Report
TheVardellReport
Cascade Terrace Post Acute
Skilled nursing facility and nursing facility
5601 SE 122Nd Avenue
Portland, OR 97236
Report
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The Vardell Report.Cascade Terrace Post Acute
The deeper story, beautifully organized. Available records, historical context, and questions worth asking.
- Provider Category
- Nursing home
- Location
- Portland, OR
- Record Period
- 2024–2026
- Source Documents
- 9
This report is free. Vardell does not certify, grade or endorse; it shows what the record documents.
The Essentials
Summary
Across 7 inspections from January 2024 to September 2026, state surveyors documented 50 findings at Cascade Terrace Post Acute; 49 have a recorded correction and 1 awaits one; CMS lists 2 enforcement actions in the window.
- Inspections
- 7
- 2024–2026, standard and complaint
- Findings
- 50
- Deficiencies cited by state inspectors
- Corrected
- 49
- Of 50 findings, with a recorded correction date
- Penalties
- 2
- 2 fines; payment not published
Findings by Year
- Findings
- Of which, actual harm (level G or above)
* Partial year, through October 1, 2026.
| Year | Inspections | Findings | Of which, actual harm (level G or above) |
|---|---|---|---|
| 2024 | 1 | 18 | 2 |
| 2025 | 4 | 21 | 2 |
| 2026 | 2 | 11 | 0 |
What the Record Shows
- 49 of 50 findings have a recorded correction date.
- CMS lists 2 enforcement actions in the window: 2 fines totaling $185,923, their payment not published.
- 6 visits in this window included a complaint investigation. CMS publishes what a complaint investigation cited, not what the complaint alleged.
- The latest standard inspection, September 4, 2026, recorded 8 findings (most serious: Level F).
What to Ask About
- Quality of Care, Cited in Four Inspections
- Accident Hazards and Supervision, Cited in Three Inspections
- Reporting Suspected Abuse, Cited in Two Inspections
- Care Plans, Cited in Two Inspections
- Help With Daily Living, Cited in Two Inspections
- Dialysis Care, Cited in Two Inspections
- Significant Medication Errors, Cited in Two Inspections
- Kitchen and Food Safety, Cited in Two Inspections
- Infection Control, Cited in Two Inspections
- Citation F757, No Recorded Correction
Report at a Glance
- Facility
- Cascade Terrace Post Acute
- Address
- 5601 SE 122Nd Avenue, Portland, OR 97236
- CMS Certification Number
- 385187
- Provider Type
- Skilled nursing facility and nursing facility
- Certified Beds
- 105
- Ownership
- For profit - Corporation
- Record Window
- January 31, 2024 to October 1, 2026
Chronology
Inspection History
Every inspection in the record window, newest first. A finding is a deficiency an inspector cited. CMS publishes what a complaint investigation cited, not what the complaint alleged.
- 2026
Standard health inspection
8 findings
- F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Level FNo actual harm, potential for moreCorrected Sep 30, 2026
- F880Provide and implement an infection prevention and control program.Level ENo actual harm, potential for moreCorrected Sep 30, 2026
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level DNo actual harm, potential for moreCorrected Sep 30, 2026
- F698Provide safe, appropriate dialysis care/services for a resident who requires such services.Level DNo actual harm, potential for moreCorrected Sep 30, 2026
- F757Ensure each resident’s drug regimen must be free from unnecessary drugs.Level DNo actual harm, potential for moreCorrected Sep 30, 2026
- F760Ensure that residents are free from significant medication errors.Level DNo actual harm, potential for moreCorrected Sep 30, 2026
- F791Provide or obtain dental services for each resident.Level DNo actual harm, potential for moreCorrected Sep 30, 2026
- F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Level DNo actual harm, potential for moreCorrected Sep 30, 2026
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2026
Complaint investigation
3 findings
- F557Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.Level DNo actual harm, potential for moreCorrected Mar 16, 2026
- F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Level DNo actual harm, potential for moreCorrected Mar 16, 2026
- F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Level DNo actual harm, potential for moreCorrected Mar 16, 2026
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2025
Complaint investigation
1 finding
- F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected Jan 14, 2026
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2025
Complaint investigation
1 finding
- F757Ensure each resident’s drug regimen must be free from unnecessary drugs.Level GActual harmPast Non-Compliance
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2025
Standard health inspection
17 findings
The same visit included a complaint investigation.
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level JImmediate jeopardyCorrected Apr 28, 2025
- F851Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.Level FNo actual harm, potential for moreCorrected May 29, 2025
- F944Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.Level FNo actual harm, potential for moreCorrected May 29, 2025
- F727Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.Level ENo actual harm, potential for moreCorrected May 29, 2025
- F732Post nurse staffing information every day.Level ENo actual harm, potential for moreCorrected May 29, 2025
- F761Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.Level ENo actual harm, potential for moreCorrected May 29, 2025
- F800Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.Level ENo actual harm, potential for moreCorrected May 29, 2025
- F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Level ENo actual harm, potential for moreCorrected May 29, 2025
- F554Allow residents to self-administer drugs if determined clinically appropriate.Level DNo actual harm, potential for moreCorrected May 29, 2025
- F583Keep residents' personal and medical records private and confidential.Level DNo actual harm, potential for moreCorrected May 29, 2025
- F636Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.Level DNo actual harm, potential for moreCorrected May 29, 2025
- F641Ensure each resident receives an accurate assessment.Level DNo actual harm, potential for moreCorrected May 29, 2025
- F677Provide care and assistance to perform activities of daily living for any resident who is unable.Level DNo actual harm, potential for moreCorrected May 29, 2025
- F679Provide activities to meet all resident's needs.Level DNo actual harm, potential for moreCorrected May 29, 2025
- F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected May 29, 2025
- F698Provide safe, appropriate dialysis care/services for a resident who requires such services.Level DNo actual harm, potential for moreCorrected May 29, 2025
- F757Ensure each resident’s drug regimen must be free from unnecessary drugs.Level DNo actual harm, potential for moreCorrected May 29, 2025
Enforcement Action
Civil money penalty, $149,783 imposed April 28, 2025. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the standard health inspection of April 28, 2025, the nearest before the penalty date.
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2025
Complaint investigation
2 findings
- F677Provide care and assistance to perform activities of daily living for any resident who is unable.Level DNo actual harm, potential for moreCorrected Feb 17, 2025
- F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected Feb 17, 2025
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2024
Standard health inspection
18 findings
The same visit included a complaint investigation.
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level JImmediate jeopardyCorrected Mar 26, 2024
- F740Ensure each resident must receive and the facility must provide necessary behavioral health care and services.Level JImmediate jeopardyCorrected Feb 16, 2024
- F880Provide and implement an infection prevention and control program.Level FNo actual harm, potential for moreCorrected Feb 16, 2024
- F584Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.Level ENo actual harm, potential for moreCorrected Feb 16, 2024
- F725Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.Level ENo actual harm, potential for moreCorrected Mar 26, 2024
- F847Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.Level ENo actual harm, potential for moreCorrected Feb 16, 2024
- F947Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.Level ENo actual harm, potential for moreCorrected Feb 16, 2024
- F552Ensure that residents are fully informed and understand their health status, care and treatments.Level DNo actual harm, potential for moreCorrected Feb 16, 2024
- F558Reasonably accommodate the needs and preferences of each resident.Level DNo actual harm, potential for moreCorrected Feb 16, 2024
- F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Level DNo actual harm, potential for moreCorrected Feb 16, 2024
- F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Level DNo actual harm, potential for moreCorrected Feb 16, 2024
- F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Level DNo actual harm, potential for moreCorrected Feb 16, 2024
- F610Respond appropriately to all alleged violations.Level DNo actual harm, potential for moreCorrected Feb 16, 2024
- F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Level DNo actual harm, potential for moreCorrected Feb 16, 2024
- F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Level DNo actual harm, potential for moreCorrected Feb 16, 2024
- F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected Feb 16, 2024
- F730Observe each nurse aide's job performance and give regular training.Level DNo actual harm, potential for moreCorrected Feb 16, 2024
- F760Ensure that residents are free from significant medication errors.Level DNo actual harm, potential for moreCorrected Sep 30, 2023
Enforcement Action
Civil money penalty, $36,140 imposed January 31, 2024. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the standard health inspection of January 31, 2024, the nearest before the penalty date.
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Severity levels follow the CMS scope and severity grid. A–C: potential for minimal harm. D–F: no actual harm, potential for more than minimal harm. G–I: actual harm. J–L: immediate jeopardy.
Context
Patterns Worth Examining
A repeated citation can merit attention, but context and corrective action must be reviewed before drawing a conclusion.
- 1
Quality of Care, Cited in Four Inspections
Inspectors cited F684 in January 2024, January 2025, April 2025 and December 2025. This citation covers whether residents receive the treatment their orders, preferences and goals call for. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
24252525252626F684 across all 7 inspections, oldest to newest - 2
Accident Hazards and Supervision, Cited in Three Inspections
Inspectors cited F689 in January 2024, April 2025 and September 2026. This citation covers whether residents are protected from accident hazards and supervised closely enough to prevent accidents, including falls. The most serious of these was recorded at level J (immediate jeopardy). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
24252525252626F689 across all 7 inspections, oldest to newest - 3
Reporting Suspected Abuse, Cited in Two Inspections
Inspectors cited F609 in January 2024 and February 2026. This citation covers whether suspected abuse, neglect or theft is reported to the authorities on time, with the results of the home’s investigation. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
24252525252626F609 across all 7 inspections, oldest to newest - 4
Care Plans, Cited in Two Inspections
Inspectors cited F656 in January 2024 and February 2026. This citation covers whether each resident has a written care plan that meets their needs, with goals that can be measured. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
24252525252626F656 across all 7 inspections, oldest to newest - 5
Help With Daily Living, Cited in Two Inspections
Inspectors cited F677 in January 2025 and April 2025. This citation covers help with bathing, dressing, eating and toileting for residents who cannot manage alone. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
24252525252626F677 across all 7 inspections, oldest to newest - 6
Dialysis Care, Cited in Two Inspections
Inspectors cited F698 in April 2025 and September 2026. This citation covers care for residents who need dialysis. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
24252525252626F698 across all 7 inspections, oldest to newest - 7
Significant Medication Errors, Cited in Two Inspections
Inspectors cited F760 in January 2024 and September 2026. This citation covers whether residents are free from significant medication errors. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
24252525252626F760 across all 7 inspections, oldest to newest - 8
Kitchen and Food Safety, Cited in Two Inspections
Inspectors cited F812 in April 2025 and September 2026. This citation covers how food is stored, prepared and served. None rose above level F (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
24252525252626F812 across all 7 inspections, oldest to newest - 9
Infection Control, Cited in Two Inspections
Inspectors cited F880 in January 2024 and September 2026. This citation covers hand hygiene, isolation practice and the home’s infection-prevention program. None rose above level F (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
24252525252626F880 across all 7 inspections, oldest to newest - 10
Citation F757, No Recorded Correction
F757 was cited in April 2025, November 2025 and September 2026. The agency describes it this way: Ensure each resident’s drug regimen must be free from unnecessary drugs. The most serious was level G (actual harm). The November 2025 citation has no recorded correction date; its status reads “Past Non-Compliance.” The record does not show whether the problem was fixed.
24252525252626F757 across all 7 inspections, oldest to newest
For Your Next Visit
Questions to Ask on Your Visit
Bring these to the tour. Each one comes from something in the record; the reason is under the question.
- 01
How do nurses make sure a doctor’s orders are carried out, and how are families told when something is missed?
Quality of Care: cited in four inspections, most seriously at level D.
- 02
What changed in fall prevention and supervision after the last citation, and how do you check that it is still working?
Accident Hazards and Supervision: cited in three inspections, most seriously at level J.
- 03
How are staff trained to report suspected abuse or neglect, and who reports it to the state?
Reporting Suspected Abuse: cited in two inspections, most seriously at level D.
- 04
How is a care plan written and reviewed here, and how do families take part in it?
Care Plans: cited in two inspections, most seriously at level D.
- 05
How long do residents usually wait for help with bathing, dressing or the bathroom, and how is that tracked?
Help With Daily Living: cited in two inspections, most seriously at level D.
- 06
How is dialysis care coordinated, and who monitors residents before and after treatment?
Dialysis Care: cited in two inspections, most seriously at level D.
- 07
What happened after the medication error citation, and how are high-risk drugs double-checked?
Significant Medication Errors: cited in two inspections, most seriously at level D.
- 08
May we see the kitchen, and what do your own sanitation checks look like week to week?
Kitchen and Food Safety: cited in two inspections, most seriously at level F.
- 09
Who leads infection control here, and how often are hand-hygiene and isolation practices audited?
Infection Control: cited in two inspections, most seriously at level F.
- 10
What changed after F757 was cited, and how do you check it now?
Citation F757: cited in three inspections, most seriously at level G. The November 6, 2025 citation has no recorded correction date.
- 11
How many nurses and aides are on each shift, including nights and weekends, for the unit we are considering?
Insufficient nursing staff was cited in January 2024.
- 12
What led to the 2025 fine, and has it been paid?
A $149,783 civil money penalty was imposed April 28, 2025. CMS publishes the fine, not whether it has been paid. The record holds two enforcement actions in the window.
The Evidence
Sources and Coverage
Inspection results and penalties are published by the Centers for Medicare & Medicaid Services from surveys conducted by the Oregon state survey agency.
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Oregon state survey agency
Inspection Jan 31, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Oregon state survey agency
Inspection Jan 23, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Oregon state survey agency
Inspection Apr 28, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Oregon state survey agency
Inspection Nov 6, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Oregon state survey agency
Inspection Dec 26, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Oregon state survey agency
Inspection Feb 18, 2026 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Oregon state survey agency
Inspection Sep 4, 2026 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Penalties, Provider Data CatalogView Dataset ↗
Centers for Medicare & Medicaid Services
Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Provider Information, Provider Data CatalogView Dataset ↗
Centers for Medicare & Medicaid Services · 385187
Published Oct 1, 2026 · Retrieved Nov 1, 2026
Coverage
Record windowJanuary 31, 2024 – October 1, 2026
- CMS publishes about three inspection cycles; inspections before January 2024 are not in this release.
- CMS refreshes these files monthly, after statements of deficiencies are processed, so an inspection from the last two months may not appear yet.
What This Report Cannot Tell You
- Complaints not investigated onsite
- Allegations screened out by the state before an onsite visit are not published.
- Complaint allegations
- CMS publishes the deficiencies a complaint survey cited, not the allegation itself.
- Facility-reported incidents
- Self-reported incidents appear only if they led to an inspection.
- Follow-up visits
- CMS's files list standard, complaint and infection control surveys, not revisits; a correction date is the one CMS records.
- Fire safety inspections
- Published by CMS separately and not included in this record yet.
- Staffing levels and ownership history
- Published by CMS separately and not included in this record.
- Whether fines were paid
- CMS publishes the fines imposed, not whether or when they were paid.
Historical coverage varies by agency and location. Missing records do not mean that no complaint or violation occurred.
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