Cascade Terrace Post Acute
Inspection Findings
F-Tag F0684
F 0684
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Level of Harm - Minimal harm or potential for actual harm
Based on interview and record review it was determined the facility failed to ensure physician orders were followed for 1 of 3 sampled residents (#1) reviewed for medication. This placed residents at risk for adverse medication side effects. Findings include:Resident 1 admitted to the facility in 2025 with diagnoses including obesity and diabetes. The 9/23/25 physician order indicated Resident 1 was to receive semaglutide (Ozempic) injection once weekly.On 12/23/25 at 11:47 AM, Resident 1 stated that she/he missed several doses of Ozempic due to the medication not being ordered. A review of Resident 1's 10/2025, 11/2025 and 12/2025 MARs and TARs indicated she/he did not receive semaglutide on the following dates:-12/16/25-10/30/25-10/23/25-10/16/25-10/9/25-10/2/25Resident 1's Progress Notes indicated that Staff 2 (LPN) administered medication to Resident 1 on 10/2/25, 10/9/25, 10/16/25, 10/23/25 and 10/30/25, but did not administer semaglutide for the following reasons: medication was not filled last week, a new order was needed, the prescription had ended, the resident requested a prescription, or the notes were left blank.On 12/23/25 at 1:19 PM, a message was left for Staff 2. A return call was not received.On 12/23/25 at 2:31 PM, Staff 3 (LPN) stated she did not administer Ozempic on 12/16/25 because she thought it had to be refrigerated and she was not aware it was kept in the medication cart once opened. On 12/23/25 at 2:52 PM, Staff 1 (DNS) acknowledged Resident 1 did not receive semaglutide as ordered on the identified dates.
Residents Affected - Few
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99) Previous Versions Obsolete
Facility ID:
If continuation sheet
Event ID:
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.