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Multiple residents had specific care plans requiring two-person assistance with Hoyer lifts for transfers.

The resident agreed to transfer voluntarily after the previous administrator told him about a Houston facility that would accept him.

The resident, identified as R5 in the inspection report, was found on the floor next to the bed at 4:45 AM on October 30, entangled in bedding and snoring.

But the facility's medication records showed something different.

Hospital records showed the patient's last dose was administered at 9:08 AM that morning.

The CEO told inspectors on November 9th that he believed the bills were paid on November 3rd.

The aide raised the head of the bed and set up the meal tray without washing their hands before or after.

The resident remained unattended until RN C arrived for the 7:20 a.m.

Resident #1 had been without her Percocet since the weekend when federal inspectors arrived on November 11.

The nurse blamed a "typo" when confronted three months later.

Federal inspectors found the facility failed to protect residents from physical abuse by other residents.

The medication error at Cascade Terrace Post Acute involved temozolomide, a cancer drug that was supposed to stop after five days in April 2025.