Avamere Rehabilitation of Beaverton

Resident 63 was admitted to the facility in 2024 with diagnoses including cerebral infarction (disrupted blood flow to the brain)The 6/2/25 Quarterly MDS indicated Resident 63 was cognitively intact, utilized a wheelchair and walker, and was impaired on side.The 6/6/25 Care Plan indicated Resident 63 was GÇ£non-ambulatory and was wheelchair boundGÇ¥.A 2/18/25 progress note indicated an AFO (Ankle Foot Orthesis) was ordered for Resident 63 in January. The note indicated staff reached out to orthotics and prosthetics and the referral did not include a provider signature and chart notes to support necessity of the AFO.A 3/5/25 Progress Note indicated Resident 63 was still waiting for the AFO to be delivered to start an ambulation restorative program. Resident 63 attended group therapy with the wheelchair.A 4/7/25 physician note clarified Resident 63 required a custom AFO permanently.On 8/4/25 at 2:55 PM, Resident 63 was observed without an AFO. The resident stated she/he participated with the physical therapist individually and was able to walk with assistance. Resident 63 stated she/he stopped walking, and used the wheelchair to participate in group therapy. Resident 63 stated her/his right leg was weaker and ROM decreased when physical therapy services ended.On 8/7/25 at 9:50AM, Staff 13 (CNA) stated staff did not ambulate Resident 63. Staff 13 stated Resident 63 had a stroke and was unable to ambulate due to right sided weakness. Staff 13 stated Resident 63 worked with PT and used a walker to ambulate.-áOn 8/7/25 at 9:25 AM, Staff 14 (Restorative Aide) stated Resident 63 ambulated with PT. She stated restorative orders indicated Resident 63 participated in group therapy until the AFO arrived. Resident 63 was waiting for the AFO to be delivered to start an ambulating restorative program.-áOn 8/7/25 at 12:23PM, Staff 15 (Physical Therapist) stated Resident 63 received physical therapy from 12/18/24 to 12/24/24. Staff 15 stated Resident 63 was required to use an AFO to ambulate. A referral was sent to prosthetics and orthotics. Resident 63 was measured and was waiting for the AFO to be delivered. Staff 15 stated he thought insurance approval was delayed. Staff 15 stated Resident 63GÇÖs gait was unsafe, and she/he was waiting for the AFO to be delivered to start an ambulating restorative program. Staff 15 stated Resident 63 did participate in group therapy. Staff 15 stated staff agreed to notify the therapy team when the AFO arrived.On 8/7/25 at 2:13PM, Staff 16 (LPN- Resident Care Coordinator) stated restorative orders indicated Resident 63 participated in group therapy. Staff 16 stated Resident 63 used a wheelchair and walker at baseline. Staff 16 stated the-á prosthetics and orthotics clinic denied the referral and requested additional documentation. Staff 16 stated additional documentation was sent and she was waiting for the AFO to be delivered. Staff 16 stated she reached out to prosthetics and orthotics clinic on 7/22/25.On 8/8/25 at 9:47 AM, Staff 2 (Director of Nursing Services) acknowledged the arrival of the AFO was not timely. She stated referral requests were not processed in a timely manner. Staff 2 stated she expected staff to follow up with outpatient providers in a timely manner.

The facility's 8/2022 Trauma Informed Care and Culturally Competent Care Policy indicated to provide trauma-informed care in accordance with professional standards of practice and to address the needs of trauma survivors by minimizing triggers and/or re-traumatization. It directed staff to identify and decrease exposure to triggers that may retraumatize the resident.Resident 8 was admitted to the facility in 6/2025 with diagnoses including PTSD (Post-Traumatic Stress Disorder, mental condition with intense emotional and/or physical reaction after a traumatic event or experience).Resident 8GÇÖs 6/19/25 Admission MDS revealed the resident was cognitively intact, able to make herself/himself understood and understood others without difficulty, and had a PTSD diagnosis.Resident 8GÇÖs 6/16/25 Trauma Informed Care Evaluation was marked as GÇ£The resident does not want to complete this assessment and/or states they have not experienced trauma (end assessment here).GÇ¥-áNo evidence was found in Resident 8's 6/16/25 to indicate a care plan was developed to address the resident's trauma history or involved family members were interviewed to provide information about the resident's trauma history and potential triggers.A 7/1/25 FRI Resident 8 reported Staff 9 (LPN) while alone in the hallway, Staff 9 smelled her/his hair, then pushed her/his wheelchair into their room and smelled her/his hair again. While in the room, Staff 9 hugged Resident 8 from behind seated in the wheelchair and rubbed the residentGÇÖs arms several times. Resident 8 stated these actions triggered her/his PTSD.On 8/5/25 at 4:38 PM Resident 8 stated the facility should have been aware of her/his PTSD from the hospital notes. Resident 8 stated she/he spoke to several staff of her/his experience with PTSD and triggers and the staff should have been aware.On 8/7/25 at 9:27 AM Staff 9 confirmed he smelled Resident 8GÇÖs hair and rubbed her/his arms in the hallway and in the room. Staff 9 stated he was aware of Resident 8GÇÖs PTSD diagnoses from her/his medical history and conversations with the resident.On 8/7/25 at 2:41 PM Staff 2 (DNS) stated all residents with PTSD diagnoses had an initial care plan developed by the admission nurse at the time of admission. She expected Social Services to develop a resident-centered care plan within 72-hours from admission.On 8/8/25 at 9:16 AM Staff 1 (Administrator) acknowledged Resident 8GÇÖs a history of trauma and nothing was implemented related to her/his trauma triggers.-á

The 2014 Oregon Health Authority HIV, STD, TB, Viral Hepatitis Program specified the following:- Vials in use more than 30 days should be discarded due to oxidation and degradation which may affect potency.The facility's 11/2020 Storage of Medications Policy specified the following:- Drug containers that have missing, incomplete, improper, or incorrect labels are returned to the pharmacy for proper labeling before storing. Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed.On 8/6/25 at 10:09 AM, two open, undated vials of tuberculin (used for the testing in the diagnosis of Tuberculosis) and two open, undated insulin pens were observed inside the refrigerator located in the north hall medication storage room.On 8/6/25 at 10:35 AM, Staff 2 (Director of Nursing) acknowledged the vials of tuberculin and insulin pens were undated and expected staff to discard tuberculin vial and insulin pens within 30 days of opening.-á-á-á

Resident 63 admitted to the facility in 2024 with diagnoses including hearing loss.The 4/14/25 Audiologic report AVS (after visit summary) indicated Resident 63 was to start an aural rehabilitation program and to obtain a referral to speech pathology.The 6/24/25 Care Conference indicated Resident 63 did not hear with her/his hearing aids and requested staff to communicate in written form.A review of Resident 63GÇÖs orders indicated a speech evaluation and treatment orders was entered on 8/7/25. No evidence was found in the resident's medical record to indicate she/he saw a speech pathologist.-á-áOn 8/4/25 at 2:55 PM, Resident 63 stated she/he preferred to communicate via written form. Resident 63 proceeded to point at her/his ears and said she/he was not able to hear.On 8/8/25 at 9:07 AM, Staff 5 (Director of Rehab) stated Staff 16 (LPN-Resident Care Coordinator) discussed aural rehabilitation services for Resident 63 early in the week. Staff 5 stated Resident 63 was referred to speech therapy ""a couple days ago."" Staff 5 was unaware Resident 63 was seen at the ear clinic in April 2025. Staff 5 expected a referral to speech therapy to be entered the following day after Resident 63's ear clinic appointment.On 8/8/25 at 9:47 AM, Staff 2 stated it was expected for staff to request an AVS after each visit to outpatient appointments. Staff acknowledged the referral to speech therapy was not entered within a timely manner.-á

Based on interview and record review it was determined the facility failed to provide the required written notice of a bed-hold policy before or upon transfer to the hospital for 2 of 3 sampled residents (#s 11 and 47) reviewed for hospitalization. This placed residents at risk for being uninformed of their rights. Findings include:

The facility's revised 10/2022 bed-hold policy indicated "all residents/representatives are provided written information regarding the facility and state bed-hold policies, which address holding or reserving a resident's bed during periods of absence (hospitalization or therapeutic leave). Residents, regardless of payer source, are provided written notice about these policies at least twice:

a. Notice 1: Well in advance of any transfer (e.g., in the admission packet); and

b. Notice 2: At the time of transfer (or, if the transfer was an emergency, within 24 hours)."

1. Resident 47 admitted to the facility in 5/2023 with diagnoses including vascular dementia.

A 1/19/24 progress note indicated Resident 47 was admitted to the hospital.

A 1/24/24 progress note indicated Resident 47 was readmitted to the facility.

No evidence was found in the resident's clinical record to indicate the resident or the resident's representative was notified in writing of the facility's bed-hold policy at the time of transfer to the hospital.

On 3/25/24 at 9:24 AM Staff 4 (Admission Coordinator) stated she never gave a resident a written notice for a bed hold. Staff 4 stated she did not include the bed-hold policy in the resident's transfer paperwork. Staff 4 stated she did not have Resident 47 sign bed-hold paperwork prior to transferring to the hospital.

On 3/25/24 at 10:18 AM Staff 2 (DNS) stated she was not sure what paperwork the facility gave residents when they transferred to the hospital.

On 3/25/24 at 10:21 AM Staff 14 (LPN) stated the paperwork residents were given prior to transferring to the hospital did not include information on a bed-hold from the facility.

,
2. Resident 11 re-admitted to the facility in 12/2023 with diagnoses including multiple sclerosis (disease of the central nervous system).

A review of Resident 11's clinical record indicated the resident was discharged to the hospital on the following dates:
- 3/13/23
- 3/25/23
- 4/6/23
- 6/27/23
- 10/19/23
- 12/5/23

Resident 11's clinical record revealed no indication the resident was provided with a written bed-hold policy when she/he discharged to the hospital, or within 24 hours of discharge on 3/13/23, 3/25/23, 4/6/23, 6/27/23, 10/19/23 or 12/5/23.

On 3/20/24 at 9:42 AM Resident 11 stated she/he was not provided information about the bed-hold process when she/he was sent to the hospital.

On 3/22/24 at 10:52 AM Staff 4 (Admissions Director) confirmed Resident 11 was not provided bed- hold information on 3/13/23, 3/25/23, 4/6/23, 6/27/23, 10/19/23, and 12/5/23 when she/he discharged to the hospital.

Based on interview and record review it was determined the facility failed to develop a comprehensive care plan related to the presence of a pressure ulcer for 1 of 2 sampled residents (#60) reviewed for pressure ulcers. This placed residents at risk for worsening wounds. Findings include:

Resident 60 was admitted to the facility in 11/2023 with diagnoses including diabetes and a pressure ulcer on the left heel.

An 11/10/23 Admission MDS and associated CAAs revealed Resident 60 had a pressure ulcer upon admission and she/he was at risk for a worsening pressure ulcer due to the need for repositioning assistance, cognitive loss, and a diagnosis of diabetes.

Resident 60's TARs and weekly wound assessments from 11/2023 through 3/2024 revealed treatment was provided for the resident's pressure ulcer and the wound progressed toward healing.

A review of Resident 60's comprehensive care plan from admission through 2/20/24 did not reveal any information related to a pressure ulcer on the left heel.

On 3/25/24 at 10:10 AM these findings were shared with Staff 2 (DNS) and no additional information was provided.

Based on observation, interview and record review it was determined the facility failed to monitor and treat skin conditions for 1 of 2 sampled residents (#17) reviewed for skin conditions. This placed residents at risk for unmet care needs. Findings include:

Resident 17 was admitted to the facility in 2/2024 with diagnoses including hepatic encephalopathy (impaired brain function related to toxins in the blood) and chronic kidney disease.

A review of Resident 17's 2/26/24 Quarterly MDS revealed she/he was cognitively intact.

On 3/19/24 at 10:39 AM Resident 17 was observed to have a rash with red skin and white flakes to the right of her/his nose. Resident 17 reported the rash itched.

No evidence was found in Resident 17's health record to indicate the rash was assessed, or a signed physician's order for treatment of the rash was obtained.

On 3/21/24 at 10:10 AM Staff 17 (CMA) stated she was aware of the rash on Resident 17's face but she was not in charge of providing treatments.

On 3/21/24 at 12:21 PM Staff 5 (LPN) stated Resident 17 did not receive treatments for the rash on her/his face. The CNAs were supposed to moisturize her/his face when they provided care. She confirmed there was no documentation in Resident 17's health record to indicate the care was provided. She also confirmed there were no orders for treatment of the rash in Resident 17's health record.

No evidence was found in Resident 17's health record to indicate CNAs moisturized the rash on her/his face.

On 3/21/24 at 2:48 PM Staff 6 (LPN Resident Care Coordinator) observed Resident 17 and acknowledged she/he had a rash on her/his face. Staff 6 confirmed any staff who saw the rash was supposed to report it to the charge nurse so it could be treated.

On 3/25/24 at 11:01 AM Staff 1 (Administrator) confirmed he expected staff to assess any skin impairment to determine the cause and create an intervention.

Based on observation and interview it was determined the facility failed to ensure safe water temperatures were maintained in resident rooms 11 of 55 sampled resident rooms (#s 4, 5, 6, 11, 15, 24, 31, 55, 57, 58 and 59) reviewed for a safe environment. This placed residents at risk for burns. Findings include:

Observations of the facility's general environment and resident rooms from 3/18/24 through 3/25/24 identified the following issues:

Bathroom faucets were checked for safe temperatures in rooms 4, 5, 6, 11, 15, 24, 31, 55, 57, 58 and 59. The hot water in the identified rooms was found to be too hot to safely hold a hand under.

On 3/22/24 at 10:11 AM Staff 20 confirmed the hot water in the identified rooms was excessively hot and indicated one water heater temperature was set at 175 F.

On 3/22/24 at 10:59 AM Staff 1 (Administrator) confirmed the excessively hot water in the facility.

Based on observation, interview and record review, it was determined the facility failed to provide the prescribed therapeutic diet for 1 of 3 sampled residents (#221) reviewed for nutrition. This placed residents at risk for unmet nutritional needs. Findings include:

Resident 221 was admitted to the facility in 3/2024 with diagnoses including a spinal fracture and type 2 diabetes.

A review of Resident 221's 3/19/24 Admission MDS revealed she/he was cognitively intact.

On 3/18/24 at 9:52 AM Resident 221 reported she/he controlled her/his blood sugar at home by not eating foods with high sugar content. She/he stated, "They bring me lots of bread. I don't eat that at home. Here they serve me pancakes and other things. Then they shoot me full of insulin."

A review of Resident 221's orders dated 3/19/24 revealed she/he was to receive a "Limit CHO diet" (a diet consisting of limited carbohydrates) related to her/his diagnosis of type 2 diabetes.

On 3/20/24 at 1:20 PM Resident 221 was observed eating lunch in her/his room. Her/his lunch tray contained two breaded fish patties, French fries, cole slaw, tartar sauce, and a catsup packet. A review of the meal ticket that accompanied her/his lunch indicated she/he received a regular diet (not a Limit CHO diet).

On 3/20/24 at 2:10 PM Staff 19 (Assistant Dietary Manager) acknowledged Resident 221 was to receive a Limit CHO diet and her/his meal ticket was incorrect. Staff 19 acknowledged Resident 221 did not receive the meal ordered by her/his physician. He stated he expected diet orders in the kitchen's system to be correct.

On 3/25/24 at 10:59 AM Staff 1 (Administrator) stated he expected residents to receive meals aligned with the diets ordered by their physicians.

Based on interview and record review it was determined the facility failed to follow physician orders related to oxygen administration for 1 of 2 sampled residents (#269) reviewed for respiratory care. This placed residents at risk for adverse respiratory effects and difficulty breathing. Findings include:

Resident 269 admitted to the facility in 3/2024 with diagnoses including chronic respiratory failure with hypercapnia (buildup of carbon dioxide in the bloodstream).

Resident 269's 3/11/24 Physician Order indicated the resident was to receive oxygen at one to three LPM (liters per minute) to keep oxygen saturations between 88-92%.

On 3/19/24 at 9:38 AM Resident 269 stated she/he wore oxygen continuously.

On 3/19/24 at 9:38 AM and on 3/20/24 at 9:17 AM Resident 269's oxygen flow rate was observed at four LPM.

On 3/20/24 at 10:40 AM Staff 10 (RN) verified Resident 269's oxygen flow rate was set at four LPM and the physician's order was for the resident to receive one to three LPM. Staff 10 stated Resident 269's 3/20/24 morning oxygen saturation was 96%. Staff 10 verified the physician's order was to keep the resident's oxygen saturations between 88-92%.

On 3/21/24 at 9:56 AM Staff 9 (LPN Resident Care Coordinator) verified Resident 269 was ordered the continuous use of oxygen at one to three LPM and included parameters to keep the resident's oxygen saturation between 88-92%. Staff 9 stated when a resident's oxygen saturations were not within physician ordered parameters, she expected the nurse to titrate the oxygen and reassess to keep the resident's oxygen saturations within the ordered parameters.

Based on interview and record review it was determined the facility failed to thoroughly and accurately complete the Direct Care Staff Daily Report for 3 of 46 days reviewed for staffing. This placed all residents and the public at risk for lack of accurate staffing information. Findings include:

A review of the Direct Care Staff Daily Reports from 2/1/24 through 3/17/24 revealed the following dates with inaccurate forms:

-3/15/24 evening and night shift resident census data were not included;
-3/16/24 day, evening and night shift resident census data were not included;
-3/17/24 evening and night shift resident census data were not included.

On 3/22/24 at 2:40 PM Staff 12 (HR/Staffing) acknowledged resident census data were not included on the Direct Care Staff Daily Reports for 3/15/24, 3/16/24 and 3/17/24. She confirmed she expected these reports to be completed accurately.

On 3/25/24 at 11:03 AM Staff 1 (Administrator) confirmed he expected the Direct Care Staff Daily Reports to contain accurate resident census data.

Based on observation, interview and record review it was determined the facility failed to ensure resident refrigerators were free of expired and/or unlabeled foods for 2 of 2 resident refrigerators reviewed for food safety. This placed residents at risk for foodborne illness. Findings include:

On 3/20/24 at 9:14 AM the following was observed in the resident refrigerator located in the conference room:

- one container of homemade spaghetti, dated 3/8/24.
- one unlabeled six ounce yogurt, with a use by date of 3/11/24.
- one labeled "Rm 6" homemade food container with no date.
- one opened pina colada mix with a best by date of 9/23/23.
- one open paper bag with three bagels, unlabeled and undated.
- three bottles of soda labeled "Activities."
- four unlabeled and undated lunch boxes with food inside.

On 3/20/24 at 12:35 PM one 32-ounce yogurt, with a best by date of 11/23/23, was observed in the resident refrigerator located in the supply room.

On 3/21/24 at 9:22 AM Staff 27 (Housekeeping Manager) stated housekeeping staff deep cleaned the conference room refrigerator twice a month and the kitchen staff cleaned the supply room refrigerator, but the CNAs were responsible for the daily upkeep of the refrigerators.

On 3/21/24 at 1:49 PM Staff 24 (CNA) stated housekeeping staff was responsible for cleaning the refrigerators. CNAs labeled the residents' food and placed it in the refrigerator.

On 3/21/24 at 2:11 PM Staff 19 (Assistant Dietary Manager) stated the kitchen staff were responsible for the supply room refrigerator and he was unsure how the expired yogurt was missed.

On 3/21/24 at 2:22 PM Staff 1 (Administrator) stated the resident refrigerator in the conference room was cleaned by Staff 20 (Maintenance Director).

On 3/21/24 at 2:45 PM Staff 20 stated he was not responsible for cleaning any of the resident refrigerators.

On 3/22/24 at 12:07 PM Staff 1 acknowledged the findings related to inappropriate storage of food in the resident refrigerators.

Based on interview and record review it was determined the facility failed to ensure resident records were accurate regarding indication for use of medication for 1 of 5 sampled residents (#4) reviewed for unnecessary medications. This placed residents at risk for inaccurate medical records. Findings include:

Resident 4 was admitted to the facility in 10/2023 with diagnoses including right above knee amputation and obesity.

A review of Resident 4's 10/31/23 hospital admission orders included ursodiol (used to treat and prevent gallstones) without an associated diagnosis or indication for use.

A review of Resident 4's 12/8/23 physician orders indicated ursodiol was used for gastro-esophageal reflux disease without esophagitis (GERD).

A review of Resident 4's 3/21/24 physician orders indicated ursodiol was used for candidal stomatitis (oral thrush).

On 3/21/24 at 10:39 AM Resident 4 stated she/he used ursodiol for several years for gallstone prevention.

On 3/22/24 at 2:06 PM Staff 2 (DNS) acknowledged the ursodiol did not have an accurate indication for use.

Based on interview and record review it was determined the facility failed to ensure a RN worked as the charge nurse for eight consecutive hours between the start of day shift and the end of evening shift for 17 of 46 days reviewed for RN coverage. This placed residents at risk for lack of RN oversight including resident care and services. Findings include:

A review of the Direct Care Staff Daily Reports from 2/1/24 through 3/17/24 revealed there was no designated RN charge nurse on duty for eight consecutive hours between the start of day shift and the end of evening shift for the following days:

-2/1/24
-2/2/24
-2/5/24
-2/6/24
-2/9/24
-2/12/24
-2/13/24
-2/16/24
-2/19/24
-2/20/24
-2/22/24
-2/23/24
-2/27/24
-3/1/24
-3/4/24
-3/8/24
-3/15/24

On 3/22/24 at 2:18 PM Staff 12 (HR/Staffing) acknowledged the facility did not have a RN working on the days noted above and stated it was her goal to ensure a RN worked the required hours.

On 3/25/24 at 11:03 AM Staff 1 (Administrator) stated he expected the facility to be staffed with the minimum number of RNs.

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OAR 411-088-0050 Right to Return from Hospital

Refer to F625
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OAR 411-086-0060 Comprehensive Assessment and Care Plan

Refer to F 656
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OAR 411-086-0110 Nursing Services: Resident Care

Refer to F 684 and F695
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OAR 411-086-0140 Nursing Services: Problem Resolution & Preventive Care

Refer to F 689 and F692
**********
OAR 411-086-0100 Nursing Services: Staffing

Refer F 732
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OAR 411-086-0250 Dietary Services

Refer to F 812
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411-086-0300 Clinical Records

Refer to F842

Based on interview and record review it was determined the facility failed to ensure Staff 4 (LPN) adhered to professional standards related to taking emergency action, communicating, and documenting accurately regarding a resident's death for 1 of 2 sampled residents (#10) reviewed for death. This failure placed residents at risk for delayed critical care and inaccurate records. Findings include:

A review of the facility's Emergency Procedure- Cardiopulmonary Resuscitation revised 2/2018 indicated, "if a resident is found unresponsive and not breathing normally, a licensed staff member who is certified in CPR shall initiate CPR unless:
        
a. It is known that a Do Not Resuscitate (DNR) order that specifically prohibits CPR and/or exernal defibrillation exists for that individual; or
        
b. There are obvious signs of irreversible death (e.g., rigor mortis)."

The procedure also indicated, "If the resident's DNR status is unclear, CPR will be initiated until it is determined that there is a DNR or a physician's order not to administer CPR."

Resident 10 was admitted to the facility on 3/13/23 with diagnoses including end stage renal disease and atherosclerotic heart disease. Resident 10 attended dialysis three times a week.

Resident 10's 3/13/23 physicians' orders indicated Resident 10 was a full code (wished to receive full life-saving interventions, including CPR).

A review of the resident's clinical file revealed no indication that the resident did not want life-saving interventions.

A 6/7/23 at 5:48 AM progress note documented by Staff 4 (LPN) indicated, "CNA alerted nurse that pt is actively going. Nurse went in to assess. Pt pulse is unidentifiable, no respirations noted. Pt legs and arms are cold and yellow. Eyes are greyed. CNA stated last time she went in to check pt was 5:15-5:30 AM. Pt was awake. CNA changed pt brief nothing unusual noted. Family notified. Nurse asked if they had a funeral home, wife hung up phone and said she is on her way."

A second progress note by Staff 4 was written on 6/7/23 at 7:13 AM. The note indicated at 5:44 AM, "CNA alerted nurse that pt may have passed. Nurse went in to assess. Pt pulse is unidentifiable, no respirations noted. Pt legs and arms are cold and yellow. Eyes are greyed. Code blue inititated, CPR started, 911 operator guided nurse through process."

A public complaint received on 6/12/23 alleged the facility failed to initiate CPR (Cardio-pulmonary resuscitation) for the resident in a timely manner.

Interviews from 6/13/23 through 6/23/23 with Witness 4 (Resident 10's spouse), Staff 3 (CNA), Staff 8 (CNA), Witness 3 (911 Emergency Record Specialist), Staff 11 (CNA), Staff 17 (CNA) and Staff 2 (DNS) revealed Staff 4 did not initate CPR in a timely manner after Resident 10 was found unresponsive, not breathing, and without pulse. It was reported that Staff 4 did not initiate CPR until Witness 4 arrived at the facility and asked why CPR was not implemented.

During multiple interviews from 6/13/23 through 6/23/23 Staff 4 repeatedly indicated that she did initiate CPR immediately upon finding Resident 10 unresponsive and without breath or pulse. Staff 4 was asked about the discrepancies between her account of the events and the witnesses accounts and was unable to provide a reason for why the accounts differed.

In a written statement received on 6/23/23 at 12:30 PM Staff 4 stated on 6/7/23 at around 5:40 AM she was informed by another staff member that Resident 10 may have passed. Staff 4 stated she went to the room and the resident looked like she/he "had been gone for a while." The resident was cold, with no pulse, no respirations, eyes grayed over, open mouth, and grayish/yellow skin tones. Staff 4 stated she knew the resident passed away. Staff 4 went to her computer, called Witness 4 to let her know the resident had passed and Witness 4 started crying and stated she was on her way. Staff 4 called the doctor and then entered a progress note in the resident's chart [the 5:48 AM progress note]. Staff 4 stated at approximately 6:00 AM, shift change occurred and Staff 8 was on duty. The resident's spouse came shortly after and went into the room. The spouse was in the room for about two minutes and then asked if Staff 4 started CPR. Staff 4 stated she did not say anything. Staff 4 stated she thought, "Is she right"? Staff 4 stated she was under the impression Resident 10 had orders for DNR (Do Not Resuscitate). Staff 4 checked the computer at approximately 6:10 AM and saw that the resident was Full Code status. Staff 4 asked Staff 8 to get help from the front, said it was an emergency, and went to Resident 10's room. Staff 4 then called 911 from her cell phone and began CPR (more than 30 minutes after the resident was found unresponsive and not breathing).

During interviews with Staff 2 from 6/13/23 through 6/23/23, Staff 2 identified Staff 4 did not provide life-saving interventions to Resident 10 in a timely manner and there were discrepancies between what Staff 4 reported and documented about the incident, and what the other witnesses reported.

Refer to F687.

Based on interview and record review it was determined the facility failed to provide cardiopulmonary resuscitation (CPR) when needed for 1 of 2 sampled residents (#10) reviewed for death. This failure was determined to be an immediate jeopardy situation. Resident 10 wished to receive CPR in the event her/his heart stopped. Resident 10 was found without a pulse and CPR was not initiated timely. Resident 10 died. Findings include:

A review of the facility's Emergency Procedure- Cardiopulmonary Resuscitation revised 2/2018 indicated, "if a resident is found unresponsive and not breathing normally, a licensed staff member who is certified in CPR shall initiate CPR unless:
        
a. It is known that a Do Not Resuscitate (DNR) order that specifically prohibits CPR and/or exernal defibrillation exists for that individual; or
        
b. There are obvious signs of irreversible death (e.g., rigor mortis)."

The procedure also indicated, "If the resident's DNR status is unclear, CPR will be initiated until it is determined that there is a DNR or a physician's order not to administer CPR."

Resident 10 was admitted to the facility on 3/13/23 with diagnoses including end stage renal disease and atherosclerotic heart disease.

Resident 10's 3/13/23 physicians' orders indicated Resident 10 was a full code (wished to receive full life-saving interventions, including CPR).

A review of the resident's clinical file revealed no indication that the resident did not want life-saving interventions.

Resident 10's 3/17/23 Admission MDS indicated the resident was cognitively intact and could make her/his needs known.

The 3/28/23 care plan for Resident 10 indicated extensive assistance was needed for bed mobility and transferring.

A discharge summary written by Staff 4 (LPN) on 6/7/23 indicated Resident 10's time of death was 5:44 AM.

A 6/7/23 at 5:48 AM progress note documented by Staff 4 (LPN) at 5:51 AM indicated, "CNA alerted nurse that pt is actively going. Nurse went in to assess. Pt pulse is unidentifiable, no respirations noted. Pt legs and arms are cold and yellow. Eyes are greyed. CNA stated last time she went in to check pt was 5:15-5:30 AM. Pt was awake. CNA changed pt brief nothing unusual noted. Family notified. Nurse asked if they had a funeral home, wife hung up phone and said she is on her way." The note did not indicate CPR was performed.

A second progress note by Staff 4 was written on 6/7/23 at 7:13 AM. The note indicated at 5:44 AM, "CNA alerted nurse that pt may have passed. Nurse went in to assess. Pt pulse is unidentifiable, no respirations noted. Pt legs and arms are cold and yellow. Eyes are greyed. Code blue inititated, CPR started, 911 operator guided nurse through process."

A public complaint received on 6/12/23 alleged the facility failed to initiate CPR (Cardio-pulmonary resuscitation) for the resident in a timely manner.

A review of Staff 4's phone records on 6/13/23 revealed she called 911 on 6/7/23 at 6:15 AM.

In an interview on 6/13/23 at 2:39 PM Witness 4 stated she received a call at 5:46 AM on 6/7/23, stating Resident 10 passed away. Witness 4 called family members and then drove nine minutes to the facility. When Witness 4 arrived she went to the nurses station and asked Staff 4 what happened. Witness 4 went to the resident's room and shook her/him. Witness 4 stated Resident 10's body was still warm at that time. Witness 4 rushed back to the nurses station and asked Staff 4 why they did not perform CPR. Staff 4 jumped up from her seat, grabbed the phone, rushed to the room and kept saying, "Oh my God, oh my God." Witness 4 stated other staff came in with machines and started CPR. Soon afterwards the paramedics arrived and continued CPR.

On 6/13/23 at 4:04 PM Staff 3 (CNA) stated she and Staff 11 (CNA) assisted Resident 10 on 6/7/23 at 5:00 AM with repositioning in bed and a brief change. Staff 3 stated Resident 10 was awake when they assisted her/him. Staff 3 stated around 5:30 AM she checked on Resident 10 again and the resident was not breathing. Staff 3 immediately told Staff 4 who assessed the resident. Staff 3 stated after the assessment she overheard Staff 4 call Resident 10's spouse. Staff 3 stated CPR was not initiated. Staff 3 stated she gave report to the oncoming staff, saw Resident 10's spouse arrive, and left for the day. Staff 3 stated if Staff 4 had started CPR, she would have assisted. Staff 3 stated she assumed Resident 10 did not want CPR because Staff 4 did not call for a Code Blue (Medical Emergency).

During interviews on 6/13/23 and 6/22/23, Staff 8 (CNA) stated he worked day shift on 6/7/23 and clocked in at 6:01-6:02 AM. Staff 8 stated he received report from Staff 3 that Resident 10 passed away. Staff 8 asked if post mortem care was done and Staff 3 stated no. Staff 8 walked over to the foyer next to the nurses station, tied his shoes and wrapped his sprained ankle, when he heard Resident 10's spouse ask Staff 4, who was sitting at the nurses station, if CPR was done for Resident 10. Staff 4 and Witness 4 went to Resident 10's room. Staff 8 stated he walked towards the room and Staff 4 yelled for him to grab the crash cart (equipment for life-saving interventions). Staff 8 stated he arrived with the crash cart and Staff 4 asked him to do chest compressions on Resident 10. Staff 8 stated Witness 4 was in the room the entire time. Staff 8 stated the Emergency Medical Technicians (EMTs) were there a few minutes after Witness 4 arrived.

On 6/13/23 at 4:17 PM and at 6:44 PM Staff 4 (LPN) stated Staff 3 (CNA) grabbed her right before Staff 3 was off work before 6:00 AM and requested she go in and check Resident 10 as she/he did not look well. Staff 4 stated she found the resident had no pulse, was not breathing, and had cold legs. Staff 4 stated she called a Code Blue and told Staff 8 to get the nurse from the front. Staff 4 stated she started chest compressions and called 911. Staff 4 stated Resident 10 was a Full Code and she checked the resident's code status and started CPR right away.

On 6/14/23 at 1:43 PM Witness 3 (911 Emergency Record Specialist) stated CPR was initiated by the facility at 6:15 AM. EMTs were dispatched at 6:16 AM and arrived at the facility at 6:20 AM. Facility staff were performing CPR when EMTs arrived.

On 6/15/23 at 8:18 AM Staff 11 (CNA) stated she assisted Staff 3 with Resident 10 after 5:00 AM with repositioning in bed and a brief change and stated Resident 10 was her/his usual self. Staff 11 then assisted Staff 3 with Resident 10's roommate with repositioning and a brief change. Staff 11 then left the room to finish her rounds. Staff 11 stated about 15 minutes later she overheard Staff 3 inform Staff 4 that Resident 10 did not seem okay. Staff 11 stated she accompanied Staff 4 and Staff 3 to Resident 10's room. Staff 11 stated Staff 4 was checking Resident 10 for a pulse and vital signs and was there for a few minutes. Staff 11 left the room for a moment to continue her work and then went back to Resident 10's room and Staff 3 informed her the resident had passed. Staff 11 stated she saw Staff 4 make phone calls at the nurses station. Staff 11 stated she worked with Staff 3 to prepare the body for viewing by the family. Staff 11 stated she gave report to the next shift at 6:05 AM and saw Witness 4 enter the facility and rush to Resident 10's room.

On 6/15/23 at 11:51 AM Staff 2 (DNS) stated she spoke with Staff 4 and confirmed Staff 4 did not verify Resident 10's code status in the chart and did not initiate CPR in a timely manner. Staff 2 stated Staff 4 should have initiated CPR immediately after verifying Resident 10's code status.

On 6/23/23 at 10:04 AM Staff 17 (CNA) stated she clocked in for her shift on 6/7/23 at 5:45 AM and was informed Resident 10 had passed. Staff 17 stated it was quiet when she entered the facility and Staff 4 was sitting at the desk. Staff 17 stated after she received report and started her tasks around 6:15 AM she saw staff running down the hallway towards Resident 10's room.

During a third interview with Staff 4 on 6/23/23 at 10:31 AM Staff 4 was asked about the discrepancies between her account of this incident and what was reported by witnesses. Staff 4 stated Staff 3 informed her about Resident 10 not looking well around 6:00 AM. Staff 4 stated she checked Resident 10's code status, assessed the resident and initiated CPR by herself, without any help, for 20-30 minutes. Staff 4 stated she did not call out a Code Blue or yell for assistance or for another staff to call 911 due to concerns about the need for protected private health information. Staff 4 stated no other staff were in the room with her while she performed CPR. When Staff 4 was asked if there was a chance she could be recalling the events incorrectly, Staff 4 stated no. Staff 4 stated she did not call 911 until 20-30 minutes later because she was too busy with doing CPR by herself.

On 6/23/23 at 12:21 PM the facility was notified that the failure to initiate CPR for a resident found with no heartbeat and no respirations, and who was a Full Code status, was determined to be an Immediate Jeopardy situation.

In a written statement received on 6/23/23 at 12:30 PM Staff 4 stated on 6/7/23 at around 5:40 AM she was informed by another staff member that Resident 10 may have passed. Staff 4 stated she went to the room and the resident looked like she/he "had been gone for a while." The resident was cold, with no pulse, no respirations, eyes grayed over, open mouth, and grayish/yellow skin tones. Staff 4 stated she knew the resident passed away. Staff 4 went to her computer, called Witness 4 to let her know the resident had passed and Witness 4 started crying and stated she was on her way. Staff 4 called the doctor and then entered a progress note in the resident's chart (the 5:48 AM progress note). Staff 4 stated at approximately 6:00 AM, shift change occurred and Staff 8 was on duty. The resident's spouse came shortly after and went into the room. The spouse was in the room for about two minutes and then asked if Staff 4 started CPR. Staff 4 stated she did not say anything. Staff 4 stated she thought, "Is she right"? Staff 4 stated she was under the impression Resident 10 had orders for DNR (Do Not Resuscitate). Staff 4 checked the computer at approximately 6:10 AM and saw that the resident was Full Code status. Staff 4 asked Staff 8 to get help from the front, said it was an emergency, and went to Resident 10's room. Staff 4 then called 911 from her cell phone and began CPR (more than 30 minutes after the resident was found unresponsive and not breathing).

An acceptable plan to abate the immediate jeopardy situation was submitted by the facility on 6/23/23 at 1:11 PM. The plan indicated:

1. Staff 4 was immediately suspended pending investigation on 6/23/23.
2. House audit completed 6/23/23 for resident code status, finding current code status of all residents accurate and reflected appropriately in EMAR (electronic health record) and CPR binders on North and South Units.
3. All nursing staff presently in building (Nursing/CNA) will be trained on the following topics. Any nursing staff not presently in the building will receive training prior to the start of their next shift. For nursing staff not presently in the building or on shift currently, this training will be conducted in person as availability allows, or completed on the phone if the staff member is unable to come to the facility in the next 24 hours. This training will be completed within the next 24 hours (6/24/23). The training will be on the following topics:
        
a. CPR/Code Blue Procedure and Initiation from the role perspective of Nurse or CNA.
        
b. Code Status Location (CNA: Point of Care, Nurse: EMAR System, Both: CPR Binders)
        
c. AED and Crash Cart Locations.
        
d. Utilization of Code Blue/CPR log implemented to improve note taking, timelining, and debriefing after a code occurs.
4. Staff 4 specifically was in-serviced on the above content on 6/13/23 and successfully completed and participated in a mock code drill on 6/14/23.

The immediacy was removed on 6/23/23 at 5:14 PM after verification of completion of the abatement plan.

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OAR 411-086-0110 Nursing Services: Resident Care

Refer to F658
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OAR 411-086-0120 Nursing Services: Change of Condition

Refer to F678
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Based on interview and record review it was determined the facility failed to ensure resident pain was managed for 1 of 3 sampled residents (#376) reviewed for pain management. This placed residents at risk for unmanaged pain. Finding include:

Resident 376 was admitted to the facility in January 2023 with diagnoses including right lower leg and ankle fracture with surgical repair.

A physician's order dated 1/5/23 indicated Resident 376 was to be administered cyclobenzaprine (muscle relaxant) three times a day for muscle spasms.

Resident 376's 1/2023 MAR revealed cyclobenzaprine was ordered to be administered three times a day for muscle spasms at 7-10 AM, 4-6 PM and 7-10 PM.

A physician's progress note dated 1/9/23 at 3:22 PM indicated Resident 376 requested an adjustment to the timing of her/his cyclobenzaprine. The progress note did not specify what change was requested or why.

On 1/9/23 at 3:02 PM a physician's order was received to change the administration times of the cyclobenzaprine to 6:00 AM, 2:00 PM and 10:00 PM daily.

On 1/9/23 Resident 376 received the morning dose of cyclobenzaprine but did not receive the other two doses for the day.

Resident 376's 1/2023 TAR indicated the following pain ratings on a 1-10 pain scale:
- 1/8/23 pain rated a six on day shift and a two on NOC shift.
- 1/9/23 pain rated a four on day shift and a two on NOC shift.
- 1/10/23 pain rated a zero on day shift and a two on NOC shift.

Resident 376's physical and occupational therapy notes dated 1/9/23 and 1/10/23 indicated she/he participated in therapy and rated her/his pain as a two to a five on a 1-10 scale.

On 1/12/23 at 8:32 AM Resident 376 stated the spasms made her/his pain worse and not receiving the two missed doses on 1/9/23 increased her/his pain level to a 9 or 10 on a 1 to 10 scale.

On 1/13/23 at 9:48 AM Staff 2 (DNS) acknowledged Resident 376 did not receive two doses of cyclobenzaprine on 1/9/23 as ordered.

On 1/13/23 at 9:59 AM Staff 11 (Nurse Practitioner) stated her intention was for the cyclobenzaprine medication administration times to be changed and for the resident to receive the cyclobenzaprine dose three times a day including on 1/9/23.

Based on observation, interview and record review it was determined the facility failed to ensure a medication error rate of less than 5%. There were 13 errors in 33 opportunities resulting in a 39% error rate. This placed residents at risk for reduced medication efficacy and adverse medication side effects. Findings include:

Resident 37 admitted to the facility in 2020 with diagnoses including malnutrition and quadriplegia.

The 12/10/22 physician order indicated Resident 37 was to receive the following medications via G-tube (a tube that delivers food and medications directly to the stomach).
-Losartan Potassium 25 mg
-Acetaminophen 650 mg
-Norvasc 5 mg
-ascorbic acid 1000 mg
-aspirin 81 mg
-calcium citrate (200 ca) 950 mg
-carvedilol 12.5 mg
-cholecalciferol 2000 units
-famotidine 20 mg
-glycopyrrolate 1 mg
-polyethylene glycol 3350 17 gm powder
-Senna 8.6 mg two tabs
-simethicone 160 mg

The physician order did not include directions to crush, dissolve and administer the medications all together.

On 1/10/23 at 8:30 AM Staff 8 (LPN) was observed to crush the identified medications together, combine them with water and administer them to Resident 37 via G-tube. Staff 8 acknowledged the physician order did not indicate to crush and combine the medications together.

On 1/10/23 at 9:28 AM Staff 2 (DNS) stated the expecatation was for nurses to give each medication separately when administering them via G-tube. Staff 2 acknowledged Staff 8 combined the identified medications and administered them to Resident 37.

Based on interview and record review it was determined the facility failed to ensure labs were available in the medical record and medical records were accurate for 2 of 6 sampled residents (#s 2 and 39) reviewed for medication and ADL care. This placed residents at risk for inaccurate medical records and uninformed staff. Findings include:

1. Resident 2 admitted to the facility in 2011 with diagnoses including multiple sclerosis.

Resident 2's electronic health record included a 12/1/22 physician progress note for Resident 57.

On 1/13/23 at 10:41 AM Staff 2 (DNS) reviewed Resident 2's electronic health record. Staff 2 acknowledged a physician assessment for Resident 57 was located in Resident 2's electronic health record and was in the wrong resident's chart.

2. Resident 39 was admitted to the facility in 2021 with diagnoses including stroke and hypertension.

The 11/16/22 physician progress note indicated to collect labs on 12/1/22 including a CBC (complete blood count) and liver panel.

On 1/13/23 Resident 39's clinical record was reviewed and did not include the identified labs.

On 1/13/23 at 9:39 AM Staff 2 (DNS) stated the labs were completed on 12/1/22 and were not located in Resident 39's clinical record.

Based on interview and record review it was determined the facility failed to ensure completion of reference checks were documented for 5 of 5 newly hired facility staff (#s 4, 5, 6, 7 and 8). This placed residents at risk for abuse. Findings include:

Review of the facility's new hires from 10/5/22 through 1/2/23 revealed the following:

1. Staff 4 (CNA) hired 10/5/22.
2. Staff 5 (CNA) hired 1/2/23.
3. Staff 6 (CNA) hired 10/31/22.
4. Staff 7 (RN) hired 11/9/22.
5. Staff 8 (LPN) hired 12/7/22.

Review of employment documentation provided by the facility on 1/11/23 indicated "no references entered" for the staff identified.

On 1/11/23 at 9:00 AM Staff 1 (Administrator) and Staff 3 (Staff Coordinator/Human Resources) confirmed the identified new hires did not have references documented and could not provide evidence reference checks were completed.

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OAR 411-086-0110 Nursing Services: Resident Care

Refer to F759 and F697
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OAR 411-086-0300 Clinical Records

Refer to F842
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Based on interview and record review it was determined the facility failed to ensure an allegation of neglect was thoroughly investigated for 1 of 3 sampled residents (#16) reviewed for accidents. This placed residents at risk for aspiration due to neglect of care. Findings include:

The facility's undated Supervision Guidelines for Aspiration Precautions indicated for Close Supervision one caregiver was to be present for every four individuals requiring close supervision. The caregiver must sit with individuals. If the caregiver had to leave, they were expected to remove all food/beverages from the resident's reach.

Resident 16 admitted to the facility in 2018 with diagnoses including dementia, dysphagia (difficulty swallowing), and schizophrenia. The resident had a history of aspiration at the facility and was hospitalized for aspiration related concerns in 1/2019.

Progress Notes from 1/7/20 through 7/21/20 indicated Resident 16 would reach out to other people's food items and sought more regular textured food items outside of her/his diet texture.

A 5/5/21 Speech Evaluation indicated Resident 16 required a mechanical soft diet texture (minced and moist), thin liquids, upright posture, slow rate, and small bites/sips with close supervision.

The 12/9/21 Quarterly MDS indicated Resident 16 had a severe cognitive impairment and utilized a wheelchair for mobility.

A 2/16/22 Investigation indicated Resident 16 ate her/his meals at the nurse's station called the "Living Room." The resident was care planned to have close supervision, which meant staff were to sit near the resident while dining and not to leave the food tray and the resident unattended. The investigation indicated at 5:20 PM Staff 23 (CNA) served Resident 16 her/his tray, but the resident refused stating "just milk." Staff 23 stated she removed the tray from the resident and left the resident with the milk, which the resident was allowed to have unattended. Staff 23 stated she remained in the area and was able to "keep an eye on" the resident. The only other resident in the area was Resident 24 whose tray had not been served. At approximately 5:30 PM Staff 23 and Staff 22 (CNA) observed Resident 16 abnormally rocking back and forth in her/his wheelchair. Staff 24 (LPN) arrived on the scene at 5:30 PM and observed milk coming out of the resident's mouth, began the Heimlich maneuver, and told Staff 11 (CNA) to notify another nurse. When Staff 4 (RNCM) arrived to the room, 911 was already called and instructing Staff 24. At approximately 5:43 PM, the resident began to turn blue, so chest compressions were initiated, and an AED (automated external defibrillator, used for cardiac arrest) was placed on the resident but advised "no shock." The paramedics took over at approximately 5:43 PM. Resident 24 stated to the paramedics she/he observed Resident 16 take a roll that was on a plate and Resident 16 "ate the whole roll in one bite" and then began to drink her/his milk. Staff 24 stated the paramedics removed food with forceps from Resident 16's throat that appeared brown in color and the paramedics stated, "could be bread." The resident departed with the paramedics at approximately 5:49 PM. Observations of Resident 16's meal tray revealed the diet texture was appropriate with no bread present. All staff present denied the resident's tray having bread or observed another resident give the resident bread. Staff 23 stated she was in "supervision range" of the resident from the moment the meal was refused and removed up to the point she believed the resident began choking. A follow up interview conducted with Resident 24 on 2/18/21 indicated the resident stated she/he did not know if the plate the roll was on was Resident 16's.

The investigation did not include the following:
*Who was assigned to the resident.
*Witness statements from other residents to determine if they saw or provided Resident 16 with food.
*A detailed interview with Resident 24.
*If the tray was removed out of reach from the resident and where it was located at the time the resident began choking.
*The time frames and exact whereabouts of the CNA staff working during the dinner meal.
*How Resident 16 was able to obtain/ingest a food item when staff stated they were supervising the resident.

On 8/17/22 at 10:22 AM Staff 1 (Administrator) and Staff 2 (DNS) acknowledged the identified concerns with the investigation and stated they were unable to determine how the resident obtained a food item, aspirated, and died.

Refer to F689.

Based on interview and record review it was determined the facilty failed to administer medications as ordered for 1 of 3 sampled residents (#11) reviewed for medications. This placed residents at risk for increased pain and cholesterol levels. Findings include:

Resident 11 admitted to the facility on 10/28/22 with diagnoses including polyneuropathy (a group of diseases in which several peripheral nerves are damaged).

The 10/28/21 Admission Orders included orders for gabapentin 600 mg bid for chronic pain and simvastatin 20 mg daily at bedtime for cholesterol.

Review of the October 2021 MARs revealed the gabapentin and simvastatin were not administered on 10/28/21 as ordered.

On 8/16/22 at 8:30 AM Staff 2 (DNS) acknowledged the gabapentin and simvastatin were not administered as ordered.

Based on interview and record review it was determined the facility failed to ensure the resident did not aspirate on food for 1 of 3 sampled residents (#16) reviewed for accidents. This failure resulted in Resident 16 aspirating on food, which resulted in the resident's death. This placed other residents at risk for aspiration. Findings include:

The facility's undated Supervision Guidelines for Aspiration Precautions indicated for Close Supervision one caregiver was to be present for every four individuals requiring close supervision. The caregiver must be sitting with individuals. If the caregiver had to leave, all food/beverages were to be removed from the resident's reach.

Resident 16 admitted to the facility in 2018 with diagnoses including dementia, dysphagia (difficulty swallowing), and schizophrenia.

A 1/6/19 Investigation indicated Resident 16 choked on food while being supervised eating the appropriate pureed diet texture. Facility staff performed the Heimlich and a finger sweep and were able to remove the dislodged food. The resident was sent to the hospital.

Progress Notes from 1/7/20 through 7/21/20 indicated Resident 16 would reach out to other people's food items and sought more regular textured food items outside of her/his diet texture.

A 4/27/21 Diet Order indicated the resident had a regular diet with a minced and moist texture and thin liquids.

The 4/22/21 through 5/5/21 Speech Therapy Notes indicated Resident 16 required a mechanical soft diet texture (minced and moist), thin liquids, upright posture, slow rate, and small bites/sips with close supervision.

The 12/9/21 Quarterly MDS indicated Resident 16 had a severe cognitive impairment.

The 11/22/21 Care Plan indicated Resident 16 was non-verbal most of the time, had an inability to understand situations, and was at risk for injury due to cognitive loss and minimal understanding. The resident was able to maneuver her/his wheelchair independently but at times required one-person assistance. The resident had impaired swallowing, a history of choking, "eats too fast", and aspiration precautions. Aspiration precautions included:
*Diet per MD order.
*Feeding assistance required.
*Location: South Hall living room for all meals.
*Strategies: small sips/bites, eat/drink slowly.
*Close supervision: Staff member to sit near resident while dining for potential cueing or assistance. Do not leave food tray and resident unattended. 1:1 supervision if dining in room.
*Diet as ordered- if the resident has a decline in swallow/or chewing ability, downgrade diet until therapy/swallow evaluation.
*If choking occurs, ensure safety, evaluate the resident, notify the MD, downgrade diet if needed, refer to speech or RD and place on alert.

A 2/16/22 Investigation indicated Resident 16 ate her/his meals at the nurse station area called the "Living Room." The resident was care planned to have close supervision, which meant staff were to sit near the resident while dining and not to leave the food tray and resident unattended. The investigation indicated at 5:20 PM Staff 23 (CNA) served Resident 16 her/his tray, but the resident refused stating "just milk." Staff 23 stated she removed the tray from the resident and left the resident with the milk, which the resident was allowed to have unattended. Staff 23 stated she remained in the area and was able to "keep an eye on the resident." The only other resident in the area was Resident 24 whose tray had not been served. At approximately 5:30 PM Staff 23 and Staff 22 (CNA) observed Resident 16 abnormally rocking back and forth in her/his wheelchair. Staff 24 (LPN) arrived on the scene at 5:30 PM and observed milk coming out of the resident's mouth, began the Heimlich maneuver, and told Staff 11 (CNA) to notify another nurse. When Staff 4 (RNCM) arrived at the room, 911 was already called and instructing Staff 24. At approximately 5:43 PM, the resident began to turn blue, so chest compressions were initiated, and an AED (automated external defibrillator, used for cardiac arrest) was placed on the resident but advised "no shock." The paramedics took over at approximately 5:43 PM. Resident 24 stated to the paramedics she/he observed Resident 16 take a roll that was on a plate and Resident 16 "ate the whole roll in one bite" and then began to drink her/his milk. Staff 24 stated the paramedics removed food with forceps from Resident 16's throat that appeared brown in color and the paramedics stated, "could be bread." The resident departed with the paramedics at approximately 5:49 PM. Observations of Resident 16's meal tray revealed the diet texture was appropriate with no bread present. All staff present denied the resident's tray having bread or observing another resident give the resident bread. Staff 23 stated she was in "supervision range" of the resident from the moment the meal was refused and removed up to the point she believed the resident began choking. A follow up interview conducted with Resident 24 on 2/18/21 indicated the resident stated she/he did not know if the plate the roll was on was Resident 16's.

The 2/16/22 Dinner Menu indicated mashed potatoes and a bread roll were served.

Hospital records indicated Resident 16 "somehow got ahold of a dinner roll and choked on it." On 2/18/22 Resident 16 died. The cause of death was listed as:
A.      
Anoxic (lack of oxygen) brain injury
B.      
Due to (or as a consequence of) Acute hypoxemic (low oxygen level) respiratory failure
C.      
Due to (or as a consequence of) Aspiration of food.

Staff interviews conducted from 8/9/22 through 8/17/22 indicated the following:
*On 8/9/22 at 2:09 PM and 8/10/22 at 11:43 AM Staff 24 (LPN) stated during the dinner meal on 2/16/22 she was doing blood sugars and was alerted Resident 16 was choking by Resident 24 who yelled "hey, [she/he] is choking" and Staff 11 (CNA) who came and got Staff 24. Staff 24 stated she recalled when she arrived at the living room area there were no staff present with the resident. Staff 24 stated Resident 24 was alert and oriented and stated Resident 16 had "grabbed some bread." Staff 24 stated she "could have sworn" there was a tray nearby when she entered the room but could not be sure. Staff 24 further stated Resident 16 had a history of choking, taking other resident's food, and was "very mobile" and had to be watched as the resident was "compulsively quick."

*On 8/9/22 at 2:38 PM and 8/15/22 at 11:07 AM Staff 23 (CNA) stated on 2/16/22 she was passing trays and the resident was assigned to Staff 11 (CNA). There was a resident that was in the living room with Resident 16 who she could not recall. Staff 23 offered the resident her/his dinner but the resident did not want her/his meal, so Staff 23 took the tray away and put it in the meal cart. Resident 16 then left the dining room by the nurse's station but later returned. Staff 23 denied seeing the resident eat anything and was unable to recall when the resident started choking. Staff 23 was unsure if anyone was around when she found Resident 16 choking. Staff 23 stated the tray did not come out of the cart until "the nurse" took a picture of the tray after the resident choked. Staff 23 denied providing Resident 16 with milk and was unsure who provided the resident's milk and denied that the tray was in the room with the resident. Staff 23 stated Resident 16 "touches things" but staff would watch the resident.

*On 8/10/22 at 9:08 AM Staff 18 (Speech Therapy) stated Resident 16 could have liquids unsupervised, but the expectation was there should "never not be eyes" on the resident if any food, including other residents' trays were near the resident. Resident 16 was not to be alone with her/his food tray in reach.

*On 8/10/22 at 10:01 AM Staff 10 (CNA) stated Resident 16 would "constantly" try to take other resident's food and was "pretty mobile" and if she/he wanted something the resident could retrieve it her/himself. Staff 10 stated staff had to "keep an eye on" the resident and all staff were aware the resident attempted to take food from other residents.

*On 8/11/22 Staff 11 (CNA) stated prior to the incident on 2/16/22 she observed Resident 16 in the hallway with other residents. Staff 11 stated she went to help another resident and while she was passing the nurse's station with coffee, Staff 22 and Staff 23 were standing by the resident, calling out the resident's name. Staff 11 stated she was told to get the nurse as they thought the resident was choking. Staff 11 stated she grabbed Staff 4 (RNCM) and when they came back, 911 had been called. Staff 11 stated when the paramedics arrived, they pulled "something brown" out of Resident 16's throat. Staff 11 stated Resident 24 reported Resident 16 ate bread but Resident 16 was not allowed to have bread. Staff 11 stated Resident 24 was alert and was able to tell staff "what is going on." Staff 11 stated another CNA delivered the resident her/his meal and she was unsure if the resident was supervised but was "supposed to be" as the resident was on aspiration precautions and staff were not to leave the tray in the room with the resident. Staff 11 stated Resident 16 was, "very mobile in wheelchair" and everyone "keeps an eye out" to make sure the resident did not wander where she/he was "not supposed to go."

*On 8/15/22 at 10:07 AM Staff 22 (CNA) stated she was not assigned to Resident 16, Staff 11 was. Staff 22 stated she was working the other side of the hall passing trays and did not observe the resident choking. On the evening of 2/16/22, she saw Resident 16 sitting in her/his wheelchair in front of the nurse's station and believed two other residents were nearby. Staff 22 did not recall seeing any residents with food. Staff 22 stated when the resident was choking there were people around and Staff 23 was yelling "Oh my gosh. Help me, help me" and that is when Staff 22 went to help with Resident 16.

*On 8/10/22 at 12:26 PM Staff 4 (RNCM) and Staff 2 (DNS) stated when Staff 11 (CNA) retrieved Staff 4 and they went to Resident 16, there was a group of people there and Staff 4 called "the code." Resident 24 stated Resident 16 had gotten a roll, but all staff including kitchen staff said there was no roll present on Resident 16's tray. Staff 2 stated the only plate in the living room with Resident 16 was Resident 16's, but it was not in front of the resident. Staff 2 stated the diet was appropriate and the lid was on but did appear there was "possibly" a bite taken out of the mashed potatoes. Staff 2 stated Staff 23 denied the resident taking a bite and the lid was on the plate. Staff 2 stated the expectation for Resident 16 was for staff to stay with the resident until the meal was complete and staff were expected to stay with the resident if the tray was in the room. Staff 2 stated the tray was on a side table across the living room but stated CNA staff were present while the tray was in the room. Staff 2 stated Resident 16 was mobile and could have accessed the tray but the tray was not in front of the resident and was the appropriate diet. Staff 2 stated she observed what was removed from Resident 16's throat and it appeared the same color as mashed potatoes, cauliflower, or potentially bread.

*On 8/17/22 at 10:22 AM Staff 1 (Administrator) and Staff 2 were interviewed. Staff 2 stated Resident 24 was asleep the whole day on 2/17/22, was unable to be interviewed until 2/18/22, and did not recall the event. Staff 2 confirmed Resident 16's tray was not on the meal cart but was in the room with the resident approximately 10 feet away. When the resident refused the meal staff put it on the side table. Staff 2 confirmed the resident was able to utilize her/his wheelchair independently. Staff 1 and Staff 2 confirmed they were unable to determine how Resident 16 obtained food and aspirated. Staff 2 confirmed the facility could not rule out the possibility the resident obtained bread or a bread roll resulting in aspiration and subsequent death.

The facility completed the following by 2/16/22 to ensure no further aspiration occurred:
-Once Resident 16 was sent to the emergency department, an investigation was conducted;
-Education was provided to nursing, kitchen, housekeeping, and administrative staff regarding policies and procedures related to aspiration precautions, meal accuracy, care plans, dysphagia diets, and diet textures;
-Audits of meal trays for residents with altered diet textures/altered supervision levels and aspiration precautions were conducted daily for all meals for four weeks, then three days a week for all meals for four weeks, then one time a week for all meals for four weeks, and then monthly.

Based on interview and record review it was determined the facility failed to ensure the RNCM had the required training within nine months of hire into the RNCM position for 1 of 1 RNCM's (Staff 4) reviewed for RNCM training. This placed residents at risk for a RNCM with lack of long term care and supervisory training. Findings include:

Evidence of Staff 4's required training within nine months of hire into the RNCM position was requested from Staff 1 (Administrator) and Staff 2 (DNS). No documentation of the required training was provided.

On 8/16/22 at 8:40 AM Staff 2 verified Staff 4 had completed none of the required training for the RNCM position.

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OAR 411-085-0360 Abuse

Refer to F610
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OAR 411-086-0110 Nursing Services: Resident Care

Refer to F684
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OAR 411-086-0140 Nursing Services: Problem Resolution & Preventive Care

Refer to F689
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