Cascade Terrace Post Acute
5601 SE 122nd Avenue, Portland, OR 97236 · Multnomah County · 105 certified beds · avg 87 residents/day · certified since Jul 11, 1988
SFF Candidate
Part of chain: PACS GROUP (274 facilities, chain avg rating 2.9★)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★☆☆☆☆1/5 · CMS overall rating: 1/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Immediate jeopardy, one-off · Apr 28, 2025 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Apr 28, 2025 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, one-off · Jan 31, 2024 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Mar 26, 2024 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, one-off · Jan 31, 2024 · F-0740
The facility did not provide necessary behavioral health care and services — support for residents' mental and emotional wellbeing, including conditions like depression and anxiety.
Why it matters: A resident's untreated mental health needs can worsen and take a toll on their physical health too.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Feb 16, 2024 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Nov 6, 2025 · F-0757 · triggered by a complaint
The facility did not keep residents' medications free from unnecessary drugs. Residents should only take medicines they truly need, at the right dose, for a clear reason.
Why it matters: Unneeded drugs expose residents to side effects, drowsiness, falls, and dangerous interactions.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
All citations in the current public record (46)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Feb 18, 2026 | D · Potential for harm, one-off | The facility did not treat residents with respect and dignity, or did not let them keep and use their own personal belongings. · from a complaint |
| Feb 18, 2026 | D · Potential for harm, one-off | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint |
| Feb 18, 2026 | D · Potential for harm, one-off | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. · from a complaint |
| Dec 26, 2025 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
| Nov 6, 2025 | ▲ G · Actual harm, one-off | The facility did not keep residents' medications free from unnecessary drugs. Residents should only take medicines they truly need, at the right dose, for a clear reason. · from a complaint |
| Apr 28, 2025 | ▲ J · Immediate jeopardy, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Apr 28, 2025 | F · Potential for harm, facility-wide | The facility did not electronically submit complete and accurate staffing information to the government, based on payroll and other verifiable records. |
| Apr 28, 2025 | F · Potential for harm, facility-wide | The facility did not give all staff the required training on its quality improvement program — the internal system for finding problems and making care better. |
| Apr 28, 2025 | E · Potential for harm, repeated | The facility did not have a registered nurse on duty at least 8 hours a day, or did not have a registered nurse serving full-time as director of nursing. |
| Apr 28, 2025 | E · Potential for harm, repeated | The facility did not post its nurse staffing information every day. Nursing homes must publicly display how many nurses and aides are on duty each day. |
| Apr 28, 2025 | E · Potential for harm, repeated | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| Apr 28, 2025 | E · Potential for harm, repeated | The facility did not provide each resident with a nourishing, tasty, well-balanced diet that meets their daily nutritional and special dietary needs. |
| Apr 28, 2025 | E · Potential for harm, repeated | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Apr 28, 2025 | D · Potential for harm, one-off | The facility did not allow residents to take their own medications when a clinical review showed they could do so safely. Residents have this right if their care team determines it's appropriate. |
| Apr 28, 2025 | D · Potential for harm, one-off | The facility did not keep residents' personal and medical information private and confidential. |
| Apr 28, 2025 | D · Potential for harm, one-off | The facility did not fully assess residents on time — a complete assessment of health, abilities, and needs is required when a resident is first admitted and at least once every 12 months after that. |
| Apr 28, 2025 | D · Potential for harm, one-off | The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives. |
| Apr 28, 2025 | D · Potential for harm, one-off | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. |
| Apr 28, 2025 | D · Potential for harm, one-off | The facility did not provide activities that meet residents' needs and interests. Nursing homes must offer meaningful activity programs, not just leave residents idle. |
| Apr 28, 2025 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. |
| Apr 28, 2025 | D · Potential for harm, one-off | The facility did not provide safe, appropriate care for residents who need dialysis — the treatment that filters the blood when kidneys fail. |
| Apr 28, 2025 | D · Potential for harm, one-off | The facility did not keep residents' medications free from unnecessary drugs. Residents should only take medicines they truly need, at the right dose, for a clear reason. |
| Jan 23, 2025 | D · Potential for harm, one-off | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. · from a complaint |
| Jan 23, 2025 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
| Jan 31, 2024 | ▲ J · Immediate jeopardy, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Jan 31, 2024 | ▲ J · Immediate jeopardy, one-off | The facility did not provide necessary behavioral health care and services — support for residents' mental and emotional wellbeing, including conditions like depression and anxiety. |
| Jan 31, 2024 | F · Potential for harm, facility-wide | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · from a complaint |
| Jan 31, 2024 | E · Potential for harm, repeated | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. · from a complaint |
| Jan 31, 2024 | E · Potential for harm, repeated | The facility did not have enough nursing staff each day to meet every resident's needs, or did not have a licensed nurse in charge on each shift. Adequate staffing is one of the strongest predictors of good care. · from a complaint |
| Jan 31, 2024 | E · Potential for harm, repeated | The facility did not properly inform residents or their representatives about arbitration agreements — contracts that give up the right to sue in court — including their right to refuse to sign. · from a complaint |
| Jan 31, 2024 | E · Potential for harm, repeated | The facility did not make sure its nurse aides had the skills needed to care for residents, including training in dementia care and abuse prevention. · from a complaint |
| Jan 31, 2024 | D · Potential for harm, one-off | The facility did not make sure residents were fully informed about their own health, care, and treatments in a way they could understand. · from a complaint |
| Jan 31, 2024 | D · Potential for harm, one-off | The facility did not make reasonable adjustments to fit each resident's individual needs and preferences — things like call buttons within reach, preferred wake-up times, or accessible room setups. · from a complaint |
| Jan 31, 2024 | D · Potential for harm, one-off | The facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away. · from a complaint |
| Jan 31, 2024 | D · Potential for harm, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint |
| Jan 31, 2024 | D · Potential for harm, one-off | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint |
| Jan 31, 2024 | D · Potential for harm, one-off | The facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. · from a complaint |
| Jan 31, 2024 | D · Potential for harm, one-off | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. · from a complaint |
| Jan 31, 2024 | D · Potential for harm, one-off | The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required. · from a complaint |
| Jan 31, 2024 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
| Jan 31, 2024 | D · Potential for harm, one-off | The facility did not observe each nurse aide's job performance or provide regular training as required. · from a complaint |
| Jan 31, 2024 | D · Potential for harm, one-off | The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. · from a complaint |
| Dec 16, 2022 | E · Potential for harm, repeated | The facility did not post its nurse staffing information every day. Nursing homes must publicly display how many nurses and aides are on duty each day. |
| Dec 16, 2022 | D · Potential for harm, one-off | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. |
| Dec 16, 2022 | D · Potential for harm, one-off | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. |
| Dec 16, 2022 | D · Potential for harm, one-off | The facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time. |
Inspection trend by year
Citations from standard inspections stayed about the same across the last two inspection cycles (18 → 17).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2022 | 4 | 0 | E |
| 2024 | 18 | 2 | J ▲ |
| 2025 | 21 | 2 | J ▲ |
| 2026 | 3 | 0 | D |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
2 fines totaling $185,923.
| Date | Type | Amount / length |
|---|---|---|
| Apr 28, 2025 | Fine | $149,783 |
| Jan 31, 2024 | Fine | $36,140 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Oregon avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 5.15 | 5.42 | 3.95 | bottom 34% in Oregon; top 11% in the U.S. |
| Registered Nurse hours | 0.62 | 0.78 | 0.69 | bottom 43% in Oregon; top 45% in the U.S. |
| Weekend total nurse staffing | 4.78 | 4.85 | 3.50 | bottom 48% in Oregon; top 8% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.38 | 0.48 | 0.48 | top 49% in Oregon; bottom 49% in the U.S. |
| Total nursing staff turnover (%) | 47.1 | 47.4 | 45.8 | bottom 47% in Oregon; bottom 44% in the U.S. |
| RN turnover (%) | 50.0 | 51.6 | 42.9 | top 40% in Oregon; bottom 39% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 4.69, RN 0.56, weekend 4.35. Staffing rating: 4/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 4/5 · long-stay residents: 4/5 · short-stay residents: 5/5
Who owns this facility
For profit - Limited Liability company
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Portland 5601 Realty LLC | Organization | 5% or Greater Direct Ownership Interest | 100% | 09/01/2024 |
| Apt, Frederick | Individual | Corporate Officer | NOT APPLICABLE | 09/01/2024 |
| Apt, Frederick | Individual | Operational/Managerial Control | NOT APPLICABLE | 05/10/2024 |
| Epp, Blake | Individual | Operational/Managerial Control | NOT APPLICABLE | 09/01/2024 |
| Jergensen, Joshua | Individual | Corporate Officer | NOT APPLICABLE | 09/01/2024 |
| Larson, David | Individual | Operational/Managerial Control | NOT APPLICABLE | 09/01/2024 |
| Mitchell, John | Individual | Corporate Officer | NOT APPLICABLE | 09/01/2024 |
| Mitchell, John | Individual | Operational/Managerial Control | NOT APPLICABLE | 05/10/2024 |
| Murray, Jason | Individual | ADP of the SNF | NOT APPLICABLE | 04/03/2025 |
| Nazem, Jinan | Individual | Operational/Managerial Control | NOT APPLICABLE | 09/01/2024 |
| Providence Administrative Consulting Services INC | Organization | ADP of the SNF | NOT APPLICABLE | 09/01/2024 |
| Providence Group INC | Organization | ADP of the SNF | NOT APPLICABLE | 04/03/2025 |
| Truist Bank | Organization | ADP of the SNF | NOT APPLICABLE | 04/03/2025 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "What mental health services do you provide on-site, and who delivers them?"
- "How often is each resident's medication list reviewed, and who decides when a drug can be reduced or stopped?"
- "How do you train staff to treat residents with dignity, and how do you protect residents' personal belongings?"
- "When abuse or theft is suspected, who do you notify, how fast, and how do you inform the family?"
- "Can you show me an example care plan, and how are families included when it's created and updated?"
- "How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
- "How do your actual daily staffing levels compare to what's reported on Medicare's Care Compare website?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Avalon Care Center - Portland | 1.0 mi | Portland, OR | ★★★☆☆ | 2/5 | abuse |
| Gracelen Care Center | 1.0 mi | Portland, OR | ★☆☆☆☆ | 1/5 | |
| Cedar Crossings | 1.0 mi | Portland, OR | ★★★☆☆ | 2/5 | |
| Secora Rehabilitation of Cascadia | 1.1 mi | Portland, OR | ★★☆☆☆ | 2/5 | |
| Marquis Mill Park | 2.3 mi | Portland, OR | ★★★☆☆ | 2/5 | |
| Portland Health and Rehabilitation | 2.5 mi | Portland, OR | ★☆☆☆☆ | 1/5 | |
| Gateway Care and Retirement | 3.0 mi | Portland, OR | ★★★☆☆ | 3/5 | |
| Village Health Care | 3.0 mi | Gresham, OR | ★★☆☆☆ | 2/5 | |
| Menlo Park Post Acute | 3.2 mi | Portland, OR | ★★☆☆☆ | 2/5 | |
| Glisan Post Acute | 3.2 mi | Portland, OR | ★★☆☆☆ | 2/5 | |
| Rose City Nursing and Rehabilitation | 3.6 mi | Portland, OR | ★★★☆☆ | 3/5 | |
| Mt. Tabor Health & Rehabilitation | 3.8 mi | Portland, OR | ★★☆☆☆ | 2/5 |
Compare this facility with the 3 closest →
Facility data as of CMS processing date 2026-08-01. CCN 385187.