Village Manor of Cascadia: Pelvis Fractures from Fall - OR
The resident, admitted to the facility in 2025, was found down in the shower unattended by housekeeping staff on July 28. According to a facility incident report, the patient "sustained multiple complex fractures of the pelvis and was bleeding internally" and required immediate hospitalization.
The fall violated multiple aspects of the resident's care plan. The July 25 care plan identified the patient as a fall risk due to a prior fall and specified supervision and touch assistance for bathing. The plan also required the resident to use a shower bench or bathtub and wear non-skid footwear when up.
None of these safeguards were in place when the accident occurred.
Staff 1, a certified nursing assistant, told inspectors she "left the shower room when she thought the resident was done with her/his shower and safe." The CNA confirmed that no shower bench was used and the resident was left unattended in the shower room.
Housekeeping staff members who discovered the fallen resident provided detailed accounts of what they found. The patient was wearing underwear and pants, but the pants were not fully pulled up and the belt was not buckled. Multiple staff members confirmed the resident was not wearing socks or shoes at the time of the fall.
The resident was found in a shower stall rather than a bathtub, contrary to care plan specifications.
Five facility employees provided statements to inspectors between August 11 and 12. Three certified nursing assistants, along with the two housekeeping staff members who found the resident, all confirmed the patient was discovered unattended in the shower room.
The facility's administrator confirmed both that the accident occurred and that the resident's care plan was not followed.
Federal inspectors attempted to interview Staff 8, a licensed practical nurse, as a witness but the employee did not answer the phone call and did not return it.
The incident represents what federal regulators classified as "actual harm" to the resident. The inspection found the facility failed to implement care plan interventions to prevent falls, directly resulting in the severe injuries.
The resident's care plan had identified specific risk factors that made supervision essential. As someone with dementia who had previously fallen, the patient required one-person maximum assist for dressing and constant supervision during bathing activities.
The July 28 facility incident report stated plainly that "the fall occurred due to Resident 1's care plan not being followed."
Village Manor of Cascadia's failure to follow established safety protocols left a vulnerable resident without the protection specifically designed to prevent exactly this type of accident. The resulting injuries required emergency medical intervention and hospitalization.
The inspection narrative does not detail the resident's current condition or recovery status following the multiple pelvic fractures and internal bleeding that resulted from being left alone in a shower room where facility policy required supervision.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Village Manor of Cascadia from 2025-08-12 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 15, 2026 · Our methodology
VILLAGE MANOR OF CASCADIA in WOOD VILLAGE, OR was cited for violations during a health inspection on August 12, 2025.
The resident, admitted to the facility in 2025, was found down in the shower unattended by housekeeping staff on July 28.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.
Frequently Asked Questions
- What happened at VILLAGE MANOR OF CASCADIA?
- The resident, admitted to the facility in 2025, was found down in the shower unattended by housekeeping staff on July 28.
- How serious are these violations?
- Violation severity varies from minor documentation issues to serious safety concerns. Review the inspection report for specific deficiency codes and scope. All violations must be corrected within required timeframes and are subject to follow-up verification inspections.
- What should families do?
- Families should: (1) Ask facility administration about specific corrective actions taken, (2) Request to see the follow-up inspection report verifying corrections, (3) Check if this represents a pattern by reviewing prior inspection reports, (4) Compare this facility's ratings with other nursing homes in WOOD VILLAGE, OR, (5) Report any new concerns directly to state authorities.
- Where can I see the full inspection report?
- The complete inspection report is available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request a copy directly from VILLAGE MANOR OF CASCADIA or from the state Department of Health. The report includes specific deficiency codes, facility responses, and correction timelines. This facility's federal provider number is 38E174.
- Has this facility had violations before?
- To check VILLAGE MANOR OF CASCADIA's history, visit Medicare.gov's Care Compare and review their inspection history, quality ratings, and staffing levels. Look for patterns of repeated violations, especially in critical areas like abuse prevention, medication management, infection control, and resident safety.