Avamere Rehabilitation Of Clackamas

Based on observation, interview and record review it was determined the facility failed to provide a clean and comfortable homelike environment for 1 of 2 halls reviewed for environment. This placed residents at risk for lessened quality of life. Findings include: On 9/29/25 through 10/1/25 from 8:00 AM to 4:00 PM, resident rooms one, two and four in the [NAME] Hall were observed to be used for storage of new furniture and past resident belongings. Observations of the three rooms included:-Five mattresses stacked on top of an unoccupied bed. The right side of the room was used for storage of a metal rack, two floor mats, a knee wedge, hangers, bath basin, gown, a bag of tortillas and four side tables. On the floor, a drawer from unknown origin was left on the floor and a yellow bath basin was placed on top.-Six mattresses stacked on top of an unoccupied bed. On top of the mattress, several blue blankets were placed on top of the mattresses. A sign above an unoccupied bed stated, emergency overflow bed only.-Three floor mats on top of an empty bed. A blue blanket was placed on top of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review it was determined the facility failed to ensure dependent residents received required assistance with ADLs for 1 of 3 sampled residents (#5) reviewed for ADLs. This placed residents at risk for lack of personal hygiene. Findings include:Resident 5 was admitted to the facility in 8/2025 with diagnoses including stroke and dysphagia (difficulty swallowing).Resident 5's Quarterly MDS dated [DATE] indicated the resident was dependent on staff for personal hygiene and grooming.Resident 5's care plan dated 8/28/25 indicated the resident required total assistance with personal hygiene. Resident 5 was observed on 9/29/25 at 1:11 PM, 9/30/25 at 12:59 PM and on 12/4/25 at 11:53 AM with a significant amount of visible facial hair.On 9/30/25 at 1:10 PM Resident 5 stated she/he did not want to have facial hair and wanted staff to take care of her/his facial hair. Resident 5 stated she/he relied on staff to shave unwanted facial hair.On 10/1/25 at 12:07, Staff 10 (CNA) stated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review it was determined the facility failed to implement care plan interventions to prevent an injury during toileting for 1 of 1 sampled resident (#60) reviewed for falls. This placed residents at risk for injury during transfers and inadequate ADL assistance. Findings include:Resident 60 admitted to the facility in 5/2025 with diagnoses including stroke with left sided weakness.A review of Resident 60's care plan dated 4/29/25 revealed she/he required assistance from two staff members for all transfers and toileting due to high fall risk and multiple falls since admission.A facility investigation created and signed by Staff 2 (DNS) on 5/13/25 indicated Staff 7 (Former NA) transferred Resident 60 to the toilet. Staff 7 attempted to change Resident 60's brief while the resident was seated on the toilet and the resident jerked suddenly which caused the resident to hit her/his head on the mobility bar along the wall, resulting in a large bump on the side of the resident's head.On 12/4/25 at 11:47 AM Staff 2 confirmed Staff 7 did not follow Resident 60's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review it was determined the facility failed to implement appropriate contact precautions and properly store wound care supplies for 1 of 1 resident (#24) reviewed for hospice. This placed residents at risk for the spread of infection. Findings include:The Center for Disease Control's (CDC) 4/3/24 website, section titled, Transmission Based Precautions, specified Contact Precautions are the second tier of basic infection control and are to be used in addition to Standard Precautions for patients who may be infected or colonized with certain infectious agents for which additional precautions are needed to prevent infection transmission. Use personal protective equipment (PPE) appropriately, including gloves and gown. Wear a gown and gloves for all interactions that may involve contact with the patient or the patient's environment. Donning PPE upon room entry and properly discarding before exiting the patient room is done to contain pathogens.The facility's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and interview the facility failed to provide a comfortable and homelike environment for 1 of 1 facility reviewed for physical environment. This placed residents at risk for a lessened quality of life. Findings include: The facility's 2021 Homelike Environment Policy revealed residents were provided with a safe, clean, comfortable and homelike environment. Comfortable and adequate lighting was provided in all areas of the facility. Resident 24 admitted to the facility in 2019 with diagnoses including hypertension (high blood pressure) and depression. Resident 24's 4/21/24 Annual MDS indication she/he was cognitively intact. On 7/16/24 at 9:24 AM Resident 24 stated she/he was going to an activity in the dining room where the lighting was bad, and her/his vision was not so great so she/he sat by the window or the doors to see better. On 7/16/24 at 3:40 PM Resident 24 stated the lights in the dining room could be brighter because when residents were in activities in the dining room, other residents would ask if the lights could be turned on, but the lights were…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review it was determined the facility failed to ensure staff adhered to professional standards related to disinfection of common use glucometers for 1 of 2 licensed nurses (Staff #3) reviewed for infection control and medication administration. This placed residents at significant risk for bloodborne illness. Findings include: Per OAR [PHONE NUMBER] Scope of Practice Standards for All Licensed Nurses (1) Standards related to the licensee's responsibility for safe nursing practice. The licensee shall: (A) Adhere to professional practice and performance standards; Per OAR [PHONE NUMBER] Conduct Derogatory to the Standards of Nursing Defined: Conduct that adversely affects the health, safety, and welfare of the public, fails to conform to legal nursing standards, or fails to conform to accepted standards of the nursing profession, is conduct derogatory to the standards of nursing. Such conduct includes, but is not limited to: (2) Conduct related to achieving and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review it was determined the facility failed to implement resident-centered care plan interventions to ensure residents with dementia maintained their highest practicable level of well-being for 1 of 1 sampled resident (#18) reviewed for dementia. This placed residents at risk for a lack of psychosocial well-being and increased behaviors. Findings include: The facility's revised 2018 Dementia - Clinical Protocol revealed for individuals with confirmed dementia, the IDT (Inter-Disciplinary Team) would identify a resident-centered care plan to maximize their remaining function and quality of life. Resident 18 admitted to the facility in 2020 with diagnoses including dementia with agitation and depression. Resident 18's 8/21/23 Annual MDS indicated behaviors including rejection of care, combative behavior and agitation. Resident 18's 5/21/24 Quarterly MDS assessed her/him as severely cognitively impaired. Review of Resident 18's 7/18/24 behavioral care plan identified her/him as confrontational, rude, demanding, suspicious, manipulative and anxious. The…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review it was determined the facility failed to re-evaluate elopement risks and revise care plan interventions to prevent repeated elopements for 1 of 1 sample residents (#1) reviewed for elopement. This placed residents at risk for an unsafe elopement and injury. Findings include: Resident 1 admitted to the facility in 3/2024, with diagnosis including dementia and Type 2 diabetes. Resident 1's 3/16/24 Elopement Assessment identified she/he was a moderate risk for elopement. Resident 1's 4/15/24 Care Plan indicated the resident presented as a high risk for wandering and elopement with interventions to implement a Code Pink protocol. Code Pink was defined as a medical emergency for residents who have wandered away from the facility and was at risk of harm and/or protecting themselves. Resident 1 was also revealed to be a significant fall risk due to cognitive impairment related to dementia. No additional interventions were identified. A 4/24/24 Facility Incident Reported revealed Resident 1 had an unwitnessed exit from the facility.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview it was determined the facility failed to ensure resident rooms, bathrooms and linen supplies were maintained for 2 of 2 halls reviewed for environment. This placed residents at risk for lessened quality of life. Findings include: 1. A 5/3/23 at 10:06 AM observation of room [ROOM NUMBER] and bathroom revealed duct tape on the floor under the sink and across the toilet threshold. The grout around the toilet was uneven and patchy, there were tiles on the floor and wall in the shower stall that were cracked and broken. The dry wall leading toward the bathroom was cracked near the ceiling and the frame around the bathroom door was separated. There was a gap between the wall and ceiling along three of the bathroom walls (except the window wall). The exhaust vent did not turn on when tested. The resident in room [ROOM NUMBER] stated she/he used that bathroom. A 5/1/23 at 11:49 AM observation of the bathroom between rooms [ROOM NUMBERS] revealed the linoleum around the toilet and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review it was determined the facility failed to provide palatable meals for 2 of 2 sampled residents (#s 12 and 30) reviewed for food quality. This placed residents at risk for impaired nutrition. Findings include: 1. Resident 12 was admitted to the facility in 2023 with diagnoses including pneumonia, dysphagia (difficulty swallowing) and malnutrition. Resident 12's 4/24/23 Care Plan indicated the resident had altered nutrition related to diagnoses of malnutrition and dysphagia. Resident 12's 4/26/23 ordered diet was a regular diet with minced and moist texture. A Registered Dietitian assessment dated [DATE] indicated the resident had an underweight BMI (body mass index). On 5/1/23 at 1:06 PM Resident 12 reported the texture, preparation and appearance of the food was not good. The resident stated the meal served at lunch was minced to death and she/he was not able to identify what it was. On 5/4/23 at 12:15 PM surveyors sampled two meals (regular and minced/moist)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review it was determined the facility failed to ensure oxygen filters were cleaned for 1 of 1 sampled resident (#4) reviewed for respiratory care. This placed residents at risk for lack of respiratory care. Findings include: The facility's 2001 policy related to respiratory support indicated washable filters were to be rinsed under running water once a week to remove dust and debris. Resident 4 admitted to the facility in 2020 with diagnoses including palliative care. A physician order dated 2/10/23 indicated Resident 4 was to have 0-2 liters of supplemental oxygen PRN to maintain saturation of more than 88 percent. A 4/24/23 hospice note indicated Resident 4 used 2 liters of oxygen continuously. Review of the 4/2023 MAR indicate Resident 4 received 2 liters of oxygen routinely. On 5/1/23 at 11:17 AM Resident 4 was observed to have oxygen in place. Resident 4 stated she/he used oxygen all the time. The oxygen filter was observed to have a thick layer of dust covering the entire filter. On 5/2/23 at 12:47 PM Staff 2 (DNS) stated night shift…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review it was determined the facility failed to address pharmacy recommendations for 1 of 5 sampled residents (#24) reviewed for medications. This placed residents at risk for adverse medication side effects. Findings include: Resident 24 admitted to the facility in 2022 with diagnoses including depressive disorder. The 3/3/23 pharmacy recommendation indicated the following: -Resident 24 was taking Lexapro (antidepressant medication) 7.5 mg for depression and was due for a gradual dose reduction (GDR) assessment; The pharmacy recommendation was not signed by the provider until 4/27/23 (55 days later) and indicated no change to Resident 24's Lexapro. On 5/3/23 at 2:03 PM at Staff 2 (DNS) acknowledged the facility did not follow up with the pharmacy recommendation timely.

Based on interview and record review it was determined the facility failed to withhold bowel medication as indicated for 2 of 5 sampled residents (#s 3 and 24) reviewed for medication. This placed residents at risk for adverse side effects of bowel medication. Findings include: 1. Resident 3 was admitted to the facility in 2019 with diagnoses including stroke. Resident 3's 5/4/23 physician's orders included the following medications: - Miralax (laxative) BID for bowel care. - Senna (laxative) BID for bowel care. Resident 3's Bowel elimination records from 4/4/23 through 4/30/23 revealed she/he had loose stools or diarrhea documented on 17 of 30 days for a total of 24 occurrences. Resident 3's 4/2023 MAR indicated: - The resident's scheduled Miralax was administered routinely every day from 4/1/23 through 4/30/23. - The resident's scheduled senna was administered routinely every day from 4/1/23 through 4/30/23 except for the refusal of two doses. Resident 3's 4/19/23 Care Plan indicated the resident had loose stools and diarrhea with a goal of reduced episodes of diarrhea. On 5/4/23…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and interview it was determined the facility failed to ensure garbage storage areas were maintained in a sanitary manner to prevent the presence and feeding of pests, and to ensure garbage storage area dumpsters were covered condition for 1 of 1 facility storage areas reviewed for sanitary garbage storage. This placed residents at risk for presence of pests. Findings include: On 5/1/23 at 9:09 AM during the initial kitchen tour including the outside garbage storage area Staff 9 (Cook) stated the trash compacter was broken for over a year and the facility brought in a large dumpster. A large, approximately 20 feet by 10 feet uncovered dumpster with two hinged doors at the front was observed at back side of the building. On 5/2/23 at 12:58 PM one of the dumpster doors opened was observed open; trash bags and a pair of used gloves dangled off the edge of the dumpster. On 5/3/23 at 10:12 AM one of the the dumpster doors was observed open and one garbage bag hung over the front edge; two black crows were observed by the dumpster opening. On 5/3/23 at 10:25 AM…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.