Cascade Terrace Post Acute
Inspection Findings
F-Tag F0757
F 0757 Level of Harm - Actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
record accurately and gave Staff 2 the paper order for temozolomide which was provided by the clinic. On 11/5/25 at 11:58 AM, Staff 23 stated she received a phone call from Witness 3 in 5/2025 after Resident 2 returned from an appointment at the neuro-oncology clinic. Staff 23 stated she was informed by Witness 3
the resident was not supposed to receive temozolomide past 4/26/25.Attempts to contact Witness 3 on 11/4/25 and 11/5/25 were unsuccessful. On 11/5/25 at 1:01 PM, Staff 24 (Medical Director) stated Resident 2 was supposed to receive temozolomide for five days in 4/2025 but received the medication longer than ordered. Staff 24 stated he expected nurses to contact the prescriber of resident medications to get clarification with any order that was ambiguous and that Resident 2's 4/21/25 order for temozolomide was unclear. Staff 24 further stated this incident was a big mess up which resulted in Resident 2 going back-and-forth to the hospital.On 11/6/25 at 11:04 AM, Staff 2 stated Resident 2 returned from her/his appointment on 4/21/25 with a Neuro-Oncology Consult Encounter Note which noted the resident's current medication list was to include 390mg temozolomide taken once daily at bedtime on days one to five of a 28-day treatment cycle. Staff 2 stated this note did not constitute an order for the medication. Staff 2 stated
she completed a lengthy investigation of this medication error and was never able to find a paper order from
the resident's neuro-oncology clinic for the temozolomide. Staff 2 denied ever visualizing a paper order for
the medication or checking Staff 22's entry into Resident 2's clinical record regarding the medication. Staff 2 stated Staff 22 should have contacted Witness 2 on 4/21/24 and requested clarification for the temozolomide order in writing. The deficient practice was identified as Past Noncompliance based on the following:On 5/20/25, the deficient practice was identified by the facility and was corrected when the facility completed an investigation of the incident and determined the medication was administered for an excessive duration. The Plan of Correction included:1. Licensed nurses were educated on the process for obtaining paper copies for all prescriptions from any outside medical provider, and all prescriptions entered into a resident's medical record required a second licensed nurse to sign off for accuracy. 2. An audit of MARs was completed for all residents to ensure paper copies for all prescriptions from any outside provider were obtained and two licensed nurse signatures were present. 3. Weekly medication prescription audits were completed by Staff 2 for four weeks.
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CASCADE TERRACE POST ACUTE in PORTLAND, OR inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in PORTLAND, OR, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from CASCADE TERRACE POST ACUTE or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.