Above average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Cascade Manor during CMS and state inspections, most recent first.
Failure to Notify Provider of Low Pulse Readings: A resident admitted with HF and arterial fibrillation had an order for amiodarone 200 mg daily and repeated pulse readings below 60 BPM, including readings as low as 39 and 40 BPM. The medical record showed no evidence the provider was notified of the low pulses, and the DNS acknowledged staff were expected to notify the provider when the pulse was below 60 BPM.
A resident with HF and AFib had an order for spironolactone to be held if SBP was under 100, but BP monitoring was not completed as ordered. The resident received spironolactone when SBP was 98 on two occasions, and the DNS acknowledged the BP was not checked daily before the med was given.
Failure to track infection organisms and monitor antibiotic use. A resident with recurrent UTIs, confusion, urinary frequency, and pelvic pain was started on antibiotics after a UA with C&S was ordered. The urine culture later showed skin flora, but the provider repeatedly requested the final C&S results and the record showed no evidence the provider reviewed them. Staff acknowledged the C&S was completed earlier and that the expected 72-hour antibiotic follow-up process was not completed.
The facility failed to ensure kitchen staff wore beard restraints during meal prep and did not adhere to food storage standards. A cook was observed without a beard restraint, risking food contamination. Additionally, several food items were found past their use-by dates or unlabeled, violating the facility's storage standards.
A facility failed to develop a hospice care plan for a resident admitted to hospice services with cardiac heart failure. Despite being placed on hospice, the resident's care plan lacked any evidence of hospice care planning. An RNCM confirmed the oversight, acknowledging the absence of a required hospice care plan.
A resident with Cauda Equina Syndrome fell while trying to reach for a call light that was not within reach, contrary to the care plan. The bed was also not in the lowest position as required. The fall investigation confirmed these oversights, identifying the root cause as the call light not being accessible, placing the resident at risk for injury.
Failure to Notify Provider of Low Pulse Readings
Penalty
Summary
The facility failed to notify the provider of abnormal vital signs for Resident 2, who was admitted with diagnoses including heart failure and arterial fibrillation. Resident 2 had an order dated 3/7/26 for amiodarone 200 mg daily, and the vital record showed multiple low pulse readings, including 59, 56, 44, 55, 47, 59, 51, 52, 39, 44, and 40 beats per minute. The medical record contained no evidence that the provider was notified of the low pulses. On 4/14/26, when Resident 2 had a pulse of 42 beats per minute and a blood pressure of 108/47, the amiodarone dose was decreased from 200 mg to 100 mg. The DNS later stated staff were expected to notify the provider if the pulse was below 60 BPM per orders and acknowledged there was no evidence the provider had been notified of the pulses below 60 BPM.
Unnecessary Medication Administration With Missed Blood Pressure Monitoring
Penalty
Summary
Ensure each resident's drug regimen must be free from unnecessary drugs was not met for one sampled resident with diagnoses including heart failure and arterial fibrillation. The resident had an order for spironolactone to be held if systolic blood pressure was less than 100, and on 3/27/26 the provider recommended checking orthostatic blood pressures. The medical record showed no evidence that orthostatic blood pressures were completed, and blood pressure readings were missing on multiple dates. The resident received spironolactone when blood pressure was 98/58 and again when it was 98/52, despite the hold parameter. The DNS acknowledged that the resident's blood pressure was supposed to be checked daily before giving spironolactone and that the medication should have been held when systolic blood pressure was less than 100.
Failure to Track Urine Culture Results and Monitor Antibiotic Use
Penalty
Summary
Implement a program that monitors antibiotic use. The facility failed to track infection organisms for 1 of 5 sampled residents reviewed for unnecessary medications, placing residents at risk for antibiotic resistance. Resident 2 was admitted with diagnoses including UTI and heart failure, and progress notes documented three UTIs in the year, frequent UTIs, increased confusion, frequent urination, and pelvic pain. A urinary analysis with culture and sensitivity was ordered and antibiotics were started. The urinary culture later indicated skin flora, but the resident's provider requested the final culture and sensitivity results on multiple occasions, and the medical record showed no evidence that the provider reviewed those results. Staff 2 stated the culture and sensitivity results were not received until 4/20/26, even though the lab completed them on 4/5/26, and acknowledged that staff were expected to follow up on antibiotics 72 hours after they start to ensure culture results are received and the right antibiotics are being used; this process was not completed for Resident 2.
Non-compliance with Food Safety Protocols
Penalty
Summary
The facility failed to ensure that kitchen staff adhered to proper food safety protocols, specifically regarding the use of beard restraints during meal preparation. During an observation, a cook with facial hair was seen preparing food without a beard restraint, contrary to the US FDA Food Code 2022, which mandates that food employees wear hair restraints to prevent hair from contacting exposed food. The Dietary Manager initially stated that beard restraints were only required for long and unkempt beards, but later acknowledged that the food code did not specify this and that the cook's facial hair posed a contamination risk. Additionally, the facility did not comply with its own General Food Storage Standards, which require proper labeling, dating, and timely disposal of food items. During a kitchen tour, several food items were found to be past their use-by dates, including pancake mix, breadcrumbs, soy sauce, lemon juice, blackberries, and blueberries. Furthermore, slices of cake were stored in unlabeled containers. The Dining Room Supervisor confirmed these findings, acknowledging that the items were either unlabeled or kept beyond their expiration dates, which could lead to unsanitary food conditions and potential food-borne illnesses for residents.
Failure to Care Plan for Hospice Services
Penalty
Summary
The facility failed to develop a care plan for hospice care for a resident who was admitted to hospice services. The resident, who was admitted to the facility in January 2023 with a diagnosis of cardiac heart failure, was placed on hospice care on January 24, 2023. However, a review of the resident's care plan showed no evidence of a hospice care plan being implemented. During an interview on March 25, 2025, a Registered Nurse Case Manager (RNCM) confirmed that the resident was admitted to hospice on January 24, 2025, and acknowledged that there was no care plan in place for hospice care, despite the requirement to do so when a resident is placed on hospice services.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to ensure that care planned interventions to reduce the risk of injury from falls were in place for a resident diagnosed with Cauda Equina Syndrome. The resident's care plan directed staff to encourage the use of a call light for assistance, to keep the call light within reach, and to keep the bed in the low position. However, on December 21, 2024, the resident was found on the fall mat next to the bed after falling while trying to reach for the call light, which was not within reach. The bed was also not in the lowest position as required by the care plan. The fall investigation summary confirmed that the care plan was not followed, identifying the root cause of the fall as the call light not being within the resident's reach. Staff interviews corroborated that the resident's call light was expected to be within reach and the bed in the lowest position, which was not adhered to at the time of the incident. This oversight placed the resident at risk for injury.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 154 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Eugene
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| South Hills Rehabilitation Center | 0.5 mi | ★★★★★ | 22 | 1 |
| Creekside Health And Rehabilitation Of Cascadia | 0.6 mi | ★★★★★ | 5 | 0 |
| Hillside Heights Rehabilitation Center | 1 mi | ★★★★★ | 14 | 0 |
| Avamere Rehabilitation Of Eugene | 1.6 mi | ★★★★★ | 17 | 1 |
| Valley West Health Care Center | 3 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Cascade Manor.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.