Beaverton Post Acute Care of Cascadia

In the surveyor’s words

From the most serious findings on record at Beaverton Post Acute Care of Cascadia, in the surveyor’s own words.

• Immediate jeopardy, isolatedF678Jun 26, 2023

  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 ,d+[DATE] 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. […]

• Actual harm, isolatedF689Aug 17, 2022

  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. […]

• No harm, potential for more than minimal, patternF761Aug 8, 2025

  Based on observation, interview and record review it was determined the facility failed to ensure medication storage was free of expired biologicals for 1 of 3 sampled medication rooms reviewed for medication storage. This placed residents at risk for diminished treatment efficacy. Findings include: 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. […]

• No harm, potential for more than minimal, patternF812Mar 25, 2024

  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 [DATE] at 9:14 AM the following was observed in the resident refrigerator located in the conference room: - one container of homemade spaghetti, dated [DATE]. - one unlabeled six ounce yogurt, with a use by date of [DATE]. - one labeled Rm 6 homemade food container with no date. - one opened pina colada mix with a best by date of [DATE]. - one open paper bag with three bagels, unlabeled and undated. - three bottles of soda labeled Activities. […]

• No harm, potential for more than minimal, isolatedF689Jun 17, 2026

  Based on interview and record review it was determined the facility failed to follow the resident's plan of care to prevent a fall for 1 of 3 sampled residents (#3) reviewed for accidents. This placed residents at risk for falls with injury. Findings include:Resident 3 admitted to the facility in 6/2021 with diagnoses including a stroke and dementia.A 3/13/26 Quarterly MDS indicated Resident 3 had severe cognitive impairment.A 3/31/26 care plan indicated Resident 3 required 1 one-person participation for mobility while in a wheelchair and to use a tilt back wheelchair or stretcher for all transportation.A 5/11/26 post fall note revealed Resident 3 was at a dental appointment on 5/7/26 and slipped out of her/his wheelchair onto the ground. […]