Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Terrace Post Acute during CMS and state inspections, most recent first.
Two residents with psychosocial risk factors reported that an RN made repeated undignified and unprofessional comments during intimate care, including telling them not to fart on him during peri and catheter care. Both residents described feeling uncomfortable, awkward, and disrespected. The RN acknowledged routinely using a phrase about not falling or farting on him with all residents as a supposed rapport-building joke, and another staff member confirmed hearing this comment during care. Facility leadership acknowledged that these comments did not honor resident dignity.
The facility failed to timely report an allegation of physical abuse to the State Agency after a resident with cognitive impairment was documented as placing a pillow over another resident’s face and throwing heat packs at the resident while sleeping. Nursing staff reported the incident to the Administrator, who decided it would be investigated internally but not reported externally, and other RNs confirmed that administration determined the event was not reportable. The Administrator acknowledged awareness that all abuse allegations must be reported within two hours but did not do so, resulting in a deficiency for failure to report suspected abuse.
A cognitively intact resident with type 2 DM and depression had a documented care plan specifying a preference for female caregivers to be present during care, including routine and skin assessments, to ensure comfort. Despite this, a male RN performed a skin assessment without a female caregiver in the room. An LPN and a CNA confirmed that the resident’s care plan and facility protocol required at least one female caregiver to be present during such assessments, and the administrator acknowledged that the RN failed to honor the resident’s stated needs and preferences.
A resident with obesity and diabetes did not receive prescribed weekly semaglutide injections on several occasions due to issues such as the medication not being filled, confusion about storage requirements, and unclear documentation. LPNs and the DNS confirmed the missed doses, with some staff unaware of proper medication storage procedures.
A resident with brain cancer received temozolomide chemotherapy for 23 days instead of the prescribed 5-day cycle due to a failure in order verification and documentation. This error led to severe blood cell deficiencies and required multiple transfusions and hospitalizations.
The facility did not ensure adequate supervision or hazard prevention for two residents—one with a history of substance use disorder who experienced fatal and non-fatal overdoses without appropriate care planning or staff training, and another with hemiplegia who was involved in a transfer-related fall without subsequent education or intervention for safe transfers.
The facility did not submit mandatory direct care staffing information for a fiscal quarter as required by policy, with both payroll/human resources staff and the administrator unaware of the omission and indicating that the corporate office was responsible for the submission.
The facility did not provide required training on its Quality Assurance and Performance Improvement (QAPI) program to staff. Multiple staff members, including CNAs and an LPN, reported they were unaware of the QAPI program and had not received any related training. Review of training records confirmed the absence of QAPI training for all staff.
The facility did not provide RN coverage for eight consecutive hours on four separate Saturdays, as required. Staff acknowledged the lack of RN coverage and noted challenges in staffing on weekends, while the administrator was unaware of these lapses.
The facility did not accurately post daily nurse staffing information, with errors including misclassification of staff roles and missing entries for Nursing Assistants on several days. Staff were incorrectly listed or omitted from the Direct Care Staff Daily Report, and administrative staff were unaware of these inaccuracies.
Surveyors found that medication carts containing prescription and over-the-counter drugs, including antibiotics and insulin, were left unlocked and unattended in hallways with staff and residents nearby. Additionally, expired medications and an opened vial of Tubersol without a documented open date were found in the medication storage room. Staff acknowledged these lapses in medication security and storage practices.
A resident with diabetes and an amputation, who was cognitively intact, did not receive requested double portions and a hamburger despite repeated requests and an order card specifying these preferences. Staff confirmed the resident's ongoing requests and noted inadequate systems for meeting food and cultural preferences.
Surveyors found that food items in unit refrigerators were not labeled or dated after opening, and personal employee beverages were stored alongside resident items. Additionally, the facility's only ice machine was not plumbed with an air gap, creating a risk of contamination for ice used in resident beverages. Staff acknowledged these practices did not meet facility expectations.
A resident with dementia and no documented cognitive impairment was found with Aspercreme lidocaine gel at the bedside, which the resident used independently. Staff confirmed that medications should not be kept at the bedside and that no assessment had been completed to determine the resident's ability to self-administer the medication.
Staff failed to maintain the privacy of resident health information by leaving an unlocked computer screen displaying sensitive data unattended and by leaving confidential paper records exposed on the nurses station counter. These actions resulted in multiple residents' personal and medical information being accessible to unauthorized individuals, with staff and administration acknowledging that such information should have been secured.
The facility did not complete comprehensive admission assessments within 14 days for three residents with complex medical conditions, including diabetes, chronic kidney disease, stroke, and amputation. Required MDS documentation and Care Area Assessments were incomplete or unsigned, and staff confirmed the assessments were overdue, resulting in a lack of timely information for individualized care planning.
Two residents had inaccurate MDS assessments: one was not coded as edentulous despite lacking natural teeth, and another was coded as having adequate hearing despite documented and observed hearing impairment. Staff confirmed the inaccuracies in both cases.
A resident with dementia and urinary retention, dependent on staff for bathing, did not receive scheduled showers as outlined in their care plan. Documentation and staff interviews confirmed that the resident did not refuse showers, yet bathing logs showed inconsistent provision of showers and a lack of documentation for missed or refused showers.
Two residents did not receive individualized activities in accordance with their documented preferences and care plans. Both were frequently left in their rooms without access to music, reading materials, or other preferred activities, and staff did not offer or facilitate these options, despite facility policy and care plan requirements.
Three residents did not receive care as ordered, including failure to obtain a custom AFO for a resident with hemiplegia, lack of assessment and treatment for a resident's pre-existing facial skin condition, and failure to administer PRN hydralazine for another resident with hypertension despite elevated blood pressure readings. Staff interviews confirmed that required actions were not taken in each case.
A resident with end-stage renal disease and severe cognitive impairment did not consistently receive required pre- and post-dialysis assessments or proper communication between the facility and the dialysis center. Documentation was missing for multiple dialysis sessions, and staff interviews confirmed that licensed nurses did not always complete necessary forms or assessments as outlined in facility policy.
A resident receiving Clopidogrel for clot prevention was not monitored for adverse side effects, despite developing multiple unexplained bruises. Staff interviews and record reviews confirmed that there was no documentation or orders for monitoring anticoagulant side effects, and expected shift documentation was not completed.
A resident with a stroke and cerebral edema, requiring extensive assistance, did not receive scheduled baths or showers as per their care plan. Despite being nonverbal and unable to refuse care, the resident's family noted the lack of bathing, and staff confirmed that showers were not completed due to low staffing levels. The facility's administration was informed but did not provide further information.
A resident with a PEG tube for nutrition was not administered tube feedings according to physician orders, with frequent delays documented. Staff confirmed that feedings should occur within an hour of scheduled times, but this was not consistently followed, risking insufficient nutrition.
Undignified Comments by RN During Intimate Care to Two Residents
Penalty
Summary
The deficiency involves staff failure to honor residents’ rights to be treated with respect and dignity during personal care. Resident 1, admitted with type 2 diabetes and depression, had a care plan dated 7/25/25 identifying risk for decreased psychosocial well-being and adjustment issues, with directions for staff to use appropriate and effective communication, encourage personal preferences, and honor quality-of-life choices to ensure dignity and respect. During a routine skin assessment on 2/6/26, Resident 1 reported that a registered nurse (Staff 6) stated, “don’t fart on me, a lot of people fart on me,” while examining the resident’s peri-area and areas near the anus. Resident 1 reported feeling disrespected, uncomfortable, and undignified, and stated the comment was unnecessary and did not want Staff 6 to provide care in the future. A CNA (Staff 7) corroborated hearing Staff 6 tell Resident 1 not to fart in his/her face during the skin assessment. Resident 5, admitted with cellulitis and agoraphobia, had a care plan dated 1/23/26 identifying risk to psychosocial well-being, including increased agitation and tearfulness, and directing staff to honor the resident’s preferences and choices to promote dignity and decrease anxiety. Resident 5 reported that the same RN (Staff 6) made unprofessional comments and “weird jokes” during care, including asking the resident not to fart on him while performing routine catheter care, which made the resident feel awkward and uncomfortable. In an interview, Staff 6 confirmed using the statement, “I am the registered nurse today. I have a couple of rules, don’t fall on me, don’t fart on me,” with all residents during care, explaining he believed it was humorous and a way to establish rapport. The Administrator (Staff 1) stated that Staff 6’s behavior and comments, including the phrase “don’t fart on me,” did not honor resident dignity and were inappropriate when providing resident care.
Failure to Timely Report Allegation of Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to report an allegation of physical abuse to the State Agency within the required two hours after an incident involving two residents. Resident 9, who was admitted in 10/2024 with metabolic encephalopathy and atrial fibrillation and had a care plan dated 11/4/24 identifying cognitive loss affecting decision-making ability, was documented in a 2/7/26 facility incident report (completed on 2/15/26) as having placed a pillow over another resident’s face and thrown heat packs at that resident while the resident was sleeping. Staff interviews revealed that a RN case manager reported the incident to the Administrator, who stated the incident would be investigated but not reported to the State Agency, and the RN case manager believed administration handled the investigation. Another RN stated she reported the incident based on information from care staff, and that administration determined it was not reportable to the State Agency. The Administrator stated he was notified of the incident by care staff and did not report it to the State Agency because he did not believe it to be abuse, while acknowledging that all allegations of abuse must be reported to the State Agency within two hours of the allegation. This sequence of events, including the documented allegation of potentially abusive behavior by one resident toward another and the Administrator’s decision not to report the allegation despite staff notification and his awareness of reporting requirements, led to the deficiency for failure to timely report suspected abuse to the proper authorities.
Failure to Honor Resident’s Care Plan for Female Caregiver Preference During Nursing Assessment
Penalty
Summary
The deficiency involves the facility’s failure to implement a resident’s care plan regarding caregiver gender preference during the provision of nursing care. The resident, admitted in July 2025 with diagnoses including type 2 diabetes and depression, had a 7/7/25 cognitive assessment showing a BIMS score of 15/15, indicating no cognitive impairment. The resident’s 7/25/25 care plan documented an individualized preference for female caregivers to promote comfort during care, and directed staff to ensure female caregivers were available when providing care. During a routine skin assessment on 2/17/26 at 10:19 AM, the resident reported that Staff 6 (RN), a male nurse, conducted the assessment without an additional female caregiver present in the room, contrary to the resident’s stated preference and the care plan directives. Interviews with staff confirmed awareness of the resident’s care plan and the expectation to honor the resident’s preference. On 2/17/26 at 11:07 AM, Staff 5 (LPN) stated that standard protocol based on the resident’s care plan was to ensure at least one female caregiver was present during routine assessments, including skin assessments, and acknowledged that staff were expected to honor this preference. At 11:15 AM, Staff 6 (RN) acknowledged providing care to the resident but refused to answer whether a female caregiver was present. At 12:04 PM, Staff 8 (CNA) stated that the resident’s preference was for female caregivers only and reported that Staff 6 provided nursing services without a female caregiver in the room. At 3:26 PM, Staff 1 (Administrator) stated that Staff 6 failed to honor the resident’s needs and preferences by performing nursing services without ensuring female caregivers were present.
Failure to Administer Medication as Ordered
Penalty
Summary
The facility failed to ensure that physician orders for semaglutide (Ozempic) injections were followed for a resident with obesity and diabetes. The resident was admitted in 2025 and had a physician order dated 9/23/25 for weekly semaglutide injections. However, medication administration records and treatment administration records for October, November, and December 2025 showed that the resident did not receive the medication on multiple scheduled dates. Progress notes indicated that the medication was not administered due to reasons such as the prescription not being filled, a new order being needed, the prescription having ended, or the resident requesting a prescription, with some notes left blank. Staff interviews confirmed that the medication was not given as ordered, with one LPN stating she did not administer the medication because she believed it needed refrigeration and was unaware it was kept in the medication cart once opened. The Director of Nursing Services acknowledged the missed doses.
Chemotherapy Medication Administered in Excess of Prescribed Duration
Penalty
Summary
The facility failed to ensure that chemotherapy medications were administered as ordered for a resident with a diagnosis of Glioblastoma. The resident was supposed to receive temozolomide, a chemotherapy drug, for five days as part of a 28-day maintenance cycle, in accordance with standard dosing schedules and the prescriber's intent. However, due to a lack of clear documentation and order verification, the medication was administered daily for 23 consecutive days, far exceeding the prescribed duration. The error originated when a nurse transcribed the temozolomide order into the resident's clinical record without confirming the exact duration of administration, despite having a conversation with the neuro-oncology clinic. The nurse could not recall the specific instructions regarding the number of days the medication was to be given and relied on a paper order that was never located during the subsequent investigation. The Director of Nursing did not verify the entry or the existence of a valid paper order, and the medication was administered according to the incorrect transcription. The facility's policy required clarification of ambiguous orders and documentation of such clarifications, but this process was not followed. As a result of the prolonged administration of temozolomide, the resident developed severe complications, including thrombocytopenia, pancytopenia, and neutropenia, which necessitated multiple blood transfusions, emergency department visits, and hospitalizations. Interviews with facility staff and the resident's medical providers confirmed that the medication was given for a much longer period than intended, directly leading to these adverse outcomes.
Failure to Prevent Hazards and Provide Adequate Supervision for Residents with SUD and Mobility Risks
Penalty
Summary
The facility failed to keep residents free from hazards and provide adequate supervision, particularly for residents with a known history of substance use disorder (SUD) and those at risk for accidents during transfers. One resident with a history of polysubstance use was admitted and later experienced two critical incidents: first, being found unresponsive in the facility's parking lot due to a suspected opioid overdose, and second, being found deceased in their bathroom with drug paraphernalia present. Despite these events, there was no evidence that the resident's care plan addressed their history of substance use, nor was there any indication that monitoring for opioid use was initiated after the resident returned from the hospital following the first overdose. Staff interviews revealed a lack of knowledge and training regarding SUD. Multiple staff members, including CNAs, LPNs, and housekeepers, reported not receiving education on identifying signs and symptoms of drug use, monitoring residents with SUD, or handling drug paraphernalia. The Social Services Director confirmed that training on SUD was only provided to licensed nursing staff and not to CNAs or other direct care staff. Additionally, the facility did not update care plans or implement monitoring for other residents with a history of SUD, as identified by the Social Services Director. In another case, a resident with hemiplegia and severe cognitive impairment required extensive assistance for car transfers and had a witnessed fall during a transfer with a family member. Although a physical therapy referral was made, neither the resident nor the family member received education or training on safe car transfers following the incident. Staff were unaware that the resident continued to go out with the family member after the fall, and no further interventions were implemented to address the risk of future accidents.
Removal Plan
- Review all residents' records to identify other residents with history of or active substance use disorder.
- Identify residents with active, suspected, or history of substance use and list them in a binder at the nursing stations. Place a sticker on the residents' name plates outside their rooms to alert staff of potential hazards associated with active substance use disorder.
- Offer substance use treatment services to residents identified with history of or active substance use disorder.
- Assess residents identified with history of or active substance use disorder upon return from independent offsite outing for suspected substance use.
- Generate an incident report and notify law enforcement if required for residents assessed upon return from independent offsite outing or identified as active substance use.
- Educate staff, including temporary or agency staff, on the location of the binder with residents identified with suspected or history of substance use disorder.
- In-service staff, including temporary or agency staff, on substance use disorder, signs of abuse related to drug use, actions to take if active use is suspected, reporting suspected drug paraphernalia, and facility policy on resident possession and use of illegal substances.
- Place residents identified with drug paraphernalia or signs/symptoms of active drug use on alert monitoring, notify MD, place POC task to alert CNA for increased monitoring for drug paraphernalia, notify law enforcement if required, generate an incident report, and complete resident assessment.
Failure to Submit Required Payroll-Based Staffing Data
Penalty
Summary
The facility failed to submit the required direct care staffing information for fiscal year 2024, quarter four, as mandated by their Reporting Direct Care Staffing Information (Payroll-Based Journal) policy. The policy requires that complete and accurate staffing data, based on payroll and other verifiable and auditable sources, be electronically reported to CMS for each fiscal quarter within 45 days after the quarter ends. Review of records showed that the data for the specified quarter was not submitted. During interviews, the staff member responsible for payroll and human resources was unaware of the missing submission and indicated that the corporate office was responsible for this task. The facility administrator was also unaware that the data had not been submitted.
Failure to Provide QAPI Training to Staff
Penalty
Summary
The facility failed to provide mandatory training to staff on the elements and goals of its Quality Assurance and Performance Improvement (QAPI) program. During interviews, multiple staff members, including certified nursing assistants and an LPN, reported being unaware of the QAPI program and confirmed they had not received any related training. A review of the facility's list of new hire and annual trainings by the Payroll/Human Resources staff and the administrator confirmed that QAPI training was not included. This deficiency was identified for the entire facility, as no staff had received the required QAPI training.
Failure to Ensure Required RN Coverage on Multiple Days
Penalty
Summary
The facility failed to provide registered nurse (RN) coverage for eight consecutive hours on four separate Saturdays within a 33-day review period, as evidenced by the Direct Care Staff Daily Reports (DCSDR). Specifically, there was no RN coverage for the required duration on 7/20/24, 8/3/24, 3/22/25, and 4/12/25. Staff responsible for payroll and human resources acknowledged the lack of RN coverage on these dates and cited difficulty in finding RN coverage on weekends. The facility administrator was not aware of the absence of RN coverage on the identified days. No information was provided regarding specific residents affected, their medical history, or their condition at the time of the deficiency.
Failure to Accurately Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post accurate and complete nurse staffing information for 14 out of 34 days reviewed. Review of the Direct Care Staff Daily Report (DCSDR) revealed incorrect information on multiple dates, including the entry of a 'Sitter' with hours worked as part of the staff count, and the absence of entries for Nursing Assistants on certain shifts. On one occasion, a staff member was observed wearing a CNA badge but confirmed he was not a CNA, and was not listed correctly on the DCSDR. Payroll/Human Resources staff acknowledged that the Sitter was a CNA assigned to one-on-one duties and should have been included in the CNA count, but the DCSDR did not accurately reflect this information. Further interviews confirmed that the same staff member worked with residents on several dates and should have been counted as a Nursing Assistant, but was not. The Administrator was unaware of the incorrect information on the DCSDR. These inaccuracies resulted in incomplete and inaccurate staffing information being posted for residents and the public.
Unsecured Medication Storage and Expired Medications Identified
Penalty
Summary
Surveyors observed multiple instances where medication carts were left unlocked and unattended in hallways, with both staff and residents passing by. On several occasions, medication carts containing prescription medications, over-the-counter drugs, antibiotics such as ceftriaxone, and insulin were found unlocked near resident rooms. Staff members, including a CMA and RNs, were noted to leave the carts unattended and unlocked, despite the expectation that medication carts should be locked when not in use. These observations were confirmed through interviews with staff, who acknowledged the expectation for secure storage. Additionally, the medication storage room was found to contain expired medications, including Vitamin A, Complete Women 50+ multi-vitamin with minerals, and L-Argine. A vial of Tubersol, used for tuberculosis testing, was also found opened without a documented open date, despite the requirement that it is only good for 30 days after opening. Staff confirmed the presence of expired medications and the lack of an open date on the Tubersol vial.
Failure to Meet Resident Dietary Preferences and Portion Requests
Penalty
Summary
A resident with diabetes and a below-the-knee amputation, who was cognitively intact, reported not receiving enough food and specifically requested larger portions. Despite having an order card for double portions and a hamburger on the side, the resident was observed receiving small portions and no hamburger. Staff interviews confirmed that the resident had requested double portions and a hamburger regularly, and that there was not a good system in place to meet resident preferences and cultural preferences for food. The dining manager and dietary staff acknowledged the resident's requests, but the upgrade to double portions was not implemented until after the deficiency was observed.
Improper Food Storage and Ice Machine Plumbing Deficiencies
Penalty
Summary
Surveyors observed that the facility failed to ensure proper labeling and storage of food items in refrigerators located behind two nurses stations. Specifically, multiple food items, including covered plastic ramekins of peanut butter, a coffee mug with clear liquid and ice, and containers of nutritional shakes, were found opened, unlabeled, and undated. Staff members acknowledged these items should have been labeled with the date they were opened to ensure proper tracking and timely disposal. Additionally, an employee's personal beverage was found stored in one of the unit refrigerators, contrary to facility expectations. Further, the facility's only ice machine was found to be improperly plumbed, with its drain pipe lacking an air gap and discharging directly through a wall to the outside garden area. This setup did not prevent potential backflow of contaminated matter into the ice machine. The Dietary Manager confirmed the ice from this machine was used for preparing residents' beverages, and the Administrator acknowledged the risk of contamination due to the current drainage system.
Failure to Assess Resident for Safe Self-Administration of Medication
Penalty
Summary
A resident admitted with dementia and no cognitive impairment documented on the most recent MDS was found to have Aspercreme lidocaine gel, a topical pain reliever, at their bedside within reach. The resident reported using the gel on their heels. Review of the health record showed that no assessment had been completed to determine the resident's ability to safely self-administer this medication. Multiple staff members, including CNAs and an LPN, confirmed the presence of the medication at the bedside and stated that medications should not be kept in resident rooms, but rather in medication carts. The regional clinical support staff also confirmed that no self-administration assessment had been performed and that the medication should not have been left in the resident's room.
Failure to Protect Resident Health Information Privacy
Penalty
Summary
Facility staff failed to maintain the privacy and confidentiality of resident records for three residents. In one instance, an unlocked computer screen on a treatment cart in a hallway displayed a resident's photo, name, gender, date of birth, age, allergies, code status, attending physician, vital signs, and scheduled treatments. The responsible LPN acknowledged forgetting to lock the computer screen, and the administrator confirmed that screens are expected to be locked when unattended to protect resident information. Additionally, four sheets of resident records containing private information, such as room numbers, names, and details about care (including ostomy bag changes, brief changes, and catheter care), were left unattended on the counter at the central nurses station. Staff were observed leaving these records unsupervised while going in and out of resident rooms, and other residents were seen passing by the exposed information. The LPN on duty confirmed the records were left out from the previous shift and acknowledged that confidential information should not be left in the open. The administrator stated that private information should be under staff supervision or covered.
Failure to Complete Timely Comprehensive Admission Assessments
Penalty
Summary
The facility failed to complete comprehensive admission assessments within the required 14-day timeframe for three residents. For one resident with type 2 diabetes mellitus and chronic kidney disease, the Admission MDS was found incomplete 17 days after admission, lacking provider signatures in key sections and missing completed Care Area Assessments (CAAs) for multiple triggered care areas, including functional abilities, urinary incontinence, nutritional status, pressure ulcers, and pain. Another resident with a history of stroke and type 2 diabetes had an Admission MDS that was still in progress and overdue by five days, as confirmed by facility staff. A third resident, admitted with type 2 diabetes mellitus and a below-the-knee amputation, also had an incomplete Admission MDS 18 days after admission, with unsigned and incomplete CAAs for several triggered care areas such as cognitive status, mood, nutritional status, pressure ulcers, and pain. Staff interviews confirmed that the facility had overdue admission assessments for these residents. The lack of timely and complete comprehensive assessments placed the residents at risk for unmet care needs, as the necessary information to guide individualized care planning was not available within the required timeframe.
Inaccurate MDS Coding for Dental and Hearing Status
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessments were coded accurately for two residents in the areas of dental status and hearing. For one resident with a history of traumatic brain injury, the dental treatment record indicated the resident was fully edentulous, yet the annual MDS did not reflect this status. Direct observation confirmed the absence of natural teeth, and facility staff acknowledged the inaccuracy in the MDS coding for this resident. For another resident admitted with heart failure, the nursing admission evaluation documented poor hearing in both ears. However, the admission MDS indicated the resident's hearing was adequate. Observations showed that the resident could only hear when spoken to at close range and with increased volume, and the resident reported being unable to hear and needing hearing aids. Multiple staff members confirmed the need to speak loudly and closely for the resident to hear, and facility staff acknowledged the MDS was inaccurately coded regarding the resident's hearing status.
Failure to Provide Scheduled Showers for Dependent Resident
Penalty
Summary
The facility failed to ensure that a dependent resident received showers as scheduled, resulting in a deficiency related to activities of daily living (ADLs). The resident, who was admitted with dementia and had a catheter due to urine retention and bowel incontinence, was care planned to receive bathing or showering twice weekly or per preference. Documentation showed that the resident was dependent on staff for bathing and did not refuse showers. However, bathing logs indicated that the resident did not consistently receive showers according to the scheduled days, with significant gaps between shower dates. Interviews with the resident and multiple staff members confirmed that the resident did not refuse showers and expected to receive them at least twice a week. Staff acknowledged that missed showers should be made up the next day and refusals should be documented, but there was no evidence in the progress notes that additional showering opportunities were provided when showers were missed or refused. The regional clinical support staff confirmed that the resident did not receive showers as scheduled and that missed or refused showers should have been documented.
Failure to Provide Person-Centered Activities for Residents
Penalty
Summary
The facility failed to provide an ongoing, person-centered activity program for two of three sampled residents, resulting in unmet psychosocial and quality of life needs. For one resident with dementia, assessments and care plans indicated preferences for activities such as reading, listening to music, spending time outdoors, and participating in religious services. Despite these documented preferences, the resident was frequently observed alone in their room, either in bed or in a wheelchair, often yelling for help. There were no books, newspapers, magazines, music, or TV available in the room, and the resident was not observed participating in group or one-to-one activities. Staff interviews confirmed the absence of activity materials and a lack of engagement with the resident's stated interests, with staff unaware of or not providing the preferred activities. Another resident, admitted with necrotizing fasciitis, had an activity assessment and care plan indicating the importance of listening to music, keeping up with the news, and having reading materials. Observations revealed that this resident was also left in their room without music, TV, or other activity materials, and staff did not offer to assist with turning on the TV or music. The resident expressed not knowing what activities were available and indicated interest in listening to music, podcasts, or audiobooks, but these were not provided. Staff interviews further revealed a lack of awareness of the resident's preferences and a failure to offer or facilitate the use of available activity resources. The facility's own policy required activities to be based on comprehensive, resident-centered assessments and to reflect individual preferences, with documentation in the medical record. However, both direct observation and staff interviews demonstrated that these requirements were not met for the two residents, as their preferences were not honored and activity materials were not provided or facilitated, despite being documented in their care plans and assessments.
Failure to Provide Ordered Treatments, Skin Assessments, and PRN Medication Administration
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders and resident needs for three residents. One resident with hemiplegia was determined to require a custom Ankle Foot Orthosis (AFO) for stabilization and assistance with activities of daily living. Despite multiple clinical notes and evaluations indicating the need for a custom AFO, there was no evidence that the facility obtained the device. Staff interviews confirmed that no action had been taken to secure the orthosis, and the resident and family member both reported that the brace had not been received or used as ordered. Another resident was admitted with spastic hemiplegia and was found to have red blotches and bumps on both cheeks, which were present prior to admission and caused irritation. The facility's policy required identification, assessment, and documentation of skin impairments, as well as notification of the physician and obtaining treatment orders if needed. However, the skin condition was not assessed or documented by nursing staff, and no treatment was initiated. Staff interviews revealed that the skin issue was not reported or evaluated, and the required procedures for new skin impairments were not followed. A third resident with hypertension had a physician order for as-needed hydralazine to be administered for blood pressures greater than 160. Multiple blood pressure readings above this threshold were recorded, but there was no evidence in the medication administration record that the medication was given as ordered. Staff confirmed that the resident should have received the medication when indicated, but this did not occur.
Failure to Ensure Proper Dialysis Care and Communication
Penalty
Summary
The facility failed to ensure proper dialysis care and communication for a resident with end-stage renal disease and severe cognitive impairment. According to the facility's policy, licensed nurses were required to complete pre-dialysis and post-dialysis communication forms, monitor the resident before and after dialysis, and ensure communication with the dialysis center. Record review showed that for multiple dialysis sessions, there was missing documentation, including absent pre-dialysis, post-dialysis, and dialysis center communication forms. There was also no evidence that nursing staff contacted the dialysis center to obtain reports for several treatment dates. Interviews with staff confirmed that the required forms were not consistently completed and that assessments by licensed nurses were sometimes missed upon the resident's return from dialysis. A private caregiver reported that only CNAs typically took vital signs after dialysis, and licensed nurses did not perform assessments as required. Staff acknowledged the importance of the communication forms and assessments, and confirmed the gaps in documentation and communication for the identified dates.
Failure to Monitor for Adverse Effects of Anticoagulant Medication
Penalty
Summary
A resident with a diagnosis of peripheral vascular disease was admitted to the facility and prescribed Clopidogrel Bisulfate, an anticoagulant, for clot prevention. The April 2025 Medication Administration Record (MAR) indicated the resident was to receive 75mg of the medication daily at bedtime. Despite the known side effects of Clopidogrel, such as collection of blood under the skin and deep, dark purple bruises, there was no evidence in the medical record that adverse side effects were being monitored. During an interview, the resident displayed multiple bruises on both arms and was unaware of their origin. Staff interviews revealed that skin checks were only completed weekly, and no bruising had been documented. Additionally, a new skin tear was noted by staff, but there was no documentation of bruising or monitoring for side effects related to the anticoagulant in the resident's chart. Further review and interviews with nursing staff and clinical leadership confirmed the absence of any orders or documentation for monitoring the resident for adverse effects of anticoagulant therapy. Staff acknowledged that monitoring for side effects should have been conducted and documented each shift, but this was not done. The lack of monitoring and documentation placed the resident at risk for medication complications associated with anticoagulant use.
Failure to Provide ADL Care for Resident
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADL) for a resident who required extensive assistance due to conditions including a stroke and cerebral edema. The resident was admitted in August 2024 and was nonverbal, unable to express understanding, and required total assistance for bathing. The care plan specified that the resident was to be bathed or showered twice a week. However, records from August 2024 indicated that no baths or showers were completed for the resident during that time. Interviews with staff and a complainant revealed that the resident's family members frequently visited and noted the lack of bathing, even washing the resident's hair themselves due to neglect. A CNA confirmed that the resident was scheduled for showers during the evening shift, but these were not carried out. Another former CNA mentioned that staffing levels were low during that period, contributing to the failure to provide the necessary care. The facility's administrator and director of nursing services were informed of these findings but did not provide additional information.
Failure to Administer Tube Feeding as Ordered
Penalty
Summary
The facility failed to administer tube feeding according to physician orders for a resident who was admitted with diagnoses including stroke and cerebral edema. The resident was nonverbal, NPO, and received nutrition via a PEG tube. The physician's orders specified that the resident should receive 290 ml of a standard formula with fiber five times a day at specific times. However, the facility did not adhere to these orders, as the tube feedings were frequently administered late, sometimes by several hours, as documented in the MAR Audit Report. Witnesses, including a complainant and several staff members, confirmed the discrepancies in the administration times. The registered dietitian and other staff members acknowledged that tube feedings should be administered within an hour before or after the scheduled times, but this was not consistently done. The assistant director of nursing and other staff confirmed the audit results, indicating that the tube feedings were not administered within the time frames ordered by the physician, placing the resident at risk for insufficient nutrition.
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 539 citations issued within 25 miles in the last 12 months — including the 5 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.
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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.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Portland
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Avalon Care Center - Portland | 1 mi | ★★★★★ | 4 | 0 |
| Gracelen Care Center | 1 mi | ★★★★★ | 5 | 0 |
| Cedar Crossings | 1 mi | ★★★★★ | 14 | 0 |
| Secora Rehabilitation Of Cascadia | 1.1 mi | ★★★★★ | 0 | 0 |
| Marquis Mill Park | 2.3 mi | ★★★★★ | 13 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.