2
Inspections
5
Deficiencies
8
Abuse Violations
9
Licensing Violations
0
Regulatory Actions
In plain language
- The most recent inspection was on April 25, 2024 (state licensure visit) and found no deficiencies.
- Across 2 inspections since 2023, inspectors cited 5 deficiencies in total. Each one has a correction date recorded by the state.
- There are 8 substantiated abuse violations on record.
- The provider also has 9 substantiated licensing violations — rule breaches that did not involve abuse.
Deficiencies are rule violations noted by a state inspector. Most are minor and get corrected quickly; the sections below show exactly what was found and how the provider responded.
Provider Information
Status
Open
Type
Assisted Living Facility
County
Coos
Licensed Since
November 22, 1995
Classification
Not listed
Phone
541-756-0176
Email
melissaa@cascadeliving.com
Administrator
Melissa Dominguez
Accepts Medicaid
Yes
Memory Care
No
Inspections
2 records4/25/2024 State Licensure · Event KM1S State LicensureNo deficiencies ▼
No deficiencies cited
This inspection closed without citations.
1/3/2023 Validation · Event 82XS Validation5 deficiencies ▼
Deficiencies cited (5)
C0370 Staffing Requirements and Training – Pre-Serv Severity 2 ▼
Visit 1 · 1/5/2023 · Scope: Pattern/Minimal harm or potential for moderate harm
No correction date recorded
Findings
Based on interview and record review, it was determined the facility failed to ensure pre-service dementia care training had been completed, with certification, prior to staff providing direct care to residents, for 4 of 4 newly hired staff (#s 6, 10, 11 and 12). Findings include, but are not limited to:
The facility's training records reviewed on 01/04/23 revealed:
Staff 6 (CG), hired 07/14/22, Staff 10 (Cook), hired 10/11/21 Staff 11 (CG), hired 10/04/22 and Staff 12 (CG), hired 12/08/22, lacked documented evidence they had completed the required pre-service infection training prior to providing direct care to residents.
Requirements for pre-service training were reviewed with Staff 1 (ED) on 01/05/23. She acknowledged the findings.
Plan of Correction
1. All employee files will be reviewed for incomplete pre-service training. All missing pre-service training will be assigned and completed, and certificate of completion is placed in employee file.
2. "training" prior to providing direct care to residents.
3. Ensure that training is complete prior to a new hire performing direct care to residents.
4. Executive Director will be responsible to see that the corrections are completed/monitored.
Visit 2 · 5/10/2023 · Scope: Pattern/Minimal harm or potential for moderate harm
Corrected 2/28/2023
There are no detail notes for this visit.
C0372 Training Within 30 Days: Direct Care Staff Severity 2 ▼
Visit 1 · 1/5/2023 · Scope: Pattern/Minimal harm or potential for moderate harm
No correction date recorded
Findings
Based on interview and record review, it was determined the facility failed to ensure 3 of 3 newly hired direct care staff (#s 6, 11 and 12) demonstrated competency of skills in all assigned job duties within 30 days of hire. Findings include, but are not limited to:
Training records were reviewed on 01/04/23 and identified the following:
Staff 6 (CG) hired 07/14/22, Staff 11 (CG) hired 10/04/22 and Staff 12 (CG) hired 12/08/22 lacked documentation of demonstrated competency in changes associated with normal aging and first aid/abdominal thrust.
The need to ensure staff demonstrated competency in all assigned job duties within 30 days of hire was discussed with Staff 1 (ED) on 01/05/23. She acknowledged the findings.
Plan of Correction
1. All employee files will be reviewed for demonstrated competency of skills in all assigned job duties. Employee files missing training will be assigned and completed. Skills Check list will be filed in employee's file.
2. Demonstrated competency of skills in all assigned job duties will be assigned to and completed with all new hires within 30 days of hire, including normal aging and first aid/abdominal thrust.
3. Employee Files will be audited prior to new hires completing their 30 days and quarterly to ensure completion of demonstrated competencies.
4. Executive Director will be responsible to see that the corrections are completed and monitored.
Visit 2 · 5/10/2023 · Scope: Pattern/Minimal harm or potential for moderate harm
Corrected 2/28/2023
There are no detail notes for this visit.
C0374 Annual and Biennial Inservice For All Staff Severity 2 ▼
Visit 1 · 1/5/2023 · Scope: Pattern/Minimal harm or potential for moderate harm
No correction date recorded
Findings
Based on interview and record review, it was determined the facility failed to ensure documented evidence of the required 12 hours of annual in-service training, including six hours of dementia care training, was completed for 3 of 3 long term staff (#s 5, 7 and 8) whose training records were reviewed. Findings include, but are not limited to:
Staff training records were reviewed on 01/04/23.
Annual training records, provided through online training courses and monthly staff meetings, based on anniversary date of hire, for Staff 5 (CG) hired 01/27/21, Staff 7 (MT) hired 10/02/17 and Staff 8 (CG) hired 10/10/18 were reviewed.
The records indicated Staff 5, 7 and 8 did not complete all twelve hours of in-service training on topics related to dementia care or community based care.
The need to ensure direct care staff completed the required annual training was reviewed with Staff 1 (ED) on 01/05/23. She acknowledged the findings.
Plan of Correction
1. All employee files will be reviewed for required annual training. Missing annual trainings will be assigned and completed, with documentation of completion placed in employee's file. Training will be completed prior to the associate's anniversary hire date. 2. Staff will receive monthly staff training in the form of a staff meetings or online training courses. Staff will receive no less than 6 hours of dementia training and an additional 6 hours of community-based care. Documentation of completion will be filed in employee's file.
3. System will be reviewed quartley and 1 month prior to anniversay date to ensure staff is receiving the training they need and that it is documented in the appropriate 12-month period. 4. Executive Director will be responsible for ensuring that the corrections are completed/monitored.
Visit 2 · 5/10/2023 · Scope: Pattern/Minimal harm or potential for moderate harm
Corrected 2/28/2023
There are no detail notes for this visit.
C0420 Fire and Life Safety: Safety Severity 2 ▼
Visit 1 · 1/5/2023 · Scope: Widespread/Minimal harm or potential for moderate harm
No correction date recorded
Findings
Based on interview and record review, it was determined the facility failed to ensure all required elements were documented for fire drills in accordance with Oregon Fire Code (OFC) and fire and life safety instruction was provided on alternate months. Findings include, but are not limited to:
Review of fire drill and fire and life safety records from 06/18/22 through 12/22/22 identified the following:
a. The facility failed to provide fire and life safety instruction to staff on alternate months.
b. The facility failed to document the following required elements on firs drills; * Escape route used; * Problems encountered, comments relating to residents who resisted or failed to participate in the drill; * Number of occupants evacuated; and * Alternate routes used during fire drills were not documented.
The need to ensure the facility documented all required elements for fire drills and fire life safety training was completed on alternate months was reviewed with Staff 1 (ED). She acknowledged the findings.
Plan of Correction
1. (a) The facility will provide fire and life safety instruction to staff on alternate months. (b) the facility will document all elements on fire drills.
2. Monthly fire and safety instructions will be completed. (b) All elements will be addressed and documented.
3. (a)(b) Area of correction to be evaluated.
4. Executive Director will be responsible to see that the corrections are completed and monitored.
Visit 2 · 5/10/2023 · Scope: Widespread/Minimal harm or potential for moderate harm
Corrected 2/28/2023
There are no detail notes for this visit.
C0422 Fire and Life Safety: Training For Residents Severity 2 ▼
Visit 1 · 1/5/2023 · Scope: Widespread/Minimal harm or potential for moderate harm
No correction date recorded
Findings
Based on interview and record review, it was determined the facility failed to instruct new residents on fire and life safety within 24 hours of admission and provide Fire and Life Safety instruction to residents annually. Findings include, but are not limited to:
Fire drill records, from 06/2022 through 12/2022, were reviewed on 01/04/23 with Staff 1 (ED) and revealed the following:
* There was no documented evidence new residents were instructed on fire and life safety within 24 hours of admission; and * Staff 2 stated the facility was not providing or documenting annual instruction for residents in general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places outside the building or within the fire safe area in the event of an actual fire. The requirements for Fire and Life Safety instruction for residents were reviewed with Staff 1 on 01/04/23. She acknowledged the findings.
Plan of Correction
1. All resident files will be reviewed for incomplete training. 2. "training" Residents will receive training within 24 hours of move in and annually
3. "training" will be review quarterly.
4. Executive Director will be responsible to see that the corrections are completed and monitored.
Visit 2 · 5/10/2023 · Scope: Widespread/Minimal harm or potential for moderate harm
Corrected 2/28/2023
There are no detail notes for this visit.
Inspection notes
C0000 Comment Severity 0 ▼
Visit 1 · 1/5/2023
No correction date recorded
Findings
The findings of the re-licensure survey conducted 01/03/23 through 01/05/23 are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 Home and Community Based Services Regulations.
Abbreviations possibly used in this document:
ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar CG: caregiver cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MA: Medication Aide MAR: Medication Administration Record MCC: Memory Care Community mg: milligram ml: milliliter MT: Medication Technician OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day QI: quality improvement RCC: Resident Care Coordinator RN: Registered Nurse TAR: Treatment Administration Record tid: three times a day
Visit 2 · 5/10/2023
No correction date recorded
Findings
The findings of the revisit to the re-licensure survey of 01/05/23, conducted on 05/10/23, are documented in this report. It was determined the facility was in substantial compliance with the OARs Division 54 for Residential Care and Assisted Living Facilities.
Abuse Violations
8 records11/1/2023 Failed to provide safe environment · 00294412-AP-248189 Level 2Substantiated ▼
Type
Abuse: Neglect
Level
2 - Minor harm or potential for moderate harm
Rules violated (OAR)
411-054-0025(1)(a) and (b)
411-054-0027(1)(a)(g) and (s)
411-054-0028(2)(a) and (b)
411-054-0030(1) (e)(I)
411-054-0036(2)(g)
Findings
Alleged Victim (AV) relies on the facility for a safe environment. Witness 1 (W1) has history of behaviors, making perverse comments toward staff and/or making staff feel uncomfortable. W1 and AV started hand holding and were observed sitting together on occasions with blankets. Staff reported having apprehension regarding the appropriateness of the dynamic between W1 and AV. On or about November 1, 2023, Witness 3 (W3) noticed AV had a startled, frozen expression in W1's presence. AV told W3 that W1 tried to have AV touch W1's privates. There was a negative change to AV's baseline mood throughout the following day. AV appeared more confused, skittish, and guarded. AV was observed to be tearful during the night shift. The facility failed to adjust the service plan for W1 behaviors, and failed to provide a safe environment for AV, which is a violation of resident rights, is neglect of care and constitutes abuse.
Sanction
ALFCP24-00710 $188.00 fine assessed
7/8/2019 Failed to protect resident from financial exploitation · 00039047AP-027460 Level 2Substantiated ▼
Type
Abuse: Financial abuse
Level
2 - Minor harm or potential for moderate harm
Rules violated (OAR)
411-054-0025(1)(a) and (b)
411-054-0027(1)(r)
Findings
AP neglected AV as defined in OAR 4110200002(1)(b)(A) by the active or passive failure to provide basic care or services necessary to maintain the health and safety of an adult.
7/7/2019 Failed to protect resident from financial exploitation · 00039632AP-027882 Level 2Substantiated ▼
Type
Abuse: Financial abuse
Level
2 - Minor harm or potential for moderate harm
Rules violated (OAR)
411-054-0025(1)(a)
411-054-0027(1)(r)
Findings
AP neglected AV as defined in OAR 4110200002(1)(b)(A) by the active or passive failure to provide basic care or services necessary to maintain the health and safety of an adult.
5/30/2012 Failed to properly plan care · NB120152 Level 2Substantiated ▼
Type
Abuse: Neglect
Level
2 - Minor harm or potential for moderate harm
Rules violated (OAR)
411-054-0027(1)(f)
411-054-0028(2)
411-054-0036(1)
411-054-0055(1)(f)
Findings
The facility failed to maintain a safe environment.
1/26/2012 Failed to provide safe environment · NB129485 Level 3Substantiated ▼
Type
Abuse: Financial abuse
Level
3 - Moderate harm or potential for serious harm
Rules violated (OAR)
411-054-0025(1)(b)
411-054-0027(1)(r)
Findings
The facility failed to protect RV from misappropriation of RV's resources for the gain of another.
10/7/2011 Failed to provide safe environment · NB118171 Level 2Substantiated ▼
Type
Abuse: Financial abuse
Level
2 - Minor harm or potential for moderate harm
Rules violated (OAR)
411-054-0027(1)(r)
Findings
The facility failed to protect RV from theft.
4/27/2011 Failed to provide safe environment · NB116869 Level 3Substantiated ▼
Type
Abuse: Financial abuse
Level
3 - Moderate harm or potential for serious harm
Rules violated (OAR)
411-054-0025(1)(b)
411-054-0027(1)(r)
Findings
Facility failed to provide a safe environment.
1/24/2011 Failed to provide safe environment · NB116220 Level 4Substantiated ▼
Type
Abuse: Neglect
Level
4 - Serious harm, death, imminent danger or chronic regulatory noncompliance
Rules violated (OAR)
411-054-0025(1)(a) and (4)
411-054-0027(1)(f) and (r)
411-054-0028(2)(a), (b) and (c) and (3)
411-054-0034(2)(b), (c) and (f) and (4)(b) and (c)
411-054-0036(1)(a) and (g)
411-054-0040(1)(b) and (c) and (2)
411-054-0045(1)(c), (d) and (f)(A) and (C)
Findings
The facility failed to provide a safe environment.
Sanction
ALFCP11-025 $400.00 fine assessed
Licensing Violations
9 records9/10/2025 Failed to protect resident from financial exploitation · 00425596-AP-377171 Level 2Substantiated ▼
Type
Licensing Violation
Level
2 - Minor harm or potential for moderate harm
Rules violated (OAR)
411-054-0025(1)(a) and (b)
411-054-0027(1)(a)(g) and (s)
411-054-0028(2)
Findings
The Alleged Victim (AV) orders items from door dash often. AV ordered a coffee and Alleged Perpetrator #2 (AP2) made a comment to AV, "Where's mine?". The next time that AV ordered from door dash, AV asked AP2 if he/she wanted anything. AV ordered AP2 a burrito. On another occasion, AV had ordered too much of pasta and shared that with AP2. AP2 has been trained and counseled not to accept money, gratuities or gifts from residents, AP2's actions are a violation of resident rights, are considered neglect of care and constitute financial abuse. The facility's failure to ensure AV was safe from financial abuse is a violation of Oregon Administrative Rules.
9/6/2025 Failed to protect resident from financial exploitation · 00425225-AP-376777 Level 2Substantiated ▼
Type
Licensing Violation
Level
2 - Minor harm or potential for moderate harm
Rules violated (OAR)
411-054-0025(1)(a) and (b)
411-054-0027(1)(a)(g) and (s)
411-054-0028(2)
Findings
On or about September 6, 2025, the Alleged Victim (AV) was setting up his/her television and Alleged Perpetrator #2 (AP2) assisted AV with that task. AV gave AP2 $20.00 for assisting him/ her with this task. On a prior occasion, AP2 also accepted money from AV after assisting AV with moving into the facility. AP2 has been trained and counseled not to accept money, gratuities or gifts from residents, AP2's actions are a violation of resident rights, are considered neglect of care and constitute financial abuse, per OAR 411-020-0002(1)(e)(E). The facility's failure to ensure AV was safe from financial abuse is a violation of Oregon Administrative Rules.
9/1/2025 Failed to protect resident from financial exploitation · 00425594-AP-377167 Level 2Substantiated ▼
Type
Licensing Violation
Level
2 - Minor harm or potential for moderate harm
Rules violated (OAR)
411-054-0025(1)(a) and (b)
411-054-0027(1)(a)(g) and (s)
411-054-0028(2)
Findings
On or about September 1, 2025, Alleged Perpetrator #2 (AP2) asked the Alleged Victim (AV) for $20.00 because he/ she needed gas money. AV gave the money to AP2 and asked when their payday was and advised they would see them then. AP2 never paid AV back the borrowed money. AP2 has been trained and counseled not to accept money, gratuities or gifts from residents, AP2's actions are a violation of resident rights, are considered neglect of care and constitute financial abuse, per OAR 411-020-0002(1)(e)(E). The facility's failure to ensure AV was safe from financial abuse is a violation of Oregon Administrative Rules.
3/16/2025 Failed to provide or assist with hygiene · 00396272-AP-346954 Level 2Substantiated ▼
Type
Licensing Violation
Level
2 - Minor harm or potential for moderate harm
Rules violated (OAR)
411-054-0025(1)(a) and (b)
411-054-0027(1)(g) and (s)
411-054-0028(2)
411-054-0030(1)(e)(H)
Findings
On or about March 16, 2025, at approximately 9:00 PM, the Alleged Victim (AV) used his/her pendant to call for assistance. Alleged Perpetrator #2 (AP2) answered AV's call. AV stated they needed to use the restroom so they didn't miss breakfast. AP2 stated it wasn't time for breakfast so no need to get up and did not get AV out of bed to use the restroom. AV's phone and pendant were on the bedside table, which was moved by AP2, therefore, AV could not reach either item to call for assistance. At 1:00 or 2:00 AM, AV could not hold his/her urine any longer and had no way to call staff for help. Alleged Perpetrator #3 (AP3) was responsible for checking on AV in the morning and did not check on AV all morning or at lunch time. AV was not checked on until another staff arrived at work at 1:00 PM to assist AV with a shower. AV laid in his/her urine, in his/her bed for approximately 12 hours, leaving him/her in unreasonable discomfort, frustrated, trapped and embarrassed. AP2 and AP3's failure is a violation of resident rights, is considered neglect of care and constitutes abuse. The facility's failure to ensure AV's needs were met is a violation of Oregon Administrative Rules.
3/22/2024 Failed to protect resident from financial exploitation · 00320403-AP-272244 Level 2Substantiated ▼
Type
Licensing Violation
Level
2 - Minor harm or potential for moderate harm
Rules violated (OAR)
411-054-0025(1)(a) and (b)
411-054-0027(1)(g) and (s)
411-054-0028(2)
Findings
Alleged Victim (AV) is missing two envelopes of money in a total of approximately $800.00 to $900.00. AV did not lock the money in their lock box. Around the same time there was money missing from the beauty shop. A video was taken of a person in the beauty shop in the middle of the night on April 12, 2024. In the video a light comes on, a hand in a brace opening drawers and cabinets as well as looking through a book is seen. Alleged Perpetrator 2 (AP2) was identified in the video by their hand brace and watch. AP2 was seen on camera in the beauty shop. There were no cameras or witnesses who saw AP2 enter AV's apartment nor saw AP2 take AV's money. The money was taken by an Unknown Alleged Perpetrator #3 (AP3) and this person is responsible for theft of property, which is considered financial exploitation and constitutes abuse. The facility failed to protect AV from financial exploitation which is a violation of Oregon Administrative Rules.
2/16/2024 Failed to protect resident from financial exploitation · 00319535-AP-271382 Level 2Substantiated ▼
Type
Licensing Violation
Level
2 - Minor harm or potential for moderate harm
Rules violated (OAR)
411-054-0025(1)(a) and (b)
411-054-0027(1)(f) and (r)
411-054-0028(2)
Findings
On or about February 16, 2024, Alleged Victim (AV) reported AV was missing $300.00 s/he withdrew from the bank on February 6, 2024. AV reported AV was missing another $150.00, but AV was not able to provide a timeframe of when money went missing. AV reported $15.00 was taken from AV's apartment on or about March 18, 2024. AV reported CBD oils were missing from AV's medicine cabinet. After the money was reported missing, AV gave management permission to search AV's apartment. AV originally indicated AV didn't have a key for AV's lock box but AV was ultimately able to produce the lock box key to check the lock box. Money missing from AV's apartment is not an isolated incident. Around the time this happened, money was missing from the beauty shop and from another resident. The facility set up a camera in the beauty shop in efforts to find out who is responsible. Alleged Perpetrator (AP2) has a wrist brace and wears a particular watch. AP2's face is not visible in the footage, but the wrist brace and the watch are. There was no money in the drawers at the time the footage was captured of AP2 going through the drawers. It was suspected AP2 was responsible for the theft. AP2 denied having any involvement with taking money, CBD Oil from AV's apartment or beauty shop. It is unknown who took the money and CBD oils. The items were taken by an Unknown Alleged Perpetrator #3 (AP) and this person is responsible for theft of property, which is considered financial exploitation and constitutes abuse. The facility failed to protect AV from financial exploitation which is a violation of Oregon Administrative Rules. The allegation that AP2 financially exploited AV was investigated, and wrongdoing was not determined.
9/24/2021 Failed to follow care plan · 00161858-AP-128340 Level 2Substantiated ▼
Type
Licensing Violation
Level
2 - Minor harm or potential for moderate harm
Rules violated (OAR)
411-054-0027(1)(a)(f) and (r)
411-054-0028(2)
411-054-0036(2)(g)
Findings
Alleged Victim (AV) relies on the facility for h/h care. On or about September 24, 2021, AV had a fall while being transferred by Alleged Perpetrator #2 (AP2). AV is care planned to use a gait belt for all transfers. AP2 was not using a gait belt when attempting to transfer AV. AP2’s actions are a violation of resident rights, are considered neglect of care and constitute abuse. The facility failed to follow the care plan which is a violation of Oregon Administrative Rules.
11/19/2018 Failed to protect resident from financial exploitation · NB181185 Level 2Substantiated ▼
Type
Licensing Violation
Level
2 - Minor harm or potential for moderate harm
Rules violated (OAR)
411-054-0025(1)(a)
411-054-0027(1)(r)
Findings
AP financially exploited AV as defined in OAR 4110200002(1)(e)(A) by wrongfully taking funds belonging to AV by means including coercion and duress which resulted in financial loss to AV.
3/2/2014 Failed to follow care plan · NB146249 Level 2Substantiated ▼
Type
Licensing Violation
Level
2 - Minor harm or potential for moderate harm
Rules violated (OAR)
411-054-0036(1)(g)
Findings
The facility failed to provide appropriate care.
Regulatory Actions
No regulatory actions
The state portal lists no regulatory actions for this provider.