Cascade Terrace

Based on observation, and interview, it was determined the facility failed to meet dietary preferences for 1 of 3 Residents (#468) sampled residents reviewed for food preferences. This placed residents at risk for limited food choices and potential weight loss. Findings include: Resident 468 was admitted to the facility in 4/2025 with diagnoses including diabetes and below the knee amputation.

Resident 468's most recent MDS dated [DATE REDACTED] revealed a BIMS score of 14 which indicated the resident was cognitively intact.

In an 04/21/25 interview at 1:30 PM Resident 468 stated, she/he would like more food. Resident 468 stated he/she asked staff for bigger portions but did not receive them. Resident 468 stated she/he did not get enough food.

On 4/ 24/25 at 12:14 PM Resident 468's meal tray was observed to have an order card for double portions and a hamburger on the side. Resident 468 received small portions and no hamburger.

On 04/24/25 at 12:23 PM Staff 36 (CNA), stated there is not a good system in place to meet resident preferences and cultural preferences for food.

On 4/25/25 at 10:30 AM in an interview Staff 43 (dinning manager) stated he had spoken to Resident 468 about her/his preference for more food and the resident did request double portions per her/his preference

on 4/12/25.

On 4/25/25 at 11:32 AM Staff stated 46 (dietary) stated Resident 468 requested double portions and a hamburger on the side, all the time but she/he was upgraded to double portions on 4/25/25. 08/28/2025 Department of Health & Human Services Centers for Medicare & Medicaid ServicesPrinted: N o. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION NAME OF PROVIDER OR SUPPLIER(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIESSTREET ADDRESS, CITY, STATE, ZIP CODE B. Wing (Each deficiency must be preceded by full regulatory or LSC identifying information) 04/28/2025 Cascade Terrace Post Acute 5601 SE 122nd Avenue Portland, OR 97236 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food

in accordance with professional standards.

Based on observation, interview and record review it was determined the facility failed ensure food was labeled and stored in a manner to avoid spoilage in 1 of 1 kitchen and 2 of 3 nurses stations reviewed for sanitary food storage. The facility also failed to ensure the ice machine was plumbed correctly to prevent backflow of contaminated matter into the ice machine for 1 of 1 kitchen reviewed for sanitary conditions. This placed residents at risk for foodborne illness. Findings include:

The facility's undated Key Food Safety Practices policy indicated: -All food must be labeled and dated when opened; and -Raw ingredients will be free from contamination.

1. 1. On 4/21/25 at 9:22 AM the following items were observed in the unit refrigerator located behind Nurses

Station One: -Two unlabeled, undated covered plastic ramekins of peanut butter; -One unlabeled, undated covered plastic coffee mug containing a clear liquid and ice; -One previously opened, unlabeled and undated 32 fluid ounce container of Med Pass 2.0+ Vanilla Fortified Nutritional Shake.

On 4/21/25 at 9:22 AM Staff 27 (LPN) acknowledged the unlabeled and undated items and stated they need to be labeled with the date they were opened so the nursing staff would know when they were opened.

On 4/21/25 at 9:35 AM the following items were observed in the unit refrigerator located behind Nurses Station Three: -One opened, undated and partially used 32 fluid ounce Sysco butter pecan flavored Med Plus 2.0 nutritional shake; -One unlabeled 16 fluid ounce can of Monster Energy drink.

On 4/21/25 9:35 AM Staff 44 (LPN) acknowledged the undated shake and stated it should be thrown out because there was no way to know when it was opened. Staff 44 stated the Monster Energy drink belonged to an employee.

On 4/28/25 at 2:16 PM Staff 1 (Administrator) stated he expected items in the nurses station refrigerators to be labeled with the date they were opened so staff will know when to discard them. Staff 1 also stated these refrigerators were not to be used by employees to store their personal items.

08/28/2025 Department of Health & Human Services Centers for Medicare & Medicaid ServicesPrinted: N o. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION NAME OF PROVIDER OR SUPPLIER(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIESSTREET ADDRESS, CITY, STATE, ZIP CODE B. Wing (Each deficiency must be preceded by full regulatory or LSC identifying information) 04/28/2025 Cascade Terrace Post Acute 5601 SE 122nd Avenue Portland, OR 97236 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

2. 2. On 4/28/25 11:32 AM the facility's ice machine was observed to drain through a white plastic pipe into the

wall behind the machine. No air gap was observed under the machine or connected to the drain pipe. The drain pipe exited the wall on the facility's north side and drained directly into the garden adjacent to the smoking gazebo. Staff 43 (Dietary Manager) stated this was the facility's only ice machine and the ice was used for preparing residents' beverages.

On 4/28/25 at 11:45 AM Staff 1 (Administrator) acknowledged the ice machine drained unabated through a hole in the wall. Staff 1 stated he expected the ice machine to produce clean ice for residents' use and the current drain system involved the risk of contamination from the outside. 08/28/2025 Department of Health & Human Services Centers for Medicare & Medicaid ServicesPrinted: N o. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION NAME OF PROVIDER OR SUPPLIER(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIESSTREET ADDRESS, CITY, STATE, ZIP CODE B. Wing (Each deficiency must be preceded by full regulatory or LSC identifying information) 04/28/2025 Cascade Terrace Post Acute 5601 SE 122nd Avenue Portland, OR 97236 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.

Based on interview and record review it was determined the facility failed to submit mandatory staffing information based on the payroll data journal and other verifiable and auditable data as required. This placed residents at risk for inaccurate staffing information. Findings include: - The facility's Reporting Direct Care Staffing Information (Payroll-Based Journal) policy, dated 8/2022, indicated complete and accurate direct care staffing information is reported electronically to CMS through the Payroll-Based Journal system. Staffing information is collected daily and reported for each fiscal quarter no later than 45 days after the end of the reporting quarter. Dates included Fiscal Quarter 4 with a date range of 7/1 through 9/30 to be submitted by 11/14.

Review of the Payroll Based Journal Staffing Data for fiscal year 2024, quarter four (7/1/24 through 9/30/24), revealed the facility failed to submit required data for the quarter.

On 4/28/25 at 12:07 PM, Staff 6 (Payroll/Human Resources) was unaware the data was not submitted and stated the corporate office was responsible for submitting the information.

On 4/28/25 at 2:25PM, Staff 1 (Administrator) was unaware the data was not submitted. 08/28/2025 Department of Health & Human Services Centers for Medicare & Medicaid ServicesPrinted: N o. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION NAME OF PROVIDER OR SUPPLIER(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIESSTREET ADDRESS, CITY, STATE, ZIP CODE B. Wing (Each deficiency must be preceded by full regulatory or LSC identifying information) 04/28/2025 Cascade Terrace Post Acute 5601 SE 122nd Avenue Portland, OR 97236 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.

Based on interview and record review it was determined the facility failed to train staff of the elements and goals of the facility QAPI program for 1 of 1 facility reviewed for QAPI training. This placed residents at risk for lack of safety and quality of care. Findings include:

On 4/24/25 at 4:42 PM, Staff 6 (Payroll/Human Resources) provided a list of new hire and annual trainings offered by the facility. There was no QAPI training.

On 4/25/25 between the hours of 8:15 AM and 8:36 AM, Staff 12 (CNA), Staff 35 (NA), Staff 41 (LPN) and Staff 42 (CNA) reported they were unaware of the facility's QAPI program and had not received any training related to QAPI.

On 4/25/25 at 2:05 PM, Staff 1 reviewed the list of new hire and annual trainings provided by the facility and confirmed the facility did not offer QAPI training to staff. Staff 1 stated he expected the facility to provide staff required trainings. 08/28/2025