Avamere Rehabilitation Of Hillsboro

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689May 11, 2026

  Based on observation, interview, and record review, the facility failed to ensure residents were adequately supervised and protected from avoidable accidents. Specifically, the facility failed to:(1) Ensure adequate supervision to prevent accidents for 1 of 4 sampled residents (#44), a severely cognitively impaired resident, who was left unsupervised in the community in a high-traffic, [NAME] area for an unknown period of time and was subsequently located and returned to the facility by law enforcement. […]

• Immediate jeopardy, isolatedF660Mar 11, 2021

  Based on interview and record review the facility failed to develop and implement an effective discharge planning process to ensure post-discharge care and safety needs were met for 1 of 3 sampled residents (#10) reviewed for discharge. This failure to provide a safe discharge, determined to be an immediate jeopardy situation, placed resident's health and safety at risk, including symptoms of pain, medical complications, hospital readmission and death. Findings include: The facility's Transfer or Discharge, Preparing a Resident for policy, revised 2016, directed a post-discharge plan would be developed for each resident prior to her/his transfer or discharge. […]

• Actual harm, isolatedF686May 11, 2026

  Based on interview and record review, it was determined the facility failed to provide necessary treatment to promote healing of pressure ulcers for 1 of 1 sampled resident (#92) reviewed for pressure ulcers. This failure resulted in worsening of Resident 92's pressure ulcers and subsequent hospitalization. Findings include: The facility's Pressure Injuries Overview and Wound Staging Skin Management policy dated 3/2020 included the following:Pressure Ulcer/Injury refers to localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device.Avoidable means that the resident developed a pressure ulcer/injury and that one or more of the following was not completed:- Definition or implementation of interventions that are not… […]

• Actual harm, isolatedF689May 15, 2025

  Based on interview and record review, it was determined the facility failed to implement care plan interventions to prevent a fall for 1 of 1 sampled resident (#3) reviewed for accidents. As a result, Resident 3 sustained a fracture of the right distal femur (the lower portion of the thigh bone). Findings include: Resident 3 was admitted to the facility in 2013, with diagnoses including fracture of the right hip joint and right femur. Resident 3's 7/26/24 Care Plan revealed Resident 3 was a high fall risk related to a prior fall with right hip injury. Resident 3 was identified as a 2-person transfer with a Hoyer lift (a mechanical device used to lift and transfer residents who have difficulty moving themselves). […]

• Actual harm, isolatedF684Jul 31, 2023

  Based on observation, interview and record review it was determined the facility failed to ensure resident skin impairments were identified, comprehensively assessed, routinely assessed, treated and monitored for healing or worsening for 1 of 2 sampled residents (#45) reviewed for skin conditions. This placed residents at risk for unidentified, untreated and worsening skin impairments. Findings include: The facility's 12/2010 Skin Program Guideline specified upon admission the nurse will complete a skin evaluation and document the resident's skin condition on the Nursing Database and the resident's clinical record. […]