Above average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
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 Village Manor Of Cascadia during CMS and state inspections, most recent first.
A resident with dementia and a history of falls was left unattended in the shower room without required supervision, a shower bench, or non-skid footwear. The resident was found by housekeeping staff after sustaining multiple pelvic fractures and internal bleeding, and staff confirmed that the care plan interventions to prevent falls were not followed.
A resident with a history of schizoaffective disorder struck another resident with psychosis in the face while the latter was sleeping. Staff responded to yelling, separated the residents, and called EMTs. The assaulted resident was not physically injured but reported feeling scared and uncomfortable sharing a room with the aggressor. Staff and documentation confirmed the incident met the definition of abuse.
A resident with schizophrenia and traumatic brain injury was forcefully shoved and thrown against a wall by another resident with dementia and delirium. Staff intervened and separated the residents, but the LPN involved, being new, did not submit the required abuse report to the State Agency within the mandated timeframe, despite assistance from the DNS and another nurse.
A resident with borderline personality disorder was unable to independently operate their bedside light due to a shortened chain, leading to frustration and repeated requests for staff assistance. Staff had inconsistent knowledge about the resident's ability to use the light, and the care plan did not address the modification. The chain had been shortened for safety, but key staff were unaware this prevented the resident from using the light without help.
A resident with a history of anxiety, hallucinations, and disorientation was repeatedly administered haloperidol without documented indications or behaviors warranting its use. Multiple LPNs gave the antipsychotic for reasons such as agitation or difficulty sleeping, but failed to record specific symptoms, non-pharmacological interventions, or the effectiveness of the medication, resulting in the use of unnecessary psychotropic medication as a chemical restraint.
A resident with multiple psychiatric diagnoses was prescribed several psychotropic medications, but the facility did not include any interventions for the use of these medications in the resident's care plan. Review of the clinical record and confirmation by the DNS showed no resident-specific interventions were documented.
A resident with a history of stroke and swallowing difficulties experienced a choking episode during dinner that required the Heimlich maneuver by an LPN. Despite this event, the resident's diet was not immediately downgraded, and the speech-language pathologist was not notified until several days later. The delay in assessment and intervention following the choking incident led to the deficiency.
A resident with cognitive impairment and a care plan requiring smoking gloves to prevent burns was observed smoking without the gloves. The resident reported that staff did not offer the gloves, and staff confirmed the omission, resulting in a failure to follow the care plan for accident prevention.
Two residents with PTSD did not receive trauma-informed care as required by facility policy. Staff failed to complete trauma assessments or develop care plans addressing trauma triggers, and were unaware of the residents' trauma histories or specific needs. Both residents confirmed that trauma triggers and histories were not discussed with them.
A resident with anxiety, hallucinations, and disorientation was prescribed Olanzapine. The pharmacist recommended updating the medical record with specific symptoms, consideration of other causes, and use of nonpharmacological interventions if the antipsychotic was to continue. These recommendations were not followed, and the required documentation was missing from the clinical record.
Two residents received unnecessary medications when staff failed to follow physician orders to withhold midodrine for elevated SBP and senna for loose stools. Despite clear parameters, both medications were administered on multiple occasions when they should have been held, as confirmed by MAR reviews and staff interviews.
A resident with dementia and a history of frequent falls did not receive a physician-ordered PT evaluation after staff determined therapy was not appropriate due to recent prior therapy. The decision was not communicated to the provider, and the ordered service was not completed, leaving the resident without the specialized rehabilitative intervention intended to address fall risk.
Failure to Follow Fall Prevention Care Plan During Bathing
Penalty
Summary
A deficiency occurred when the facility failed to implement care plan interventions designed to prevent falls for a resident with dementia who was identified as a fall risk. The resident's care plan specified the need for supervision and touch assistance during bathing, use of a shower bench or bathtub, and wearing non-skid footwear when up. Despite these interventions, the resident was found unattended in the shower room by housekeeping staff, not fully clothed, without socks or shoes, and without a shower bench present. The resident was in a shower stall rather than a bathtub, and staff interviews confirmed that the care plan was not followed. As a result of these failures, the resident sustained multiple complex pelvic fractures and internal bleeding, requiring transfer to the hospital for evaluation. Staff statements and administrative confirmation indicated that the resident was left alone in the shower room, and the required safety equipment and supervision were not provided at the time of the incident.
Resident-to-Resident Physical Abuse Incident
Penalty
Summary
A resident with schizoaffective disorder was admitted to the facility and shared a room with another resident diagnosed with psychosis. On the night of the incident, staff heard yelling and discovered the first resident standing over the second resident's bed, having struck the resident in the face while the latter was sleeping. The assaulted resident reported being woken by the physical contact and responded by kicking the aggressor away. Staff intervened to separate the residents and emergency medical technicians were called to the scene. The assaulted resident did not sustain physical injuries but expressed fear and discomfort about sharing a room with the aggressor. Staff confirmed that the incident involved one resident hitting another and acknowledged that it met the definition of abuse. The incident was reported to the State Survey Agency, and facility documentation corroborated the sequence of events, including the lack of injury and the emotional impact on the assaulted resident.
Failure to Timely Report Resident-to-Resident Abuse Incident
Penalty
Summary
The facility failed to report an allegation of abuse to the State Agency within the mandated timeframe for one resident. According to the facility's policy, allegations of abuse, including physical altercations between residents, must be reported to the administrator immediately and to the state agency within two hours if there is alleged abuse or serious bodily injury. In this incident, a resident with schizophrenia and a history of traumatic brain injury was forcefully shoved and thrown against a wall by another resident with dementia and delirium. Staff intervened and separated the residents, and the incident was documented in the facility's FRI. However, the FRI was not submitted to the State Agency within the required timeframe. The LPN involved was new and unfamiliar with the FRI process, so she sought assistance from the DNS and another nurse, which contributed to the delay. The DNS confirmed that she was in contact with the LPN multiple times regarding the incident, but acknowledged that the report was not completed and submitted as mandated.
Failure to Ensure Resident Access to Bedside Light
Penalty
Summary
A deficiency was identified when a resident with a diagnosis of borderline personality disorder was found to be unable to independently operate the bedside light in their room due to a short three to four inch chain. The resident reported frustration at being unable to turn the light on or off without assistance, requiring them to use the call bell for help. The resident's care plan did not indicate any need for a shortened chain on the bedside light. Staff interviews revealed inconsistent awareness of the resident's ability to use the light. One CNA believed the resident could use a reacher to operate the light, while an LPN stated the resident was not capable of doing so and frequently called for assistance. The RN Case Manager was unaware of the shortened chain, and the Environmental Services Director explained the chain had been shortened for safety reasons after the resident previously pulled on it to reposition, but was unaware the resident could no longer use the light independently. The Director of Nursing Services confirmed knowledge of the short chain but was not aware the resident required help to operate the light.
Failure to Prevent Unnecessary Use of Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a resident was free from chemical restraints and unnecessary psychotropic medication use. The resident, admitted with diagnoses including anxiety, hallucinations, and disorientation, was prescribed haloperidol as needed for hallucinations or aggression. However, medication administration records, behavior monitoring, and progress notes showed that haloperidol was given on multiple occasions without documented indications for use. Nursing staff administered the medication for reasons such as difficulty sleeping, agitation, or being difficult to control, but did not consistently document the specific behaviors or symptoms that warranted its use. Interviews with several LPNs revealed uncertainty about the reasons for administering haloperidol and a lack of documentation regarding the resident's behaviors or the effectiveness of the medication. The Director of Nursing Services confirmed that haloperidol should only have been given for aggression or hallucinations and that staff were expected to document the specific behaviors, non-pharmacological interventions attempted, and the outcome of the medication administration. The absence of this documentation and the administration of haloperidol without clear indications constituted a failure to prevent the use of unnecessary psychotropic medications and chemical restraints.
Failure to Develop Care Plan Interventions for Psychotropic Medication Use
Penalty
Summary
The facility failed to develop comprehensive care plans that included interventions for the use of psychotropic medications for one resident who was admitted with diagnoses of anxiety, hallucinations, and disorientation. Physician orders for this resident included multiple psychotropic medications such as Buspirone, Lamotrigine, Mirtazapine, Duloxetine, Olanzapine, and Haloperidol, each prescribed for specific symptoms including irritability, mood stabilization, insomnia, depression, and hallucinations. A review of the resident's care plan dated 2/24/25 revealed no documented interventions addressing the use of these psychotropic medications. Additionally, there was no evidence in the resident's health record of any resident-specific interventions related to psychotropic medication use. This lack of documentation was confirmed by the Director of Nursing Services during an interview.
Failure to Timely Assess and Intervene After Choking Incident
Penalty
Summary
A resident with a history of stroke was admitted to the facility and had documented issues with coughing and choking during meals and when swallowing medications. The resident was on a dental/mechanical soft texture diet with nectar thick liquids per physician orders. On one occasion, the resident choked during dinner, requiring the Heimlich maneuver to be performed by an LPN, after which the resident recovered. Despite this significant choking episode, the resident's diet was not immediately downgraded, and there was no evidence that the speech-language pathologist was notified following the incident. The LPN involved acknowledged that the resident's diet should have been changed to puree at the time of the choking event but did not take this action. The Director of Rehabilitation was not informed of the choking incident until three days later, at which point the diet was downgraded and a consultation with the speech-language pathologist was initiated. The Director of Nursing Services also confirmed that the diet should have been downgraded immediately after the choking episode. The delay in assessment and intervention following the resident's change in condition constituted the deficiency.
Failure to Provide Care Planned Smoking Safety Interventions
Penalty
Summary
A deficiency occurred when a resident with Wernicke's encephalopathy and dementia, who was care planned to wear smoking gloves while smoking to prevent burns, was observed smoking in the designated area without the required gloves. The resident's care plan and quarterly smoking evaluation both specified the use of smoking gloves, and the most recent MDS assessment indicated moderate cognitive impairment. During the observation, the resident stated that staff did not offer the smoking gloves, and a CNA confirmed the resident was not wearing them as required. The Director of Nursing Services acknowledged that staff failed to provide the gloves as outlined in the care plan.
Failure to Provide Trauma-Informed Care and Assessment
Penalty
Summary
The facility failed to provide trauma-informed care for two residents with behavioral and emotional care needs, both of whom had diagnoses including PTSD. According to the facility's own Trauma Informed Care Policy, residents should be screened for traumatic events, and individualized care plans should be developed to address trauma triggers and interventions. However, for both residents, there was no evidence in their clinical records that trauma assessments were completed or that care plans addressing trauma triggers were developed. Staff interviews confirmed a lack of awareness regarding the residents' trauma histories or potential triggers, and social services staff acknowledged that required trauma screenings and care planning had not been completed for these residents. One resident, admitted with schizophrenia and PTSD, reported experiencing auditory hallucinations and distress but could not recall being asked about trauma triggers. Staff members were unaware of any specific triggers or interventions in place for this resident. The second resident, admitted with major depressive disorder and PTSD, also had no documented trauma assessment or care plan. This resident stated that no one had discussed the cause of their PTSD or potential triggers, and staff were similarly unaware of any trauma-related needs or interventions. The lack of trauma-informed assessments and care planning placed these residents at risk for re-traumatization.
Failure to Implement Pharmacist Recommendations for Antipsychotic Use
Penalty
Summary
The facility failed to act upon a pharmacist's recommendations for a resident who was prescribed Olanzapine, an antipsychotic medication, for hallucinations. The pharmacist had recommended that, if the antipsychotic was to be continued, the medical record should be updated to include a list of symptoms or target behaviors and their impact on the resident, documentation that other causes and medications had been considered, evidence of individualized nonpharmacological interventions, and ongoing monitoring. A review of the resident's clinical record showed that these recommendations were not implemented, as there was no documentation of specific target behaviors, their impact, consideration of other causes or medications, or individualized nonpharmacological interventions. The Director of Nursing Services confirmed that the pharmacist's recommendations were not followed.
Failure to Withhold Unnecessary Medications as Ordered
Penalty
Summary
The facility failed to ensure that two residents were free from unnecessary medications, specifically bowel and antihypotensive drugs. One resident with a diagnosis of hypotension was prescribed midodrine to be administered three times daily, with clear physician orders to hold the medication if the systolic blood pressure (SBP) exceeded a specified threshold. Despite these orders, the medication was administered on at least 24 occasions when the resident's SBP was above the hold parameter, as confirmed by medication administration records and staff interviews. Nursing staff acknowledged that the medication should have been withheld on these occasions but was not. Another resident with a history of bipolar disorder and hip fracture was prescribed senna for constipation, with instructions to hold the medication for loose stools. Review of medication administration and bowel movement records showed that the resident continued to receive senna even after experiencing multiple episodes of loose or watery stools, as indicated by type 6 and type 7 bowel movements. Staff interviews confirmed that the medication should have been withheld until normal stool consistency returned, but this was not done, and the medication was administered daily regardless of bowel movement consistency.
Failure to Provide Ordered Physical Therapy Evaluation for Resident with Frequent Falls
Penalty
Summary
A deficiency occurred when the facility failed to provide therapy services as ordered for a resident with a history of frequent falls and a diagnosis of dementia. The resident had multiple falls in recent months, with eight falls documented in one month, and was known to be impulsive and prone to self-transferring. A physician's order was written for a physical therapy (PT) evaluation due to these frequent falls. However, the PT evaluation was not completed as ordered. Staff interviews revealed that the therapy manager determined PT was not appropriate because the resident had recently completed therapy, but this decision was not discussed with the resident's provider. Further review showed that the interdisciplinary team assumed the provider was informed of the decision to not proceed with the PT evaluation, but there was no evidence of direct communication with the provider regarding the appropriateness of the order. The failure to follow the physician's order for a PT evaluation left the resident without the specialized rehabilitative services that had been deemed necessary to address their risk for falls.
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 491 citations issued within 25 miles in the last 12 months — including the 3 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 Wood Village
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Marquis Centennial Post Acute Rehab | 2.4 mi | ★★★★★ | 14 | 0 |
| Fairlawn Health And Rehab Of Cascadia | 2.5 mi | ★★★★★ | 4 | 0 |
| Gresham Post Acute Care And Rehabilitation | 2.6 mi | ★★★★★ | 26 | 0 |
| Lacamas Creek Post Acute | 3.5 mi | ★★★★★ | 4 | 0 |
| Regency Gresham Nursing & Rehabilitation Center | 4.2 mi | ★★★★★ | 12 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Village Manor Of Cascadia.
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.