Avamere Rehabilitation of Oregon City

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Feb 8, 2021

  a. Based on observation, interview and record review it was determined the facility failed to provide supervision for swallowing safety for 1 of 5 residents (# 2) identified at risk for aspiration and who was to be supervised while eating. Resident 2 was observed to be left unattended with her/his meal tray two times during continuous observations. Resident 2 was able to independently feed her/himself. This failure resulted in an immediate jeopardy situation. This placed Resident 2 at risk for aspiration and death. Findings include: Resident 2 was admitted to the facility in 2018 with [DIAGNOSES REDACTED]. Resident 2's 1/18/21 physician order [REDACTED]. The 1/26/21 physician note indicated Resident 2 was severely demented and was unable to perform ADLs due to dementia. […]

• Actual harm, isolatedF689Aug 29, 2025

  Based on interview and record review it was determined the facility failed to provide adequate supervision and assistance to prevent a fall with injury for 1 of 2 sampled residents (#8) reviewed for falls. As a result, Resident 8 sustained a fractured arm. Findings include:Resident 8 was admitted to the facility in 5/2025, with diagnoses including neck fracture.Resident 8's 5/27/25 Care Plan revealed the resident had limited mobility due to her/his neck fracture and required a two-person transfer assist for toileting. […]

• Actual harm, isolatedF686Feb 13, 2024

  Based on interview, and record review it was determined the facility failed to provide the necessary care to prevent pressure ulcers, and accurately assess and provide timely treatment and repositioning to promote healing of pressure ulcers for 2 of 2 sampled residents (#s 2 and 46) reviewed for pressure ulcers. Resident 2 developed a preventable Stage 3 pressure ulcer. Findings include: CMS Appendix PP defined a Stage 3 pressure ulcer as: Full-thickness skin loss. Full-thickness loss of skin, in which subcutaneous fat may be visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. […]

• Actual harm, isolatedF600Jan 13, 2023

  Based on interview and record review it was determined the facility failed to protect the residents right to be free from physical abuse by staff for 1 of 1 sampled resident (#25) reviewed for abuse. This resulted in Resident 25 experiencing increased agitation post event. This placed residents at risk for physical and psychosocial harm. Findings include: Resident 25 admitted to the facility in 2018 with diagnoses including Alzheimer's disease and major depressive disorder. The 11/30/22 Quarterly MDS indicated Resident 25 was rarely/never understood and staff interviews indicated the resident experienced memory deficits. […]

• Actual harm, isolatedF610Jan 13, 2023

  Based on interview and record review it was determined the facility failed to ensure a thorough investigation was completed related to an allegation of physical abuse for 1 of 1 sampled resident (#25) reviewed for abuse. This resulted in Resident 25 experiencing increased agitation post event and placed residents at risk for continued abuse. Findings include: Resident 25 admitted to the facility in 2018 with diagnoses including Alzheimer's disease and major depressive disorder. The 11/30/22 Quarterly MDS indicated Resident 25 was rarely/never understood and staff interviews indicated the resident experienced memory deficits. […]