Avamere at Pacific Ridge

In the surveyor’s words

From the most serious findings on record at Avamere at Pacific Ridge, in the surveyor’s own words.

• Actual harm, isolatedF760Apr 23, 2026

  Based on interview and record review, the facility failed to ensure residents were free from significant medication errors when medications were not administered per physician orders for 1 of 3 residents (Resident 1) reviewed for medication management. Resident 1, who was newly placed on an anticoagulant (blood thinning) medication to treat multiple blood clots, experienced harm when the facility failed to administer the medication resulting in pain, increased swelling, and required inpatient treatment at the hospital. This failure placed residents at risk for medical complications, unintended health consequences, and a diminished quality of life. […]

• Actual harm, isolatedF693Jan 17, 2025

  Based on observation, interview and record review, the facility failed to ensure enteral nutrition (the delivery of nutrients through a tube feeding [TF] directly into the stomach or small intestine) was administered in accordance with physician's orders and professional standards of practice for 4 of 4 residents (Resident 1, 2, 3, & 4), reviewed for TF management. Resident 1 experienced harm when they were found positioned in bed at a 10 degree angle while actively receiving TF in respiratory distress and had tube feeding formula coming from their mouth requiring transfer to the hospital where they were diagnosed with aspiration pneumonia (a lung infection that occurs when you inhale liquid into your lungs). […]

• Actual harm, isolatedF689Oct 4, 2024

  Based on observation, interview and record review, the facility failed to provide the required care planned supervision to prevent accidents/falls for 3 of 5 sample residents (Resident 1, 2 & 3) reviewed for two person assists with transfers. Resident 1 experienced harm when they received care without two staff assistance which resulted in a fall, hospitalization and diagnosis of a traumatic brain injury (TBI). This failure placed residents at risk for falls, injury and a diminished quality of life. Findings included . <Resident 1> According to the 07/22/2024 Admission Minimum Data Set (MDS - an assessment tool), Resident 1 required substantial to maximal assistance with standing, transfers, toileting hygiene, and was dependent for lower body dressing. […]

• Actual harm, isolatedF689Jul 19, 2024

  Based on observation, interview and record review, the facility failed to provide the required care planned supervision to prevent accidents/falls for 3 of 5 residents (Resident 1, 2 and 3) reviewed for two person assists with transfers. Resident 1 experienced harm when they received care while in bed without two staff assistance which resulted in a fall and shoulder fracture. This failure placed residents at risk for falls, injury and and diminished quality of life. Findings included . <Resident 1> According to the 07/03/2024 Quarterly Minimum Data Set (MDS - an assessment tool), Resident 1 was alert and oriented, was dependent on staff to roll left and right in bed, dependent on staff for a chair to bed transfers and had one non injury fall since the previous MDS. […]

• No harm, potential for more than minimal, widespreadF761Apr 24, 2026

  Based on observation, interview, and record review, the facility failed to consistently maintain the medication refrigerator temperature logs in 2 of 2 medication rooms (The 100/200 hall and 300/400 hall medication rooms) reviewed for medication storage. This failure placed the residents at risk for receiving compromised or ineffective medications. Findings included .Review of the facility's policy titled, Medication Storage, dated 2007, showed medications that required refrigeration, were to be kept in the refrigerator between 36 and 46 Fahrenheit (F, temperature scale) with a thermometer to allow temperature monitoring. It showed, A temperature log or tracking mechanism is maintained to verify that temperature has remained within accepted limits. […]