PORTLAND, OR - Federal inspectors found multiple food safety violations and administrative failures at Cascade Terrace Post Acute during an April 2025 inspection, including unlabeled food items in nursing station refrigerators and an improperly installed ice machine that posed contamination risks.
Food Storage and Labeling Violations Raise Safety Concerns
The inspection revealed significant food safety violations across multiple areas of the facility. In nursing station refrigerators, inspectors discovered numerous unlabeled and undated food items that posed potential health risks to residents.
At Nursing Station One, staff stored two unlabeled containers of peanut butter, an undated coffee mug containing liquid and ice, and an opened 32-ounce nutritional shake without any date marking. When questioned, the licensed practical nurse on duty acknowledged the violations and stated that items "need to be labeled with the date they were opened so the nursing staff would know when they were opened."
Similar violations were found at Nursing Station Three, where staff had stored an opened, undated nutritional shake and an employee's personal Monster Energy drink. The LPN at this station recognized the opened shake should be discarded, stating "there was no way to know when it was opened."
These violations directly contradict the facility's own food safety policy, which requires all food to be labeled and dated when opened to prevent contamination and spoilage. Proper food labeling is essential in healthcare settings because unlabeled items can harbor dangerous bacteria that multiply over time, potentially causing foodborne illnesses in vulnerable populations.
Ice Machine Contamination Risk Identified
Inspectors uncovered a serious contamination risk involving the facility's only ice machine, which serves beverages to all residents. The machine's drainage system was improperly installed, with the drain pipe passing directly through the wall and emptying into an outdoor garden area next to the facility's smoking gazebo.
The drainage system lacked the required air gap, which is a critical safety feature designed to prevent contaminated water from flowing back into the ice machine. Without this protection, bacteria, chemicals, and other contaminants from the outdoor environment could potentially enter the ice supply that residents consume daily.
The facility's administrator acknowledged the problem, stating the current drain system "involved the risk of contamination from the outside." This violation represents a significant public health concern, as contaminated ice can transmit various waterborne diseases and infections to residents who already have compromised immune systems.
Medical Significance of Food Safety Violations
Food safety violations in nursing homes carry heightened medical significance due to the vulnerable nature of the resident population. Elderly individuals often have weakened immune systems, making them more susceptible to foodborne illnesses that could be mild in healthy adults but potentially life-threatening for nursing home residents.
Unlabeled and undated food items create several health risks. Bacterial growth accelerates in opened nutritional products, particularly protein-rich items like nutritional shakes. Consuming spoiled nutrition supplements can cause gastrointestinal distress, dehydration, and nutritional deficiencies in residents who may already struggle with maintaining adequate nutrition.
The ice machine contamination risk is particularly concerning because ice is used in beverages consumed daily by residents. Contaminated ice can harbor Legionella bacteria, E. coli, and other pathogens that cause serious infections. For elderly residents with chronic conditions like diabetes or respiratory diseases, such infections can lead to hospitalizations or worse outcomes.
Resident Dietary Needs Not Adequately Met
The inspection also revealed failures in meeting individual dietary preferences and needs. One diabetic resident who had recently undergone a below-the-knee amputation repeatedly requested larger food portions but did not receive them despite having an order for double portions on their meal tray.
The resident, who was cognitively intact, told inspectors: "I would like more food" and explained that despite asking staff for bigger portions, "I did not get enough food." Even when the resident's meal tray displayed an order card for double portions and a hamburger, they received only small portions and no hamburger.
A certified nursing assistant acknowledged systematic problems, stating "there is not a good system in place to meet resident preferences and cultural preferences for food." The dietary staff confirmed the resident had requested double portions since mid-April, but the upgrade was not implemented until late April, demonstrating poor communication and follow-through.
Adequate nutrition is critical for residents recovering from medical procedures like amputations, and insufficient food intake can impair wound healing, increase infection risk, and slow rehabilitation progress.
Administrative Compliance Failures Documented
Beyond direct care issues, inspectors found significant administrative violations. The facility failed to submit required staffing data to the Centers for Medicare & Medicaid Services for the fourth quarter of 2024, which ended September 30. This information is mandatory for transparency and quality oversight purposes.
Both the payroll specialist and administrator were unaware the data had not been submitted, indicating poor internal oversight. The facility also failed to provide mandatory Quality Assurance and Performance Improvement (QAPI) training to staff, with multiple employees reporting they were unaware of the facility's quality improvement program.
These administrative failures suggest broader systemic issues with regulatory compliance and staff training that could impact resident care quality.
Additional Issues Identified
The inspection documented several other compliance concerns including inadequate dietary preference systems and gaps in staff education about quality improvement initiatives. The facility's corporate office was reportedly responsible for some administrative functions, but local staff were unaware of compliance failures, suggesting communication breakdowns between facility and corporate management.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Cascade Terrace from 2025-04-28 including all violations, facility responses, and corrective action plans.
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