Avamere Rehabilitation of Clackamas

In the surveyor’s words

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

• Immediate jeopardy, patternF880Jul 19, 2024

  Based on observation, interview and record review it was determined the facility failed to ensure the community use CBG glucometer was properly cleaned and sanitized between resident use for 1 of 1 sampled resident (# 299) reviewed during CBG checks. This failure, determined to be an Immediate Jeopardy situation, placed all residents who required CBG checks at significant risk for bloodborne illness. Findings include: The Evencare G2 blood glucose monitoring system manufacturer instructions indicated to disinfect the meter with EPA-registered wipes. The 9/2014 facility policy for Blood Sampling Capillary (Finger Sticks) indicated to follow the manufacturer's instructions. On 7/17/24 at 11:29 AM Staff 3 was observed to obtain a CBG for Resident 299. […]

• Immediate jeopardy, isolatedF689Sep 24, 2024

  Based on observation, interview and record review it was determined the facility failed to follow care plan interventions related to elopement for 1 of 1 sampled resident (#32) reviewed for elopement. This failure, determined to be an Immediate Jeopardy situation, placed all residents at risk for an unsafe elopement and injury. Findings include: The facility's revised 3/2019 Wandering and Elopement policy states the facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. […]

• Actual harm, isolatedF689Dec 2, 2022

  Based on observation, interview, and record review it was determined the facility failed to follow the plan of care for 1 of 3 sampled residents (#4) reviewed for falls. This failure resulted in Resident 4 experiencing a fall with a fracture. This placed residents at risk for increased falls. Findings include: Resident 4 admitted to the facility on [DATE] with diagnoses including dementia. Resident 4's Quarterly MDS dated [DATE] revealed she/he had a BIMS score of 5 (severely impaired). Resident 4's care plan dated 7/21/22 included padded fall mats on both bedsides when in bed, wider bed for comfort and a scoop mattress to prevent rolling out of bed. A 9/24/22 facility investigation revealed on 9/24/22 Resident 4 was found on the floor next to her/his bed and no fall mats were present. […]

• No harm, potential for more than minimal, patternF584Jul 19, 2024

  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. […]

• No harm, potential for more than minimal, patternF658Jul 19, 2024

  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 [NAME] [PHONE NUMBER] Scope of Practice Standards for All Licensed Nurses (1) Standards related to the licensee's responsibility for safe nursing practice. […]