Avamere Riverpark of Eugene

In the surveyor’s words

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

• Actual harm, isolatedF689Jul 9, 2025

  Based on interview and record review, it was determined the facility failed to ensure resident care equipment was monitored as recommended for 1 of 3 sampled residents (#12) reviewed for accidents. Resident 12 experienced a fall from a broken shower chair, sustained rib fractures, and a closed head injury. Findings include: Resident 12 was admitted to the facility in 9/2024 with diagnoses including stroke. A 5/14/25 Fall investigation revealed Staff 12 (CNA) was providing Resident 12 with a shower. Resident 12's shower chair broke and Resident 12 fell onto the shower room floor, complaining of head and right rib pain. Resident 12 was sent to the hospital. A 5/14/25 hospital After Visit Summary revealed Resident 12 was diagnosed with a rib fracture, a closed head injury, and a bruise. […]

• Actual harm, isolatedF658Oct 11, 2024

  Based on observation, interview, and record review it was determined the facility failed to ensure professional standards were followed for 2 of 6 sampled residents (#s 39 and 442) for medication administration. Resident 442's medications were inappropriately administered resulting in a change of condition which required hospitalization . 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. […]

• Actual harm, isolatedF760Oct 11, 2024

  Based on interview and record review it was determined the facility failed to ensure residents were free from significant medication errors for 1 of 4 sampled residents (#442) reviewed for change of condition. Resident 442's medications were inappropriately administered resulting in a change of condition which required hospitalization . Findings include: Resident 442 admitted to the facility in 4/2024 with diagnoses including bipolar disorder (mental health disorder). An 4/6/24 physician order indicated staff were to administer lithium ER (extended release antipsychotic for bipolar disorder) PO. On 10/10/24 Drugs.com indicated lithium ER should not be crushed, chewed, or broken. […]

• Actual harm, isolatedF686Jun 30, 2023

  Based on interview and record review it was determined the facility failed to assess and treat residents' pressure ulcers for 2 of 3 sampled residents (#s 16 and 79) reviewed for pressure ulcers. Resident 16 developed at Stage 3 pressure ulcer. This placed residents at risk for infections. Findings include: 1. Resident 79 was admitted to the facility 6/9/23 (Friday) with diagnoses including respiratory failure. Hospital Discharge Orders Report dated 6/9/23 revealed Resident 79 had a pressure ulcer to the tailbone region. Wound care was to be provided every Monday, Wednesday and Friday. A 6/9/23 Admission Nursing Database indicated the resident had a pressure ulcer to the tailbone. There were no measurements or descriptions of the ulcer on the form. […]

• Actual harm, isolatedF658Mar 29, 2023

  Based on interview and record review it was determined the facility failed to ensure Staff 6 (LPN) adhered to professional standards of practice related to abuse and residents' changes in condition for 5 of 8 sampled residents (#s 305, 309, 312, 314 and 315) reviewed for abuse and change of condition. This failure resulted in Residents 305, 309 and 314 who experienced mental and verbal abuse and Residents 312 and 315 experienced a noted decline in condition without timely intervention prior to the residents' hospitalization . Findings include: [NAME] 8510450040 Scope of Practice Standards for All Licensed Nurses indicated the following: (1) Standards related to the licensed nurse's responsibilities for client advocacy. […]