Inspection Reports for
East Cascade Retirement Community

175 NE 16TH STREET, MADRAS, OR, 97741

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Deficiencies (last 4 years)

Deficiencies (over 4 years) 10.8 deficiencies/year

Deficiencies are regulatory violations found during state inspections.

61% worse than Oregon average
Oregon average: 6.7 deficiencies/year

Deficiencies per year

24 18 12 6 0
2022
2023
2024
2025

Inspection Report

Complaint Investigation
Capacity: 20 Deficiencies: 2 Date: Nov 18, 2025

Deficiencies (2)
F0000 - INITIAL COMMENTS
M0000 - Initial Comments

Inspection Report

Complaint Investigation
Capacity: 20 Deficiencies: 2 Date: Sep 11, 2025

Deficiencies (2)
F0000 - INITIAL COMMENTS
M0000 - Initial Comments

Inspection Report

Complaint Investigation
Capacity: 20 Deficiencies: 2 Date: Aug 26, 2025

Deficiencies (2)
F0000 - INITIAL COMMENTS
M0000 - Initial Comments

Inspection Report

Complaint Investigation
Capacity: 20 Deficiencies: 2 Date: Jun 10, 2025

Deficiencies (2)
F0000 - INITIAL COMMENTS
M0000 - Initial Comments

Inspection Report

Kitchen
Capacity: 48 Deficiencies: 2 Date: Jan 6, 2025

Visit Reason
Facility failed to ensure food was prepared in accordance with Food Sanitation Rules including issues with cleanliness, food storage, labeling, temperature monitoring, and equipment operation. Staffing requirements and training deficiencies were also noted.

Findings
Facility failed to ensure food was prepared in accordance with Food Sanitation Rules including issues with cleanliness, food storage, labeling, temperature monitoring, and equipment operation. Staffing requirements and training deficiencies were also noted.

Deficiencies (2)
OAR 411-054-0030 (1)(a) Resident Services Meals, Food Sanitation Rule
OAR 411-054-0070 (3-4) Staffing Requirements and Training – Pre-service

Inspection Report

Complaint Investigation
Capacity: 20 Deficiencies: 5 Date: Oct 9, 2024

Visit Reason
Based on observation, interview, and record review it was determined the facility failed to ensure medications and biologicals were secured and accessible only to authorized personnel, and failed to monitor and maintain refrigerator and dishwasher temperatures. Additional deficiencies included failure to follow state administrative rules. Some deficiencies were corrected by 10/30/2024 but not corrected at follow-up on 11/13/2024.

Findings
Based on observation, interview, and record review it was determined the facility failed to ensure medications and biologicals were secured and accessible only to authorized personnel, and failed to monitor and maintain refrigerator and dishwasher temperatures. Additional deficiencies included failure to follow state administrative rules. Some deficiencies were corrected by 10/30/2024 but not corrected at follow-up on 11/13/2024.

Deficiencies (5)
F0000 - INITIAL COMMENTS
F0761 - Label/Store Drugs and Biologicals
F0812 - Food Procurement,Store/Prepare/Serve-Sanitary
M0000 - Initial Comments
M9999 - STATE OF OREGON ADMINISTRATIVE RULES

Inspection Report

Complaint Investigation
Capacity: 20 Deficiencies: 4 Date: Jul 11, 2024

Visit Reason
The facility failed to notify a physician and obtain orders for a worsening pressure ulcer for one resident, resulting in worsening wounds and hospitalization. Additional deficiencies included failure to follow state administrative rules and inadequate wound care documentation. Some deficiencies were corrected but others remained not corrected at follow-up.

Findings
The facility failed to notify a physician and obtain orders for a worsening pressure ulcer for one resident, resulting in worsening wounds and hospitalization. Additional deficiencies included failure to follow state administrative rules and inadequate wound care documentation. Some deficiencies were corrected but others remained not corrected at follow-up.

Deficiencies (4)
F0000 - INITIAL COMMENTS
F0686 - Treatment/Svcs to Prevent/Heal Pressure Ulcer
M0000 - Initial Comments
M9999 - STATE OF OREGON ADMINISTRATIVE RULES

Inspection Report

Validation, Re-Licensure
Capacity: 48 Deficiencies: 1 Date: Oct 17, 2023

Visit Reason
Re-licensure survey identified multiple deficiencies including resident evaluations, service plans, change of condition monitoring, health services coordination, medication and treatment systems, staffing, training, building maintenance, and documentation. Many deficiencies were corrected by revisit in February 2024, but some remained not corrected.

Findings
Re-licensure survey identified multiple deficiencies including resident evaluations, service plans, change of condition monitoring, health services coordination, medication and treatment systems, staffing, training, building maintenance, and documentation. Many deficiencies were corrected by revisit in February 2024, but some remained not corrected.

Deficiencies (1)
OAR 411-054-0030 (ALL related citations merged)

Inspection Report

State Licensure, Other
Capacity: 48 Deficiencies: 2 Date: Aug 17, 2023

Visit Reason
Kitchen inspection found failures in food sanitation including cleanliness, food storage, labeling, temperature monitoring, and equipment maintenance. Revisit findings showed substantial compliance by January 2024.

Findings
Kitchen inspection found failures in food sanitation including cleanliness, food storage, labeling, temperature monitoring, and equipment maintenance. Revisit findings showed substantial compliance by January 2024.

Deficiencies (2)
OAR 411-054-0030 (1)(a) Resident Services Meals, Food Sanitation Rule
OAR 411-054-0030 related citations

Inspection Report

Complaint Investigation
Capacity: 20 Deficiencies: 17 Date: Jun 30, 2023

Visit Reason
Multiple deficiencies including failure to maintain a safe and clean environment, inadequate ADL care, medication errors, pain management issues, staffing shortages, failure to post accurate nurse staffing information, failure to follow dietary and therapeutic diet orders, call system failures, and unsecured handrails. Many deficiencies were corrected by 7/24/2023 but not corrected at follow-up on 8/16/2023.

Findings
Multiple deficiencies including failure to maintain a safe and clean environment, inadequate ADL care, medication errors, pain management issues, staffing shortages, failure to post accurate nurse staffing information, failure to follow dietary and therapeutic diet orders, call system failures, and unsecured handrails. Many deficiencies were corrected by 7/24/2023 but not corrected at follow-up on 8/16/2023.

Deficiencies (17)
F0000 - INITIAL COMMENTS
F0584 - Safe/Clean/Comfortable/Homelike Environment
F0677 - ADL Care Provided for Dependent Residents
F0684 - Quality of Care
F0691 - Colostomy, Urostomy, or Ileostomy Care
F0695 - Respiratory/Tracheostomy Care and Suctioning
F0697 - Pain Management
F0727 - RN 8 Hrs/7 days/Wk, Full Time DON
F0732 - Posted Nurse Staffing Information
F0756 - Drug Regimen Review, Report Irregular, Act On
F0758 - Free from Unnec Psychotropic Meds/PRN Use
F0803 - Menus Meet Resident Nds/Prep in Adv/Followed
F0808 - Therapeutic Diet Prescribed by Physician
F0919 - Resident Call System
F0924 - Corridors have Firmly Secured Handrails
M0000 - Initial Comments
M9999 - STATE OF OREGON ADMINISTRATIVE RULES

Inspection Report

Capacity: 20 Deficiencies: 1 Date: Jan 3, 2023

Visit Reason
The facility failed to report complete information about COVID-19 to the CDC's National Healthcare Safety Network during a required seven-day reporting period, potentially causing more than minimal harm to all residents.

Findings
The facility failed to report complete information about COVID-19 to the CDC's National Healthcare Safety Network during a required seven-day reporting period, potentially causing more than minimal harm to all residents.

Deficiencies (1)
F0884 - Reporting - National Health Safety Network

Inspection Report

Capacity: 20 Deficiencies: 1 Date: Dec 27, 2022

Visit Reason
The facility failed to report complete information about COVID-19 to the CDC's National Healthcare Safety Network during a required seven-day reporting period, potentially causing more than minimal harm to all residents.

Findings
The facility failed to report complete information about COVID-19 to the CDC's National Healthcare Safety Network during a required seven-day reporting period, potentially causing more than minimal harm to all residents.

Deficiencies (1)
F0884 - Reporting - National Health Safety Network

Inspection Report

Capacity: 20 Deficiencies: 1 Date: Dec 19, 2022

Visit Reason
The facility failed to report complete information about COVID-19 to the CDC's National Healthcare Safety Network during a required seven-day reporting period, potentially causing more than minimal harm to all residents.

Findings
The facility failed to report complete information about COVID-19 to the CDC's National Healthcare Safety Network during a required seven-day reporting period, potentially causing more than minimal harm to all residents.

Deficiencies (1)
F0884 - Reporting - National Health Safety Network

Inspection Report

State Licensure, Other
Capacity: 48 Deficiencies: 1 Date: Jul 14, 2022

Visit Reason
Kitchen inspection identified failures in food sanitation including cleanliness, food storage, labeling, temperature monitoring, and staff hygiene. Revisit in October 2022 found substantial compliance.

Findings
Kitchen inspection identified failures in food sanitation including cleanliness, food storage, labeling, temperature monitoring, and staff hygiene. Revisit in October 2022 found substantial compliance.

Deficiencies (1)
OAR 411-054-0030 (1)(a) Resident Services Meals, Food Sanitation Rule

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