Avamere Court at Keizer

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Apr 19, 2022

  Based on observation, interview and record review it was determined the facility failed to provide supervision for swallowing safety for 1 of 9 sampled residents (#48) who were on swallowing precautions and required close supervision for all oral intake. Resident 48 was observed to be left unattended with her/his snack and fluids during continuous observations. Resident 48 was observed to independently feed her/himself. This failure resulted in an immediate jeopardy situation. This placed the resident at risk for pneumonitis (inflammation of the lung tissue), aspiration pneumonia (a type of lung infection that is due to material from the stomach or mouth entering the lungs) and death. […]

• Actual harm, isolatedF692Apr 19, 2022

  Based on interview and record review it was determined the facility failed to ensure a change of condition was addressed for 1 of 2 residents (#202) reviewed for weight loss and dehydration. This failure resulted in Resident 202 experiencing dehydration and weight loss resulting in hospitalization . This failure placed other residents at risk for weight loss and dehydration. Findings include: The 10/2017 Resident Hydration and Prevention of Dehydration Policy indicated: 1. The dietician would assess all residents for hydration adequacy and more often as clinically deemed necessary. 5. If potential inadequate intake and/or signs and symptoms of dehydration were observed, intake monitoring will be initiated and incorporated into the care plan. b. The physician would be notified. 7. […]

• Actual harm, isolatedF760May 17, 2021

  Based on interview and record review it was determined the facility failed to ensure medications were administered to the correct resident and ensure medications were timely obtained and administered for 2 of 3 sampled residents (#s 2 and 3) who were reviewed for medication administration. The failure to administer medications to the correct resident resulted in Resident 3 being transferred to the hospital for treatment as a result of adverse medication consequences. The failure to obtain and administer medications timely placed residents at risk for untreated conditions and reduced medication efficacy. Findings include: 1. […]

• No harm, potential for more than minimal, widespreadF585May 31, 2024

  Based on observation, interview and record review it was determined the facility failed to ensure a system was in place to receive and resolve resident and/or resident representative grievances for 1 of 1 sampled facility reviewed for Resident Council. This placed residents at risk for unreported and unresolved grievances. Findings include: The facility's undated Grievance policy indicated the facility was to ensure all residents and their family members were afforded the opportunity to express their concerns and suggest changes in the facility formally in writing. Record review of the facility's grievances binder revealed no written grievances were completed by residents or family members since 9/2023. […]

• No harm, potential for more than minimal, patternF565May 31, 2024

  Based on interview and record review, it was determined the facility failed to effectively respond to resident council concerns expressed at 3 of 3 resident council meetings reviewed for facility response to resident council concerns. This placed residents at risk for unmet needs concerning issues of resident care and lessened quality of life. Findings include: The facility's undated Resident Council Policy indicated a Quality Assurance form should be utilized for Resident Council meetings to help track the council's concerns and/or suggestions. […]