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: August 5, 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.