Village Manor Of Cascadia
VILLAGE MANOR OF CASCADIA in WOOD VILLAGE, OR — inspection on August 12, 2025.
Found 1 citation. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Based on interview and record review, it was determined the facility failed to implement care plan interventions to prevent a fall for 1 of 3 sampled residents (#1) reviewed for accidents. As a result, Resident 1 sustained multiple pelvic fractures.
Findings include:Resident 1 was admitted to the facility in 2025, with diagnoses including dementia. Resident 1's 7/25/25 Care Plan revealed Resident 1 was a fall risk because of a prior fall and was a one-person max assist for dressing. Resident 1 was care planned for supervision and touch assistance for bathing, used a shower bench or bathtub, and was to wear non-skid footwear when up. A 7/28/25 FRI indicated Staff 5 (Housekeeping) and Staff 6 (Housekeeping) reported Resident 1 had a fall in the shower room.
Staff 5 and 6 found staff to assist Resident 1.
The report indicated staff found Resident 1 down in the shower, unattended, and not fully clothed. Resident 1 was transferred to the hospital for evaluation.
The FRI indicated Resident 1 sustained multiple complex fractures of the pelvis and was bleeding internally.
The FRI indicated the fall occurred due to Resident 1's care plan not being followed.Between 8/11/25 at 11:00 AM to 8/12/25 at 10:00 AM, Staff 2 (CNA), Staff 3 (CNA), Staff 4 (CNA), Staff 5 (Housekeeping) and Staff 6 (Housekeeping) all provided statements, which included Resident 1 was found down in the shower room unattended. Resident 1 was wearing underwear and pants.
The resident's pants were not fully up and her/his belt was not buckled.
Staff 2, Staff 3, and Staff 4 recalled Resident 1 was not wearing socks or shoes.
All staff interviewed did not see a shower bench anywhere near the resident and she/he was found to have been in a shower stall, not a bathtub. On 8/11/25 at 10:48 AM, Staff 1 (CNA) indicated she left the shower room when she thought the resident was done with her/his shower and safe.
Staff 1 confirmed a shower bench was not used and Resident 1 was left unattended in the shower room. On 8/12/25 at 10:00 AM, Staff 8 (LPN) was called for a witness statement.
Staff 8 did not answer and did not return the phone call. On 8/12/25 at 10:45 AM, Staff 7 (Administrator) confirmed the accident occurred and Resident 1's care plan was not followed.
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
Facility ID:
38E174
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 WOOD VILLAGE, 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 VILLAGE MANOR OF CASCADIA or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.