Avamere Crestview of Portland

In the surveyor’s words

From the most serious findings on record at Avamere Crestview of Portland, in the surveyor’s own words.

• Immediate jeopardy, patternF880Jun 15, 2023

  1. Based on observation, interview and record review it was determined the facility failed to ensure standard and contact precautions for infection control were performed by staff. This failure, determined to be an immediate jeopardy situation, resulted in 30 residents identified and treatment prescribed for potential scabies (a contagious skin disease marked by itching and small raised red spots caused by mites). This placed all residents at risk for contracting scabies and the psychosocial impact related to symptoms, isolation, pain, and discomfort and serious harm and/or death. […]

• Actual harm, isolatedF689Jun 15, 2023

  1. Based on interview and record review it was determined the facility failed to safely transfer a resident according to the care plan for 1 of 4 sampled residents (#264) reviewed for accidents. This failure resulted in Resident 264 experiencing severe pain related to a right hip dislocation and requiring hospitalization and surgery. Findings include: Resident 264 was admitted to the facility in 8/2022 with diagnoses including fracture of the right femur. Resident 264's Admission MDS revealed the resident was severely cognitively impaired and required extensive assistance from two or more staff with transfers. […]

• Actual harm, isolatedF692Jun 15, 2023

  Based on observation, interview and record review it was determined the facility failed to promptly intervene when a resident experienced unplanned significant weight loss for 1 of 5 sampled residents (#12) reviewed for medications. This resulted in an unplanned severe weight loss for Resident 12 and placed residents at increased risk of unplanned weight loss. Findings include: Resident 12 admitted to the facility in 2/2016 with diagnoses including dementia. Record review of Resident 12's past year of Nutritional Assessments revealed the RD completed an assessment on 6/21/22 and 2/14/23. The 2/14/23 assessment was completed after a re-admission. No formal assessments were found reguarding weight loss after 2/14/23. […]

• Actual harm, isolatedF760Mar 2, 2023

  Based on interview and record review it was determined the facility failed to administer medications as ordered which resulted in a significant medication error for 1 of 3 sampled residents (#2) reviewed for medications. As a result Resident 2 became non-responsive to verbal stimuli and was sent out to the hospital after being administered another resident's medications. The facility identified the noncompliance, immediately initiated a plan of correction, including in service training for staff providing services and care to residents with similar orders and completed audits to ensure administration of resident medication. This incident was identified as meeting the criteria for past noncompliance. […]

• Actual harm, isolatedF689Jan 10, 2023

  Based on interview and record review it was determined the facility failed to implement care plan interventions to prevent falls for 1 of 3 sampled residents (#100) reviewed for accidents. As a result, Resident 100 fell out of bed, was hospitalized and sustained multiple fractures. Findings include: Resident 100 was admitted to the facility on [DATE] with diagnoses including hypertension (high blood pressure), congestive heart failure and fracture of the sacrum. Resident 100's 10/2/22 MDS revealed a BIMS score of 14, indicating no cognitive impairment. Resident 100's care plan dated 9/29/22 revealed she/he had orders for adaptive devices (bedside rails) on her/his bed to assist with bed mobility. […]