Complaint Investigation

Village Manor Of Cascadia

August 12, 2025 · Wood Village, OR · 2060 Ne 238th Drive

Citations 1

CMS Rating 4/5

Beds 60

Provider ID 38E174

Healthcare Facility

Village Manor Of Cascadia

Wood Village, OR · View full profile →

Source Document

Official CMS Inspection Report (Medicare.gov)

Downloaded from CMS/Medicare.gov. Reflects what state inspectors documented and does not include the facility's plan of correction, which is submitted separately. Facilities may have taken corrective actions since this report was released.

Inspection Summary

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

FF0689

Quality of Life and Care Deficiencies

Based on interview and record review, it was determined the facility failed to implement care plan

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 TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE

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.

More Reports

About This Inspection Report

Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.

Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.

Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.