Cascades of Bend Retirement Community

Last inspection

February 25, 2026

Inspections

4, 10 deficiencies cited

Substantiated abuse

4

Substantiated licensing violations

3

Regulatory actions

1

Fines assessed

$3,038.00 (4 violations)

Current owner since

October 1, 2026

License conditions and other regulatory actions

• September 6, 2022 to September 26, 2022: License Condition, Failed to update staffing plan based on ABST RCFCD22-01346; incident: CALMS - 00031170
  Based on interview and record review, it was determined the facility failed to implement an acuity-based staffing tool (ABST) that met the regulation
  Rules: 411-054-0037 (Acuity-Based Staffing Tool)

Inspections

• February 25, 2026: Kitchen, 2 deficiencies cited report
  • C0150: Facility Administration: Operation severity level 2, scope L2 Widespread
  • C0240: Resident Services Meals, Food Sanitation Rule severity level 2, scope L2 Widespread
  • C0455: Inspections and Investigation: Insp Interval severity level 2, scope L2 Widespread
  • Z0142: Administration Compliance severity level 2, scope L2 Widespread
• January 7, 2025: Kitchen, 2 deficiencies cited report
  • C0240: Resident Services Meals, Food Sanitation Rule severity level 2, scope L2 Widespread
  • C0370: Staffing Requirements and Training ? Pre-service severity level 2, scope L2 Isolated
  • C0455: Inspections and Investigation: Insp Interval severity level 2, scope L2 Widespread
• August 16, 2023: State Licensure, 1 deficiency cited report
  • C0000: Comment severity level 0
  • C0240: Resident Services Meals, Food Sanitation Rule severity level 2, scope L2 Widespread, corrected January 10, 2024
  • C0455: Inspections and Investigation: Insp Interval severity level 2, scope L2 Widespread, corrected January 10, 2024
• August 22, 2022: Validation, 5 deficiencies cited report
  • C0000: Comment severity level 0
  • C0260: Service Plan: General severity level 2, scope L2 Isolated, corrected October 22, 2022
  • C0310: Systems: Medication Administration severity level 2, scope L2 Isolated, corrected October 22, 2022
  • C0361: Acuity-Based Staffing Tool severity level 2, scope L2 Widespread, corrected October 22, 2022
  • C0420: Fire and Life Safety: Safety severity level 2, scope L2 Widespread, corrected October 22, 2022
  • C0510: General Building Exterior severity level 2, scope L2 Widespread, corrected October 22, 2022

Substantiated abuse or neglect

• July 16, 2025: Failed to properly plan care Abuse: Neglect; Level 3 - Moderate harm or potential for serious harm; fine $1,125.00; report
  Rules: 411-054-0025 (Facility Administration); 411-054-0027 (Resident Rights and Protections); 411-054-0028 (Reporting and Investigating Abuse and Other Actions Affecting Resident Welfare); 411-054-0030 (Resident Services); 411-054-0036 (Service Plan – General)
  State’s findings

  The Alleged Victim (AV) has suffered prior falls while ambulating. AV uses a wheelchair for ambulation; however, AV's care plan wasn't updated to advise staff of safety measures while assisting AV in his/her wheelchair. On or about July 16, 2025, staff were pushing AV in his/her wheelchair. AV did not have footrests on his/her wheelchair, resulting in AV putting his/her feet on the ground, causing AV to fall from the wheelchair to the floor, causing AV to have a skin tear to his/her nose. AV was sent to the hospital and diagnosed with a fractured nose, as well as receiving stitches to his/her nose. The respondent's failure to properly care plan, to ensure staff were ensuring AV had footrests on his/her wheelchair for safety. This constitutes abuse by neglect, as outlined in OAR 411-020-0002(1)(b)(A)(i).

• August 17, 2024: Failed to provide safe environment Abuse: Neglect; Level 4 - Serious harm, death, imminent danger or chronic regulatory noncompliance; fine $1,350.00; report
  Rules: 411-054-0025 (Facility Administration); 411-054-0027 (Resident Rights and Protections); 411-054-0028 (Reporting and Investigating Abuse and Other Actions Affecting Resident Welfare); 411-054-0036 (Service Plan – General)
  State’s findings

  On or about August 17, 2024, the Alleged Victim (AV) was in the dining area, sitting with Witness #1 (W1) while staff were getting others ready for dinner. W1 is known to have behaviors and impulsive actions, such as physical interactions with others. Staff heard a loud noise and went to investigate and found AV on the floor and W1 walking away. Internal investigation determined that W1 pushed AV to the ground. AV was transported to the hospital where he/she was diagnosed with a fractured hip, requiring surgerical intervention for a hip replacement. The facility's failure to properly care plan to ensure resident safety is a violation of resident rights, is considered neglect of care and constitutes abuse.

• July 16, 2024: Failed to properly plan care Abuse: Neglect; Level 2 - Minor harm or potential for moderate harm; fine $188.00; report
  Rules: 411-054-0025 (Facility Administration); 411-054-0027 (Resident Rights and Protections); 411-054-0028 (Reporting and Investigating Abuse and Other Actions Affecting Resident Welfare); 411-054-0036 (Service Plan – General)
  State’s findings

  The Alleged Victim (AV) was a resident at the facility, requiring care by the facility. During AV's one month stay at the facility, AV suffered 11 unwitnessed falls, with and without injury. On or about July 7, 2024, AV went to the hospital for an injury due to a fall. The facility failed to properly care plan to ensure AV's safety from falls. The facility failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

• March 11, 2024: Failed to provide safe environment Abuse: Neglect; Level 3 - Moderate harm or potential for serious harm; fine $375.00; report
  Rules: 411-054-0025 (Facility Administration); 411-054-0027 (Resident Rights and Protections); 411-054-0028 (Reporting and Investigating Abuse and Other Actions Affecting Resident Welfare); 411-054-0030 (Resident Services)
  State’s findings

  The Alleged Victim (AV) uses a wheelchair and needs assistance with transferring. On or about March 11, 2024, AV was returning from an outing on the facility bus. AV was assisted off the bus to his/her wheelchair, however, AV's electric wheelchair was on, and while maneuvering to sit down, when AV touched the toggle on the wheelchair, it activated the wheelchair to move, and AV fell. AV suffered a broken femur requiring surgery and eight stitches in the back of his/her head. The facility's failure to ensure a safe environment is a violation of resident rights, is considered neglect of care and constitutes abuse.

Substantiated licensing violations

• November 1, 2024: Failed to provide a safe medication administration system Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0025 (Facility Administration); 411-054-0027 (Resident Rights and Protections); 411-054-0055 (Medications and Treatments)
  State’s findings

  The facility is responsible for the ordering and administration of medication for the Alleged Victim (AV). On or about November 2nd, 3rd and 4th of 2024, AV missed his/her medication. AV's medication was not ordered timely, leaving AV without medication. The facility's failure to ensure AV's medication was available is a violation of Oregon Administrative Rules.

• January 13, 2024: Failed to protect resident from financial exploitation Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0025 (Facility Administration)
  State’s findings

  According to an investigation, on or about January 13, 2024, Alleged Perpetrator 2 (AP2) told the Alleged Victim (AV) that he/she was short on gas money with AV’s support person present. During the conversation, AP2 indicated that AV could not give AP2 money, but AV’s support person could. AV’s support person then gave AP2 $20.00 and AP2 left. AP2 returned approximately one hour later, after AV’s support person left, and told AV that he/she may not get paid timely, and that their vehicle does not do well on gas and requested additional monies from AV. AP2 then wrongfully took/accepted funds belonging to AV in the amount of $10.00. It was also discovered that AP2 had discussed financial troubles on multiple occasions. AP2’s actions are considered financial exploitation and constitutes abuse. The facility did not keep AV free from financial exploitation, which is a violation of Oregon Administrative rules.

• April 20, 2023: Failed to submit timely or adequate staffing documentation Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-061-0010
  State’s findings

  On or about April 1, 2023, the Oregon Health Authority reported to the Department that Respondent failed to comply with weekly reporting requirements of vaccinated individuals, residents and staff, to the proper authority as required by law. This failure has been ongoing for a total of 30 days.

Read the full record on the state’s site →

ODHS lists only substantiated violations: “either a substantiated instance of abuse or a licensing violation. Open investigations and complaints that are being appealed by the provider are not listed.” Oregon counts neglect as a form of abuse; see the state’s definitions of abuse. Each violation shows the level ODHS gives it, in the state’s words (for example “2 - Minor harm or potential for moderate harm”), and any fine ODHS assessed. Inspection citations show the state’s severity level and scope, and the date ODHS recorded the problem as corrected when it lists one. Rule names come from the Oregon Administrative Rules. ODHS: “Formal regulatory actions can range from a condition placed upon a license due to non-compliance or a notice to revoke a license.” This community is licensed for 70 residents; larger communities are inspected and reported on more often, so read counts with size in mind. Source: Oregon Department of Human Services, Long-Term Care Licensing, data as of October 15, 2026, showing the last five years. Always visit in person and ask the community about anything listed here.