Deficiencies (last 5 years)
Deficiencies (over 5 years)
12.6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
88% worse than Oregon average
Oregon average: 6.7 deficiencies/yearDeficiencies per year
28
21
14
7
0
Inspection Report
Deficiencies: 3
Date: Mar 27, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory standards related to resident care planning, accident prevention, and food safety in the nursing home facility.
Findings
The facility was found deficient in care planning for hospice care for one resident, failure to implement fall prevention interventions for another resident, and failure to ensure proper kitchen sanitation and food storage practices. These deficiencies posed risks for unmet resident needs, injury, and food-borne illness.
Deficiencies (3)
F 0656: The facility failed to develop and implement a complete care plan for hospice care for one resident, placing residents at risk for unmet end of life needs.
F 0689: The facility failed to ensure care planned interventions to reduce fall risk were in place for one resident, resulting in a fall due to the call light not being within reach.
F 0812: The facility failed to ensure kitchen staff wore appropriate beard restraints and failed to store and discard food properly, placing residents at risk for unsanitary foods and food-borne illness.
Report Facts
Residents Affected: 1
Residents Affected: 1
Residents Affected: 1
Inspection Report
Routine
Capacity: 32
Deficiencies: 6
Date: Mar 27, 2025
Visit Reason
Facility failed to care plan for hospice care, failed to ensure care planned interventions to reduce fall risks, failed to ensure kitchen staff wore beard restraints and food was stored properly. Multiple deficiencies remained not corrected on follow-up visits.
Findings
Facility failed to care plan for hospice care, failed to ensure care planned interventions to reduce fall risks, failed to ensure kitchen staff wore beard restraints and food was stored properly. Multiple deficiencies remained not corrected on follow-up visits.
Deficiencies (6)
F0000 - INITIAL COMMENTS
F0656 - Develop/Implement Comprehensive Care Plan
F0689 - Free of Accident Hazards/Supervision/Devices
F0812 - Food Procurement,Store/Prepare/Serve-Sanitary
M0000 - Initial Comments
M9999 - STATE OF OREGON ADMINISTRATIVE RULES
Inspection Report
Routine
Deficiencies: 10
Date: Feb 23, 2024
Visit Reason
Routine inspection survey conducted to assess compliance with healthcare regulations and standards at Cascade Manor nursing facility.
Findings
The facility was found deficient in multiple areas including failure to address advance directives, failure to provide timely Medicare Non-Coverage notices, improper care of feeding tubes leading to hospitalization, unsafe water temperatures in resident rooms, inadequate staffing of registered nurses, food safety violations, failure to implement therapy plans, lack of quality assurance processes, and failure to follow infection control precautions.
Deficiencies (10)
F 0578: Facility failed to address advance directives for 2 of 2 sampled residents, risking healthcare decisions conflicting with resident wishes.
F 0582: Facility failed to provide Notices of Medicare Non-Coverage for 1 of 2 sampled residents, risking lack of appeal information.
F 0658: Facility staff failed to meet professional standards related to care of a feeding tube for 1 resident, resulting in hospitalization and surgery.
F 0689: Facility failed to maintain water temperatures below 120 degrees F in 3 resident rooms, placing residents at risk for injury.
F 0693: Facility failed to ensure appropriate care for a feeding tube, resulting in surgery for 1 resident due to improper tube handling.
F 0727: Facility failed to ensure RN staffing for at least eight consecutive hours per day on 13 of 36 days reviewed, risking lack of comprehensive assessments.
F 0812: Facility failed to ensure proper handwashing and food safety practices in the kitchen, risking foodborne illness.
F 0825: Facility failed to implement a physician's therapy plan for 1 resident, risking lack of therapy interventions.
F 0867: Facility failed to systematically analyze data and implement corrective plans related to water temperature monitoring for 12 resident rooms.
F 0880: Facility failed to follow infection control standards for transmission-based precautions for 1 resident, risking exposure to infections.
Report Facts
Days without RN coverage: 13
Undercooked eggs served: 49
Resident rooms with unsafe water temperature: 3
Resident rooms monitored for water temperature: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff 5 | Health Services Coordinator | Named in findings related to failure to address advance directives for residents 7 and 9. |
| Staff 4 | Social Services Director | Named in findings related to failure to address advance directives for resident 9. |
| Staff 1 | Administrator | Named in findings related to Medicare Non-Coverage notices and RN staffing. |
| Staff 12 | Former RNCM | Named in feeding tube incident leading to resident hospitalization. |
| Staff 6 | RNCM | Named in feeding tube incident and therapy plan findings. |
| Staff 13 | Maintenance Supervisor | Named in findings related to water temperature monitoring. |
| Staff 14 | Director of Facility Services | Named in findings related to water temperature monitoring and QAPI. |
| Staff 7 | Certified Dietary Manager | Named in food safety and handwashing findings. |
| Staff 9 | Executive Chef | Named in food safety findings. |
| Staff 3 | LPN | Named in therapy plan findings. |
| Staff 11 | RN | Named in infection control findings. |
| Staff 2 | DNS/IP | Named in infection control findings. |
Inspection Report
Complaint Investigation
Capacity: 32
Deficiencies: 13
Date: Feb 23, 2024
Visit Reason
Facility failed to address advance directives, failed to provide Medicare Non-Coverage notices timely, failed to meet professional standards for feeding tube care, failed to maintain safe water temperatures, failed to implement therapy orders, failed infection prevention and control, and failed to ensure RN staffing coverage. Multiple deficiencies remained not corrected on follow-up visits.
Findings
Facility failed to address advance directives, failed to provide Medicare Non-Coverage notices timely, failed to meet professional standards for feeding tube care, failed to maintain safe water temperatures, failed to implement therapy orders, failed infection prevention and control, and failed to ensure RN staffing coverage. Multiple deficiencies remained not corrected on follow-up visits.
Deficiencies (13)
F0000 - INITIAL COMMENTS
F0578 - Request/Refuse/Dscntnue Trmnt;Formlte Adv Dir
F0582 - Medicaid/Medicare Coverage/Liability Notice
F0658 - Services Provided Meet Professional Standards
F0689 - Free of Accident Hazards/Supervision/Devices
F0693 - Tube Feeding Mgmt/Restore Eating Skills
F0727 - RN 8 Hrs/7 days/Wk, Full Time DON
F0812 - Food Procurement,Store/Prepare/Serve-Sanitary
F0825 - Provide/Obtain Specialized Rehab Services
F0867 - QAPI/QAA Improvement Activities
F0880 - Infection Prevention & Control
M0000 - Initial Comments
M9999 - STATE OF OREGON ADMINISTRATIVE RULES
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Feb 23, 2024
Visit Reason
The inspection was conducted following a complaint investigation related to the care and services provided to residents, including issues with feeding tube care, therapy implementation, and quality assurance processes.
Complaint Details
The complaint investigation was triggered by an allegation that staff improperly handled a feeding tube for Resident 165, cutting the feeding tube port due to lack of clean equipment, which led to hospitalization and surgery. Additional complaints included failure to implement therapy plans and inadequate quality assurance processes.
Findings
The facility failed to meet professional standards in feeding tube care for one resident, resulting in hospitalization and surgery. Additionally, the facility did not implement a physician's therapy plan for another resident and failed to systematically analyze and act on quality deficiencies related to water temperature monitoring.
Deficiencies (4)
F 0658: Facility staff failed to meet professional standards related to care and services for a feeding tube for one resident, resulting in the feeding tube port being cut and the resident requiring hospitalization and surgery.
F 0693: Facility failed to ensure appropriate care for a resident with a feeding tube, including cutting the feeding tube port due to lack of clean equipment, leading to surgical intervention.
F 0825: Facility failed to implement a physician's plan for therapy for one resident, placing residents at risk for lack of therapy interventions.
F 0867: Facility failed to systematically analyze data and implement plans of action to correct deficiencies related to water temperatures in resident rooms, impacting 12 of 12 rooms reviewed.
Report Facts
Residents affected: 1
Residents affected: 1
Resident rooms reviewed: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff 12 | Former RNCM | Named in feeding tube cutting incident |
| Staff 6 | RNCM | Reported feeding tube incident and acknowledged supplies availability |
| Staff 16 | Former RN | Reported difficulty administering feeding and medications |
| Staff 3 | LPN | Acknowledged therapy plan for Resident 9 |
| Staff 15 | Nurse Practitioner | Recommended speech evaluation for Resident 9 |
| Staff 13 | Maintenance Supervisor | Monitored water temperatures |
| Staff 14 | Director of Facility Services | Reviewed water temperature logs |
| Staff 1 | Administrator | Acknowledged QAPI process needed improvement |
Inspection Report
Capacity: 32
Deficiencies: 1
Date: May 8, 2023
Visit Reason
Facility failed to report complete COVID-19 information to CDC's NHSN during a required seven-day period.
Findings
Facility failed to report complete COVID-19 information to CDC's NHSN during a required seven-day period.
Deficiencies (1)
F0884 - Reporting - National Health Safety Network
Inspection Report
Annual Inspection
Deficiencies: 6
Date: Dec 20, 2022
Visit Reason
The inspection was conducted as a comprehensive annual survey to assess compliance with regulatory requirements for nursing home care.
Findings
The facility was found deficient in multiple areas including failure to ensure residents were informed about medication treatments, incomplete and non-specific care plans, inadequate pressure ulcer assessment and care, untimely fall investigations, insufficient RN coverage for required hours, and lack of an infection prevention water management program.
Deficiencies (6)
F 0552: The facility failed to ensure residents were informed or had the opportunity to make treatment decisions related to medications for 2 of 5 sampled residents.
F 0656: The facility failed to develop comprehensive person-centered care plans for 2 of 5 sampled residents, placing them at risk for unmet needs.
F 0686: The facility failed to accurately assess and monitor a pressure ulcer for 1 of 1 sampled resident, risking pressure ulcer complications.
F 0689: The facility failed to timely or thoroughly assess falls for 2 of 3 sampled residents, placing residents at risk for falls.
F 0727: The facility failed to ensure RN coverage for eight consecutive hours in a 24-hour period for 18 of 30 days reviewed, risking unassessed needs and lack of care.
F 0880: The facility failed to develop and implement a water management program and conduct a risk analysis for potential growth and spread of hazardous microorganisms.
Report Facts
Days without RN coverage: 18
Residents affected by medication consent deficiency: 2
Residents affected by incomplete care plans: 2
Residents affected by pressure ulcer care deficiency: 1
Residents affected by fall assessment deficiency: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff 3 | RN Care Manager (RNCM) | Named in multiple findings related to medication consent, care plan review, wound care, and fall investigations. |
| Staff 2 | Director of Nursing | Confirmed dates with no RN coverage. |
| Staff 5 | Director of Facility Services | Interviewed regarding the facility's water management program and infection control. |
Inspection Report
Routine
Capacity: 32
Deficiencies: 10
Date: Dec 20, 2022
Visit Reason
Multiple deficiencies including failure to inform residents about medications, failure to develop comprehensive care plans, failure to assess and monitor pressure ulcers, failure to timely investigate falls, failure to ensure RN coverage, failure to implement water management program, infection prevention and control issues, and failure to ensure minimum licensed nurse staffing. Some deficiencies corrected, others not corrected on follow-up visits.
Findings
Multiple deficiencies including failure to inform residents about medications, failure to develop comprehensive care plans, failure to assess and monitor pressure ulcers, failure to timely investigate falls, failure to ensure RN coverage, failure to implement water management program, infection prevention and control issues, and failure to ensure minimum licensed nurse staffing. Some deficiencies corrected, others not corrected on follow-up visits.
Deficiencies (10)
F0000 - INITIAL COMMENTS
F0552 - Right to be Informed/Make Treatment Decisions
F0656 - Develop/Implement Comprehensive Care Plan
F0686 - Treatment/Svcs to Prevent/Heal Pressure Ulcer
F0689 - Free of Accident Hazards/Supervision/Devices
F0727 - RN 8 Hrs/7 days/Wk, Full Time DON
F0880 - Infection Prevention & Control
M0000 - Initial Comments
M0182 - Nursing Services:Minimum Licensed Nurse Staff
M9999 - STATE OF OREGON ADMINISTRATIVE RULES
Inspection Report
Capacity: 32
Deficiencies: 1
Date: Sep 12, 2022
Visit Reason
Facility failed to report complete COVID-19 information to CDC's NHSN during a required seven-day period.
Findings
Facility failed to report complete COVID-19 information to CDC's NHSN during a required seven-day period.
Deficiencies (1)
F0884 - Reporting - National Health Safety Network
Inspection Report
Capacity: 32
Deficiencies: 1
Date: Dec 20, 2021
Visit Reason
Facility failed to report complete COVID-19 information to CDC's NHSN during a required seven-day period.
Findings
Facility failed to report complete COVID-19 information to CDC's NHSN during a required seven-day period.
Deficiencies (1)
F0884 - Reporting - National Health Safety Network
Inspection Report
Capacity: 32
Deficiencies: 1
Date: Dec 6, 2021
Visit Reason
Facility failed to report complete COVID-19 information to CDC's NHSN during a required seven-day period.
Findings
Facility failed to report complete COVID-19 information to CDC's NHSN during a required seven-day period.
Deficiencies (1)
F0884 - Reporting - National Health Safety Network
Inspection Report
Routine
Capacity: 32
Deficiencies: 1
Date: Oct 4, 2021
Visit Reason
No deficiencies identified during this State Licensure survey.
Findings
No deficiencies identified during this State Licensure survey.
Deficiencies (1)
M0000 - Initial Comments
Inspection Report
Capacity: 32
Deficiencies: 1
Date: Jun 28, 2021
Visit Reason
Facility failed to report complete COVID-19 information to CDC's NHSN during a required seven-day period.
Findings
Facility failed to report complete COVID-19 information to CDC's NHSN during a required seven-day period.
Deficiencies (1)
F0884 - Reporting - National Health Safety Network
Inspection Report
Complaint Investigation
Capacity: 32
Deficiencies: 5
Date: Mar 8, 2021
Visit Reason
Facility failed to report and investigate allegations of verbal abuse timely and properly. Deficiencies related to abuse reporting and investigation remained not corrected on follow-up visits.
Findings
Facility failed to report and investigate allegations of verbal abuse timely and properly. Deficiencies related to abuse reporting and investigation remained not corrected on follow-up visits.
Deficiencies (5)
F0000 - INITIAL COMMENTS
F0609 - Reporting of Alleged Violations
F0610 - Investigate/Prevent/Correct Alleged Violation
M0000 - Initial Comments
M9999 - STATE OF OREGON ADMINISTRATIVE RULES
Viewing
Loading inspection reports...
