Deficiency Records for Avamere Rehabilitation of Oregon City
Updated as of March 01, 2024
A list of the most recent deficiencies for Avamere Rehabilitation of Oregon City. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-03-27 | 2023-05-03 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-01-13 | 2023-02-22 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2023-01-13 | 2023-02-22 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-01-13 | 2023-02-22 | N |
| Provide activities to meet all resident's needs. | Health | 2023-01-13 | 2023-02-22 | N |
| Ensure the activities program is directed by a qualified professional. | Health | 2023-01-13 | 2023-02-22 | N |
| Post nurse staffing information every day. | Health | 2023-01-13 | 2023-02-22 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2023-01-13 | 2023-02-22 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-01-13 | 2023-02-22 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-01-13 | 2023-02-22 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2023-01-13 | 2023-02-22 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-01-13 | 2023-02-22 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2023-01-13 | 2023-02-22 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-01-13 | 2023-02-22 | N |
| Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2023-01-13 | 2023-02-22 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-01-13 | 2023-02-22 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2023-01-13 | 2023-02-22 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-01-13 | 2023-02-22 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-01-13 | 2023-02-22 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-01-13 | 2023-02-22 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-01-13 | 2023-02-22 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-01-13 | 2023-02-22 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-01-23 | 2023-02-22 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-01-23 | 2023-02-22 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-01-23 | 2023-02-22 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-01-23 | 2023-02-22 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-01-11 | 2022-02-21 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-01-11 | 2022-02-21 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-01-11 | 2022-02-21 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-01-11 | 2022-02-21 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-01-11 | 2022-02-21 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2022-01-11 | 2022-02-21 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2022-01-11 | 2022-02-21 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-01-11 | 2022-02-21 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-01-11 | 2022-02-21 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2022-01-05 | 2022-02-21 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2022-01-05 | 2022-02-21 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2022-01-05 | 2022-02-21 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2022-01-05 | 2022-02-21 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2022-01-05 | 2022-02-21 | N |
| Provide emergency officials' contact information. | Fire Safety | 2022-01-05 | 2022-02-21 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2022-01-05 | 2022-02-21 | N |
| Establish emergency prep training and testing. | Fire Safety | 2022-01-05 | 2022-02-21 | N |
| Establish staff and initial training requirements. | Fire Safety | 2022-01-05 | 2022-02-21 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2022-01-05 | 2022-02-21 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-01-05 | 2022-02-21 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-01-05 | 2022-02-21 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-01-05 | 2022-02-21 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2022-01-05 | 2022-02-21 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2021-08-16 | 2021-11-09 | Y |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2021-08-16 | 2021-09-29 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-08-16 | 2021-07-26 | Y |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2018-12-14 | 2019-02-02 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2018-12-14 | 2019-02-02 | N |
| Assess the resident when there is a significant change in condition | Health | 2018-12-14 | 2019-02-02 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2018-12-14 | 2019-02-02 | N |
| Ensure each resident receives an accurate assessment. | Health | 2018-12-14 | 2019-02-02 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2018-12-14 | 2019-02-02 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-12-14 | 2019-02-02 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-12-14 | 2019-02-02 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2018-12-14 | 2019-02-02 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-12-14 | 2019-02-02 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2018-12-14 | 2019-02-02 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2018-12-14 | 2019-02-02 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2018-12-14 | 2019-02-02 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2018-12-11 | 2019-02-02 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2018-12-11 | 2019-02-02 | N |
| Establish staff and initial training requirements. | Fire Safety | 2018-12-11 | 2019-02-02 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2018-12-11 | 2019-02-02 | N |
| Install noncombustible or limited-combustible interior walls. | Fire Safety | 2018-12-11 | 2019-02-02 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2018-12-11 | 2019-02-02 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2018-12-11 | 2019-02-02 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2018-12-11 | 2019-02-02 | N |
