certified medical assistant certificate instead of a medication aide license. The staff member worked 102 shifts and administered medications to a resident 69 times in one month. The facility's policy requires licensed positions to have valid state licenses, but the New Hire Checklist for this staff member did not verify the license.
The facility failed to specify an end date for PRN Lorazepam orders for two residents. One resident received Lorazepam for anxiety without a defined duration, while another was prescribed the medication for anxiety but used it for post-seizure activity without an end date. Staff interviews revealed a lack of awareness regarding the policy requiring a 14-day limit on PRN psychotropic medications unless extended by a physician.
Lack of Qualified Dietary Oversight
Penalty
Summary
The facility failed to employ a Certified Dietary Manager or a full-time dietitian to direct dietary department functions. During interview, the consultant dietitian stated she provided clinical services remotely and had not physically been to the facility kitchen to oversee dietary operations. Another staff member said she was being trained for the dietary manager role, but her prior experience was limited to front-of-house management and general kitchen management, and she reported no experience managing a dietary department in a LTC setting. Requests for the dietary manager's certification were made, but the facility reported it was unavailable because the staff member could not access the system, and no documentation was provided before survey exit. In a post-survey interview, staff stated there was confusion about the kitchen manager certification and confirmed that the staff member had only completed ServSafe and did not meet the criteria for a certified dietary manager. The report states that this lack of qualified oversight contributed to failures involving safe food temperatures, required temperature monitoring records, sanitation and cleaning schedules, and maintaining the dietary department in a clean and sanitary condition.
Cold Food and Delayed Meal Service
Penalty
Summary
The facility failed to ensure food and drink were consistently served at a palatable temperature and within the established meal service times for 8 of 18 sampled residents. Residents reported that meals were sometimes served cold, including room trays that were barely warm, and several residents stated that breakfast and other meals were frequently late. During interviews, residents described cold eggs, half-cooked hashbrowns, and repeated delays in receiving meals, with one resident stating meals were late five days per week and another expressing concern that delayed service could interfere with scheduled appointments. During an observation on 6/28/26 at 8:50 a.m., about half of the residents had been served breakfast while numerous others were still waiting, and residents appeared increasingly impatient as meal service continued. One resident repeatedly stood up and asked when breakfast would be served, while others stated they were hungry and had not yet been fed. Staff member J said breakfast service was usually completed by 8:30 a.m. but that a staff member had called out that day. Resident council minutes from January through June 2026 documented repeated complaints about cold food, long waits, and meal service delays, including reports of food served cool when it should have been warm and wait times of 45 minutes or more.
Food Temperature Monitoring and Kitchen Sanitation Failures
Penalty
Summary
Food was not stored, monitored, prepared, and served under sanitary conditions. During interviews, staff member H stated employees were filling in the next line on the refrigerator and freezer temperature logs without looking at the date, and staff member C stated missing temperature documentation had been identified about a week earlier and staff needed to be reminded to complete the logs in the morning and evening as shown on the log. Review of the refrigerator and freezer temperature log showed no temperatures documented in the morning or evening on multiple dates, and no morning temperatures recorded on two additional dates. The facility’s most recent Monthly Sanitation and Safety Audit also identified missing routine temperature documentation. Food holding temperatures were not consistently monitored or documented. During observation, staff member G stated breakfast food temperatures had been checked before meal service but had not been documented. The food temperature log posted behind the service area had no entries for the observed date, and the last entry on the log was several months earlier, showing temperatures had not been routinely recorded for an extended period. When temperatures were taken on the serving line, the cream of wheat measured 125 F, below the recommended holding temperature of 135 F. Staff member C stated the facility did not have a temperature log showing serving temperatures prior to service and was in the process of implementing the system. The kitchen was not maintained in a clean and sanitary condition. Surveyors observed ceiling air vents with heavy accumulations of dark brown to black dust and debris, a wall-mounted ventilation fan with dust, grease, and debris on the grille, blades, frame, and nearby wall and ceiling tiles, fluorescent light fixtures with visible dust, grease, and debris, and multiple stained and soiled ceiling tiles throughout the kitchen. Staff member F stated she had completed a sanitation audit in late February and had not performed another since then, and staff member C acknowledged the ventilation fans and grilles required cleaning. The facility’s monthly kitchen checklist showed blank entries for cleaning exhaust vents and fans, and the most recent sanitation audit had noted dirty ceiling vent covers, dusty sprinkler heads and vents, and a dirty wall fan.
Menu substitutions served without RD approval
Penalty
Summary
The facility failed to ensure menus were planned and followed as approved and failed to obtain registered dietitian approval before implementing facility-wide menu substitutions, including substitutions affecting therapeutic diets and altered food textures. During observation and interview, staff member D stated dinner would be a chef’s salad and said she needed to figure out something different for residents receiving minced and moist and pureed diets because they could not consume the chef’s salad. The posted week two menu showed the scheduled dinner was a chef’s salad, dinner roll, choice of dressing, chocolate frosted peanut butter bar, and milk, but there was no posted menu or therapeutic menu extension identifying the required meal conversion for therapeutic diets and altered textures. At dinner, residents seated at the assisted table who required altered textures were served thickened tomato soup, pureed roast beef, and butterscotch pudding, which differed from the approved menu, and there was no evidence the substitution had been reviewed or approved by the RD before service. At breakfast the next morning, staff served waffles and sausage patties from the prior week’s menu even though the new week had begun; fruit topping, whipped cream, and orange wedges listed on the menu were not served because the facility was out of those items, and scrambled eggs were also being prepared because the kitchen was running low on waffles. Staff members stated menu substitutions required RD approval and that the facility used menu extensions and spreadsheets for therapeutic diets and textures, but staff also stated they had not received substitution requests for the last month and that the breakfast substitution would be documented and emailed to the RD after the fact.
Unqualified Staff Assigned to Social Services Manager Role
Penalty
Summary
The facility failed to ensure that the staff member assigned as Social Services Manager was qualified and competent according to state laws and facility policy. The individual, originally hired as an assistant business office manager, was later promoted to Social Services Manager without a background or education in social work or a related field. Interviews revealed that the only training provided for the new role was a single day spent at another facility learning care plan conferences, with no further training, education, or supervised on-the-job experience in social services provided by the facility. A review of the personnel file and training transcripts confirmed the lack of relevant education or experience in human services for the staff member in question. The facility's own job description and policy require the Social Services Manager to advocate for residents and provide medically related social services to support residents' mental and psychosocial well-being. However, the staff member's records did not show any additional education or training related to social work services during her tenure in the position.
Unauthorized Electronic Signatures Used on MSP Forms
Penalty
Summary
The facility failed to safeguard resident-identifiable information and maintain medical records in accordance with accepted professional standards by allowing unauthorized use of electronic signatures on Medicare Secondary Payer (MSP) forms. Specifically, a staff member (NF3) electronically signed MSP forms on behalf of several residents and their representatives without obtaining proper authorization or consent. This was discovered when another staff member noticed a large number of MSP forms being printed in quick succession, which raised concerns about the feasibility of obtaining legitimate signatures in such a short time frame. Further investigation revealed that the residents and their representatives were unaware of the MSP forms and had not authorized or signed them. Interviews with staff confirmed that NF3 admitted to electronically signing the forms to catch up on outstanding documentation. Review of the affected residents' MSP forms and the facility's validation documents confirmed that the signatures were unauthorized. The facility's policies require that only authorized individuals use electronic signatures and that access to electronic medical records is strictly controlled, but these protocols were not followed in this instance.
Failure to Ensure Timely Meal Service and Maintain Dignity for Residents
Penalty
Summary
The facility failed to ensure that a resident was served a meal at the same time as her tablemate, resulting in the resident waiting 23 minutes for her breakfast while others at her table and surrounding tables ate their meals. Staff interviews revealed that although there was an attempt to serve all residents at a table simultaneously, the process was inconsistent, particularly when managing different diet consistencies. The affected resident had a care plan indicating risk for nutritional instability due to dementia, poor dentition, the need for a mechanically altered diet, and slow weight loss. Additionally, the facility did not maintain the dignity of a resident with a suprapubic catheter by failing to cover the catheter bag in public areas. Observations showed the resident's catheter bag was uncovered while she was seated in the dining room and day room, despite her care plan specifying that the catheter bag should be covered with a privacy bag. Staff confirmed that covers were available but were not used as required, resulting in a lack of privacy for the resident.
Failure to Change and Properly Store Oxygen Tubing
Penalty
Summary
Facility staff failed to provide safe and appropriate respiratory care for a resident by not changing oxygen tubing as ordered and not keeping the tubing off the floor. Observations revealed that the oxygen tubing at the resident's bedside was not dated and, on one occasion, the portion of the tubing that connects to the resident's face or nose was found sitting on the floor. Interviews with multiple staff members showed inconsistent understanding of the schedule for changing oxygen tubing, with responses varying between Monday, Tuesday, or Wednesday, and some staff indicating that changes depended on who was working. Review of the facility's respiratory care policy indicated requirements for safe handling, cleaning, and infection control measures for oxygen equipment, but these were not consistently followed for the resident in question.
Failure to Notify and Involve Guardians in Therapy Initiation
Penalty
Summary
The facility failed to inform and include residents' legal guardians in the decision-making process for initiating physical and occupational therapy services for three residents. In each case, the legal guardian was not notified or consulted prior to the start of therapy, despite the residents being unable to make informed decisions for themselves. Interviews with the guardians revealed frustration and a lack of awareness regarding the initiation and goals of therapy services. Documentation review confirmed that there was no evidence of guardian notification or consent prior to the commencement of therapy for these residents. Staff interviews indicated that it was the facility's expectation and policy to obtain consent from the resident or their legal representative before starting therapy services, especially when the resident was not cognitively competent. However, in these instances, staff acknowledged that the required notifications and consents were not obtained as per policy. The facility's own policy emphasized the importance of valid consent and clear communication regarding treatment options, but records and staff statements confirmed that this process was not followed for the affected residents.
Failure to Implement Care Planned Fall Interventions
Penalty
Summary
The facility failed to implement care planned fall prevention interventions for two residents, resulting in increased risk for falls. For one resident, the care plan required non-skid strips on both sides of the bed, but observations on multiple occasions showed that the strips were not visible or accessible due to the bed's positioning. Additionally, after several falls, including one resulting in major injury, there was no documentation that required interventions such as a tab alarm were in use at the time of the incident, and no new fall prevention measures were added to the care plan following these events. For another resident, the care plan included a fall mat, signage to remind the resident to call for help, and ensuring non-skid footwear was worn. However, observations revealed the absence of a floor mat, call bell, and signage within reach, and the resident was not wearing non-skid socks. Multiple staff members interviewed were unaware of the specific fall prevention interventions outlined in the care plan for this resident. The facility's policy required implementation and consistent application of such interventions, but these were not followed as documented.
Unlicensed Medication Aide Administered Medications
Penalty
Summary
The facility failed to ensure that a staff member hired as a medication aide was certified or licensed, which had the potential to affect all residents receiving medications. During interviews, it was revealed that the previous Director of Nursing (DON) mistakenly verified a certified medical assistant certificate instead of a medication aide license for the staff member in question. This oversight was discovered during an audit of nursing staff licensing, which found that the staff member did not possess the necessary medication technician license or certificate. The staff member worked approximately 102 shifts as a medication aide and administered medications to a resident around 69 times in one month. The facility's policy mandates that all employees applying for licensed positions must have a valid and active license in the state. However, the New Hire Checklist for the staff member did not have the license verification box checked. The facility's policy also specifies that certified medication aides must meet certain requirements, including completing an approved state medication aide program and passing the state certification exam.
Failure to Specify Duration for PRN Psychotropic Medications
Penalty
Summary
The facility failed to provide an end date for as-needed anti-anxiety medication orders for two residents. For one resident, physician orders for Lorazepam, an anti-anxiety medication, were issued on multiple occasions without specifying a duration. The resident's progress notes indicated a single episode of anxiety, but the medication was prescribed to be available as needed without a defined end date. During interviews, staff members were unaware of the requirement for a duration on PRN psychotropic medication orders, indicating a lack of understanding of the policy. For another resident, Lorazepam was prescribed as needed for anxiety, but the medication was used for post-seizure activity instead, as the resident did not have an anxiety diagnosis. The order was changed to reflect this new use, but again, no duration or end date was specified. Interviews with staff revealed a misunderstanding of the policy, with some staff believing that only risk versus benefits were reviewed for psychotropic medications that were not antipsychotics. The facility's policy stated that PRN orders for psychotropic medications should be limited to 14 days unless extended by a physician with documented rationale, which was not adhered to in these cases.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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