Print Inspection: RL012621

OAR 411-054-0025 (4) Reasonable Precautions (4) Reasonable precautions must be exercised against any condition that could threaten the health, safety, or welfare of residents. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to exercise reasonable precautions against any condition that could threaten the health, safety, or welfare of residents for 1 of 1 sampled resident (#1) who was prescribed a modified diet texture. Resident 1’s prescribed diet was not administered by the facility, placing him/her at risk of aspiration, choking, and/or death. Findings include, but are not limited to: Resident 1 moved into the facility in 09/2022 with diagnoses including dysphagia (difficulty swallowing) and age-related physical disability. In the acuity interview on 06/22/26, staff reported the resident was bedbound, receiving hospice services, and was prescribed a puree modified diet texture and thickened liquids. Staff further reported the resident refused the puree modified diet texture. The resident’s 03/23/36 to 6/22/26 clinical record was reviewed, and the following was identified: The resident had signed prescriber orders, dated 03/03/26, for a “pureed diet” texture and “nectar to honey consistency” liquids. The resident’s 06/02/26 service plan indicated the resident was on an “easy chew” diet, and “[Resident 1] does cough a lot when [s/he] eats and drinks. [Resident 1] knows [his/her] doctor wants [him/her] on special diet for this but [the resident] refuses this diet. [Resident 1] states [s/he] will choose softer options on [his/her] own.” Observations of Resident 1 at 1:11 pm on 06/22/26 showed the following: The resident was lying in a hospital bed at approximately a 30-degree angle. The resident was observed to be edentulous (no teeth). There was a whole piece of cake in a to-go cup and a beverage in a cup with a lid and straw on the bedside tray table to his/her right. On the bed by his/her legs was a to-go container of a hard-boiled egg and an unidentifiable food with what appeared to be sliced bits of sausage in it. The resident was leaning to his/her right, and his/her right hand was covered with bedsheets. S/he was using his/her left hand to attempt to feed him/herself. Resident 1 took a piece of the egg and appeared to swallow it whole. S/he was observed to cough immediately. Resident 1 then took a drink of the beverage via straw and coughed again. The resident attempted to self-feed a piece of cake using a spoon to tear a piece off, but it fell in his/her lap. S/he threw the cake into the garbage can by his/her bedside. An interview was attempted with the resident; however s/he did not appear to understand this surveyor’s questions. S/he did nod when asked if s/he was finished with lunch. In an interview at 1:22 pm on 06/22/26, Staff 7 (MT) stated the resident “is so picky with [his/her] food, I’m not sure what diet [s/he] is on right now.” She stated the resident had not had thickened liquids “for a long time. [S/he] won’t drink them.” S/he also stated the resident refused to sit up in bed “a lot.” In an interview at 3:02 pm on 06/22/26, Staff 8 (Cook) stated “we were doing the puree [diet texture] and sometimes thickened liquids” but she stated the resident would refuse. She stated the resident would self-select “soft foods,” but also often ate what his/her family provided for snacks. She did not know of any of the resident’s favorite foods. When asked what she was providing Resident 1 for dinner that evening, Staff 8 stated she had some “vegetable and rice soup that’s soft that she can eat.” According to the International Dysphagia Diet Standardization Initiative (IDDSI), mixed consistency soup is considered “Easy to Chew” level or above. Resident 1 was served a regular texture diet with thin liquids despite orders for a pureed modified diet texture and thickened liquids in place. The resident was also provided meals while in a semi-reclined position despite a diagnosis of dysphagia (difficulty swallowing). The failure to follow prescriber orders and take reasonable precautions for a resident with dysphagia placed him/her at risk for choking and aspiration. An immediate plan of correction was requested from Staff 1 (ED) at 3:20 pm on 06/22/26. The plan of correction was received and accepted by the survey team at 5:40 pm on 06/22/26. The immediate risk was addressed; however, the facility will need to evaluate the overall system failure associated with the licensing violation.? A subsequent meal observation was made at 12:40 pm on 06/23/26. Staff 9 (CG) was observed to assist the resident to an upright position by raising the head of the bed and using pillows behind the resident. The resident did not protest or otherwise demonstrate intolerance for the upright positioning. Staff 9 placed the resident’s meal on a tray table over his/her lap where the resident could reach it without difficulty. The resident self-fed a gelatin dessert and drank from a cup with a straw. No coughing observed. S/he then disposed of the rest of the meal items in the garbage can next to his/her bed. The need to ensure reasonable precautions were exercised against any condition that could threaten the health and safety of a resident was discussed with Staff 1 at 1:57 pm on 06/23/26. She acknowledged the findings.

C0160- OAR 411-054-0025 (4) Reasonable precautions 1. Avamere Hermiston staff have fixed the areas of concern for resident 1. Plan of correction was accepted on 6/22/26 by survey team. A meeting was held with family to review risks vs. benefits of not following the texture modified diet orders. 2. All staff were re-trained on the importance of following orders for texture modified diets and thickened liquids. If residents are not wanting to follow their diet orders, communication will occur between community LN and prescribing provider requesting a liberalized diet, however the ordered texture will be provided unless the actual order is modified. A full diet audit was completed to assure all diet orders are being followed. All staff training completed for aspiration precautions. 3. Diet orders will be audited monthly as part of our Continuous Quality Improvement (CQI) process. 4. This will be monitored by the RCC's, DHS, and Executive Director.

OAR 411-054-0025 (4) Reasonable Precautions (4) Reasonable precautions must be exercised against any condition that could threaten the health, safety, or welfare of residents. This Rule is not met as evidenced by:

OAR 411-054-0055 (1)(f-h) Systems: Treatment Orders (f) Medication and treatment orders must be carried out as prescribed.(g) Written, signed physician or other legally recognized practitioner orders must be documented in the resident's facility record for all medications and treatments that the facility is responsible to administer.(h) Only a physician or other legally recognized prescribing practitioner is authorized to make changes in a medication or treatment order. This Rule is not met as evidenced by: Based on observation,?interview?and record review, it was?determined?the facility?failed to?ensure diet orders were carried out as prescribed for 1 of 1 sampled resident (# 1) who had?modified?diet orders. Findings include, but are not limited to:? Resident 1 moved into the facility in 09/2022 with diagnoses including dysphagia (difficulty swallowing) and age-related physical disability. The resident’s 03/23/36 to 6/22/26 clinical record was reviewed, and the following was identified: The resident had signed prescriber orders, dated 03/03/26, for a “pureed diet” texture and “nectar to honey consistency” liquids. ?? During the survey on 06/22/26 at 1:11 pm, the resident was?observed?consuming regular diet textures (hardboiled egg) and thin liquids, not the prescribed diet and liquid order. In an interview at 3:02 pm on 06/22/26, Staff 8 (Cook) confirmed the food, and beverage had been provided by the facility kitchen. ?? The need to ensure orders were carried out as prescribed was reviewed with Staff 1 (ED) on 06/23/26 at 1:57 pm. She acknowledged the findings.?

C0303-OAR 411-054-0055 (1)(f-h) Systems: Treatment Order 1. Avamere Hermiston staff have fixed the areas of concern for resident 1. Hospice Dr. Larsen updated diet orders while survey team was present. Plan of correction was accepted by survey team on 6/22/26. 2. All staff have been trained on the need to follow all physician orders, including diet orders. If concerns arise regarding residents rights to refuse to follow orders, staff have been instructed to notify the LN/ED so that coordination can occur between the community and the prescribing physician and orders can be updated if deemed appropriate. Physicians will be notified timely of any refusals to follow any orders, including diet orders. 3. Diet orders will be audited monthly as part of our CQI process. All Physician orders will be audited quarterly for residents and sent to Physician for review. 4. This will be monitored by RCC's, DHS, and Executive Director.

OAR 411-054-0055 (1)(f-h) Systems: Treatment Orders (f) Medication and treatment orders must be carried out as prescribed.(g) Written, signed physician or other legally recognized practitioner orders must be documented in the resident's facility record for all medications and treatments that the facility is responsible to administer.(h) Only a physician or other legally recognized prescribing practitioner is authorized to make changes in a medication or treatment order. This Rule is not met as evidenced by: