Deficiencies per Year
24
18
12
6
0
Unclassified
Inspection Report
Renewal
Capacity: 32
Deficiencies: 24
May 12, 2025
Visit Reason
State-compiled facility profile showing 10 inspections from 2021 to 2025 with deficiency history and enforcement actions.
Findings
Across multiple inspections, Cascade Manor exhibited numerous deficiencies including failures in care planning, infection control, staffing, food safety, rehabilitation services, and reporting. Several deficiencies were corrected while others remained uncorrected at the time of the latest inspections.
Complaint Details
Complaint investigations included failures to address advance directives, failure to provide Medicare Non-Coverage notices, failure to implement therapy orders, and abuse reporting and investigation deficiencies.
Deficiencies (24)
| Description |
|---|
| F0000 - INITIAL COMMENTS |
| F0656 - Develop/Implement Comprehensive Care Plan: Failed to care plan for hospice care for 1 of 1 sampled resident. |
| F0689 - Free of Accident Hazards/Supervision/Devices: Failed to ensure care planned interventions to reduce fall risk for 1 of 1 sampled resident. |
| F0812 - Food Procurement,Store/Prepare/Serve-Sanitary: Failed to ensure kitchen staff wore beard restraints and food was stored appropriately. |
| M0000 - Initial Comments |
| M9999 - STATE OF OREGON ADMINISTRATIVE RULES: Refer to F656, F689, F812 |
| F0578 - Request/Refuse/Dscntnue Trmnt;Formlte Adv Dir: Failed to address advance directives for 2 of 2 sampled residents. |
| F0582 - Medicaid/Medicare Coverage/Liability Notice: Failed to provide Notices of Medicare Non-Coverage for 1 of 2 sampled residents. |
| F0658 - Services Provided Meet Professional Standards: Failed to meet professional standards related to feeding tube care for 1 of 1 sampled resident. |
| F0689 - Free of Accident Hazards/Supervision/Devices: Failed to maintain water temperatures for 3 of 3 resident rooms reviewed. |
| F0693 - Tube Feeding Mgmt/Restore Eating Skills: Failed to ensure appropriate care related to feeding tube for 1 of 1 resident. |
| F0727 - RN 8 Hrs/7 days/Wk, Full Time DON: Failed to ensure RN coverage for 13 of 36 days reviewed. |
| F0825 - Provide/Obtain Specialized Rehab Services: Failed to implement physician's plan for therapy for multiple residents. |
| F0867 - QAPI/QAA Improvement Activities: Failed to systematically analyze data and implement plans related to water temperatures. |
| F0880 - Infection Prevention & Control: Failed to follow infection control standards for 1 of 1 sampled resident. |
| F0884 - Reporting - National Health Safety Network: Failed to report complete COVID-19 information during required periods. |
| F0552 - Right to be Informed/Make Treatment Decisions: Failed to ensure residents were informed or consented to medications for 2 of 5 sampled residents. |
| F0609 - Reporting of Alleged Violations: Failed to report allegation of abuse to administrator and officials. |
| F0610 - Investigate/Prevent/Correct Alleged Violation: Failed to investigate allegation of abuse for 1 of 3 sampled residents. |
| F0686 - Treatment/Svcs to Prevent/Heal Pressure Ulcer: Failed to accurately assess and monitor pressure ulcer for 1 of 1 sampled resident. |
| F0689 - Free of Accident Hazards/Supervision/Devices: Failed to timely or thoroughly assess falls for 2 of 3 sampled residents. |
| F0727 - RN 8 Hrs/7 days/Wk, Full Time DON: Failed to ensure RN coverage for 18 of 30 days reviewed. |
| F0880 - Infection Prevention & Control: Failed to develop and implement water management program and risk assessment. |
| M0182 - Nursing Services:Minimum Licensed Nurse Staff: Failed to ensure eight contiguous hours of RN coverage for 18 of 30 days reviewed. |
Report Facts
Inspections on page: 10
Total deficiencies: 27
Licensing violations: 10
Abuse violations: 0
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Alexandra Schulte, RN | Director of Nursing | Named in multiple findings related to care planning, infection prevention, staffing, and plans of correction |
| Kim Sornson | Administrator | Named in findings related to Medicare Non-Coverage notices and food safety plan of correction |
| Chris Handlon | Director of Dining Services | Named in food safety deficiency plan of correction |
| Staff 12 | Former RNCM | Named in feeding tube care deficiency |
| Staff 5 | Therapy Director | Named in therapy services deficiency |
| Staff 1 | DNS (Director of Nursing Services) | Named in therapy services and Medicare Non-Coverage findings |
| Staff 3 | RNCM | Named in multiple findings including medication consent and therapy services |
| Staff 2 | DNS/IP (Director of Nursing Services/Infection Preventionist) | Named in infection control findings |
| Staff 13 | Maintenance Supervisor | Named in water temperature deficiency |
| Staff 14 | Director of Facility Services | Named in water temperature deficiency and infection control |
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