Inspection Reports for Cascade Terrace Post Acute
5601 SE 122nd Avenue, Portland, OR, 97236
Back to Facility ProfileInspection Report Summary
The most recent inspection on November 6, 2025, identified deficiencies related to medication regimen and documentation, including issues with chemotherapy medication orders. Earlier inspections showed a pattern of deficiencies involving resident care, medication management, staffing, and infection control, with some citations remaining uncorrected at follow-up visits. Complaint investigations were not noted in the available reports, and no fines or enforcement actions were listed. Prior reports included several immediate jeopardy findings that were addressed, but these were not mentioned in the most recent inspection. The inspection history suggests ongoing challenges with medication and care processes, with no clear improvement trend in recent months.
Deficiencies (last 2 years)
Deficiencies (over 2 years)
30.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
355% worse than Oregon average
Oregon average: 6.7 deficiencies/yearDeficiencies per year
24
18
12
6
0
Inspection Report
Complaint Investigation
Capacity: 105
Deficiencies: 4
Date: Nov 6, 2025
Visit Reason
Deficiencies related to medication regimen and documentation, including failure to clarify chemotherapy medication orders leading to adverse outcomes. Multiple citations not corrected at time of visit.
Findings
Deficiencies related to medication regimen and documentation, including failure to clarify chemotherapy medication orders leading to adverse outcomes. Multiple citations not corrected at time of visit.
Deficiencies (4)
F0000 - INITIAL COMMENTS
F0757 - Drug Regimen is Free from Unnecessary Drugs
M0000 - Initial Comments
M9999 - STATE OF OREGON ADMINISTRATIVE RULES
Inspection Report
Complaint Investigation
Capacity: 105
Deficiencies: 2
Date: Sep 23, 2025
Visit Reason
No deficiencies identified but citations noted with no corrections at time of visit.
Findings
No deficiencies identified but citations noted with no corrections at time of visit.
Deficiencies (2)
F0000 - INITIAL COMMENTS
M0000 - Initial Comments
Inspection Report
Complaint Investigation
Capacity: 105
Deficiencies: 21
Date: Apr 28, 2025
Visit Reason
Multiple deficiencies including failure to assess residents for safe self-administration of medications, maintain privacy/confidentiality, complete comprehensive assessments timely, accurate MDS coding, ADL care, activity programming, quality of care, accident hazards, dialysis monitoring, RN staffing, medication storage, dietary needs, infection control, and payroll based journal reporting. Many deficiencies corrected after initial visit but some remained uncorrected at follow-up.
Findings
Multiple deficiencies including failure to assess residents for safe self-administration of medications, maintain privacy/confidentiality, complete comprehensive assessments timely, accurate MDS coding, ADL care, activity programming, quality of care, accident hazards, dialysis monitoring, RN staffing, medication storage, dietary needs, infection control, and payroll based journal reporting. Many deficiencies corrected after initial visit but some remained uncorrected at follow-up.
Deficiencies (21)
F0000 - INITIAL COMMENTS
F0554 - Resident Self-Admin Meds-Clinically Approp
F0583 - Personal Privacy/Confidentiality of Records
F0636 - Comprehensive Assessments & Timing
F0641 - Accuracy of Assessments
F0677 - ADL Care Provided for Dependent Residents
F0679 - Activities Meet Interest/Needs Each Resident
F0684 - Quality of Care
F0689 - Free of Accident Hazards/Supervision/Devices
F0698 - Dialysis
F0727 - RN 8 Hrs/7 days/Wk, Full Time DON
F0732 - Posted Nurse Staffing Information
F0757 - Drug Regimen is Free from Unnecessary Drugs
F0761 - Label/Store Drugs and Biologicals
F0800 - Provided Diet Meets Needs of Each Resident
F0812 - Food Procurement,Store/Prepare/Serve-Sanitary
F0851 - Payroll Based Journal
F0944 - QAPI Training
M0000 - Initial Comments
M0182 - Nursing Services:Minimum Licensed Nurse Staff
M9999 - STATE OF OREGON ADMINISTRATIVE RULES
Inspection Report
Complaint Investigation
Capacity: 105
Deficiencies: 2
Date: Mar 6, 2025
Visit Reason
No deficiencies corrected at time of visit; citations related to initial comments.
Findings
No deficiencies corrected at time of visit; citations related to initial comments.
Deficiencies (2)
F0000 - INITIAL COMMENTS
M0000 - Initial Comments
Inspection Report
Complaint Investigation
Capacity: 105
Deficiencies: 5
Date: Jan 23, 2025
Visit Reason
Deficiencies included failure to provide ADL care, quality of care issues, and failure to implement fall prevention care plans. Some deficiencies corrected after initial visit but not all.
Findings
Deficiencies included failure to provide ADL care, quality of care issues, and failure to implement fall prevention care plans. Some deficiencies corrected after initial visit but not all.
Deficiencies (5)
F0000 - INITIAL COMMENTS
F0677 - ADL Care Provided for Dependent Residents
F0684 - Quality of Care
M0000 - Initial Comments
M9999 - STATE OF OREGON ADMINISTRATIVE RULES
Inspection Report
Complaint Investigation
Capacity: 105
Deficiencies: 2
Date: Aug 21, 2024
Visit Reason
No deficiencies corrected at time of visit; citations related to initial comments.
Findings
No deficiencies corrected at time of visit; citations related to initial comments.
Deficiencies (2)
F0000 - INITIAL COMMENTS
M0000 - Initial Comments
Inspection Report
Complaint Investigation
Capacity: 105
Deficiencies: 2
Date: Mar 12, 2024
Visit Reason
No deficiencies corrected at time of visit; citations related to initial comments.
Findings
No deficiencies corrected at time of visit; citations related to initial comments.
Deficiencies (2)
F0000 - INITIAL COMMENTS
M0000 - Initial Comments
Inspection Report
Complaint Investigation
Capacity: 105
Deficiencies: 21
Date: Jan 31, 2024
Visit Reason
Multiple deficiencies including failure to obtain vaccine consent, reasonable accommodations, notification of changes, abuse prevention, investigation of injuries, care plan implementation, elopement prevention, accident hazard prevention, staffing sufficiency, nurse aide training, behavioral health services, medication error prevention, binding arbitration agreements, infection prevention and control, and required in-service training. Several immediate jeopardy situations identified and addressed.
Findings
Multiple deficiencies including failure to obtain vaccine consent, reasonable accommodations, notification of changes, abuse prevention, investigation of injuries, care plan implementation, elopement prevention, accident hazard prevention, staffing sufficiency, nurse aide training, behavioral health services, medication error prevention, binding arbitration agreements, infection prevention and control, and required in-service training. Several immediate jeopardy situations identified and addressed.
Deficiencies (21)
F0000 - INITIAL COMMENTS
F0552 - Right to be Informed/Make Treatment Decisions
F0558 - Reasonable Accommodations Needs/Preferences
F0580 - Notify of Changes (Injury/Decline/Room, etc.)
F0584 - Safe/Clean/Comfortable/Homelike Environment
F0600 - Free from Abuse and Neglect
F0609 - Reporting of Alleged Violations
F0610 - Investigate/Prevent/Correct Alleged Violation
F0656 - Develop/Implement Comprehensive Care Plan
F0657 - Care Plan Timing and Revision
F0684 - Quality of Care
F0689 - Free of Accident Hazards/Supervision/Devices
F0725 - Sufficient Nursing Staff
F0730 - Nurse Aide Peform Review-12 hr/yr In-Service
F0740 - Behavioral Health Services
F0760 - Residents are Free of Significant Med Errors
F0847 - Entering into Binding Arbitration Agreements
F0880 - Infection Prevention & Control
F0947 - Required In-Service Training for Nurse Aides
M0000 - Initial Comments
M9999 - STATE OF OREGON ADMINISTRATIVE RULES
Inspection Report
Capacity: 105
Deficiencies: 1
Date: Jan 8, 2024
Visit Reason
Failure to report complete COVID-19 information to CDC's NHSN during required reporting period.
Findings
Failure to report complete COVID-19 information to CDC's NHSN during required reporting period.
Deficiencies (1)
F0884 - Reporting - National Health Safety Network
Inspection Report
Capacity: 105
Deficiencies: 1
Date: Jan 2, 2024
Visit Reason
Failure to report complete COVID-19 information to CDC's NHSN during required reporting period.
Findings
Failure to report complete COVID-19 information to CDC's NHSN during required reporting period.
Deficiencies (1)
F0884 - Reporting - National Health Safety Network
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