Avamere at Park Place

The facility failed to have an updated Acuity-Based Staffing Tool (ABST) that accurately reflected the resident population and their care needs. Inconsistencies were identified between the resident roster, care plans, and the data entered into the ABST. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to have an updated Acuity-Based Staffing Tool (ABST) that accurately reflected the resident population and their care needs. Inconsistencies were identified between the resident roster, care plans, and the data entered into the ABST. An investigation determined this is a violation of Oregon Administrative Rules. Corrective Action taken on related allegation.

The facility failed to consistently staff to the levels, intensity and qualifications indicated by the Acuity-Based Staffing Tool (ABST). Inconsistencies were identified between the staffing schedule and the data produced by the ABST. Facility was not staffing to the levels as indicated by the ABST to meet the scheduled and unscheduled needs of residents. An investigation determined this is a violation of Oregon Administrative Rules. Corrective Action taken on related allegation.

The facility failed to have an updated Acuity-Based Staffing Tool (ABST) that accurately reflected the resident population and their care needs. Inconsistencies were identified between the resident roster, care plans, and the data entered into the ABST. An investigation determined this is a violation of Oregon Administrative Rules. Corrective Action taken on related allegation.

The facility failed to consistently staff to the levels, intensity and qualifications indicated by the Acuity-Based Staffing Tool (ABST). Inconsistencies were identified between the staffing schedule and the data produced by the ABST. Facility was not staffing to the levels as indicated by the ABST to meet the scheduled and unscheduled needs of residents. An investigation determined this is a violation of Oregon Administrative Rules. Corrective Action taken on related allegation.

The facility failed to have an updated Acuity-Based Staffing Tool (ABST) that accurately reflected the resident population and their care needs. Inconsistencies were identified between the resident roster, care plans, and the data entered into the ABST. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to consistently staff to the levels, intensity and qualifications indicated by the Acuity-Based Staffing Tool (ABST). Inconsistencies were identified between the staffing schedule and the data produced by the ABST. Facility was not staffing to the levels as indicated by the ABST to meet the scheduled and unscheduled needs of residents. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to have an updated Acuity-Based Staffing Tool (ABST) that accurately reflected the resident population and their care needs. Inconsistencies were identified between the resident roster, care plans, and the data entered into the ABST. An investigation determined this is a violation of Oregon Administrative Rules. Corrective Action taken on related allegation.

The facility failed to consistently staff to the levels, intensity and qualifications indicated by the Acuity-Based Staffing Tool (ABST). Inconsistencies were identified between the staffing schedule and the data produced by the ABST. Facility was not staffing to the levels as indicated by the ABST to meet the scheduled and unscheduled needs of residents. An investigation determined this is a violation of Oregon Administrative Rules. Corrective Action taken on related allegation.

On or about January 21, 2026, the Oregon Department of Human Services (ODHS) Licensing Compliance Unit (LCU) conducted an investigation regarding an allegation received on May 19, 2025. The allegation stated that the facility failed to develop, maintain, and implement an Acuity-Based Staffing Tool as required by applicable regulations. Based on interview and record review, the LCU investigation determined the facility failed to update the Acuity-Based Staffing Tool (ABST) evaluation for each resident quarterly as required Findings include, but are not limited to: - A review of the facility’s last ABST evaluation update per resident indicated 63 of 105 residents had not been updated quarterly as required. The facility failed to have an updated Acuity-Based Staffing Tool (ABST) that accurately reflected the resident population and their care needs. Inconsistencies were identified between the resident roster, care plans, and the data entered into the ABST. An investigation determined this is a violation of Oregon Administrative Rules. Corrective Action taken on related allegation.

On or about January 21, 2026, the Oregon Department of Human Services (ODHS) Licensing Compliance Unit (LCU) conducted an investigation regarding an allegation received on May 19, 2025. The allegation stated that the facility failed to have qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident. Based on interview and record review, the LCU investigation determined the facility failed to have an Acuity-Based Staffing Tool (ABST) that accurately reflected the resident population, their needs, and all required Activities of Daily Living (ADL). Findings include, but are not limited to: The facility’s posted staffing plan indicated: · Day shift: 7 direct care staff; · Swing shift: 6 direct care staff; and · Night shift: 3 direct care staff. The facility’s direct care staff schedule, dated 05/19/25, indicated the facility was not staffing to its staffing plan for 1 out of 3 shifts reviewed. Facility was not staffing to the levels as indicated by the ABST to meet the scheduled and unscheduled needs of residents. An investigation determined this is a violation of Oregon Administrative Rules. Corrective Action taken on related allegation.

On or about January 21, 2026, the Oregon Department of Human Services (ODHS) Licensing Compliance Unit (LCU) conducted an investigation regarding an allegation received on May 13, 2025. The allegation stated that the facility failed to develop, maintain, and implement an Acuity-Based Staffing Tool as required by applicable regulations. The facility failed to have an Acuity-Based Staffing Tool (ABST) that accurately reflected the resident population, their needs, and all required Activities of Daily Living (ADL) on May 13, 2025. Inconsistencies were identified between the resident roster, care plans, and the data entered into the ABST. Facility was not staffing to the levels as indicated by the ABST to meet the scheduled and unscheduled needs of residents. An investigation determined this is a violation of Oregon Administrative Rules. Corrective Action taken on related allegation.

The facility failed to have an updated Acuity-Based Staffing Tool (ABST) that accurately reflected the resident population and their care needs. Inconsistencies were identified between the resident roster, care plans, and the data entered into the ABST. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to consistently staff to the levels, intensity and qualifications indicated by the Acuity-Based Staffing Tool (ABST). Inconsistencies were identified between the staffing schedule and the data produced by the ABST. Facility was not staffing to the levels as indicated by the ABST to meet the scheduled and unscheduled needs of residents. An investigation determined this is a violation of Oregon Administrative Rules.

On or about December 26, 2024, the facility failed to have an Acuity-Based Staffing Tool (ABST) that accurately reflected the resident population, their needs, and all required Activities of Daily Living (ADL). Inconsistencies were identified between the resident roster, care plans, and the data entered into the ABST. Facility was not staffing to the levels as indicated by the ABST to meet the scheduled and unscheduled needs of residents. An investigation determined this is a violation of Oregon Administrative Rules. Corrective Action taken on related allegation.

The facility failed to consistently staff to the levels, intensity and qualifications indicated by the Acuity-Based Staffing Tool (ABST). Inconsistencies were identified between the staffing schedule and the data produced by the ABST. Facility was not staffing to the levels as indicated by the ABST to meet the scheduled and unscheduled needs of residents. An investigation determined this is a violation of Oregon Administrative Rules. Corrective Action taken on related allegation.

On or about December 16, 2024, the facility failed to have an updated Acuity-Based Staffing Tool (ABST) that accurately reflected the resident population and their care needs. Inconsistencies were identified between the resident roster, care plans, and the data entered into the ABST. An investigation determined this is a violation of Oregon Administrative Rules. Corrective Action taken on related allegation.

During the night shift, Alleged Perpetrator 2 (AP2) made negative comments about Alleged Victim (AV) in the presence of AV and other staff members. Based on facility documentation and interviews, it was determined that AP2 verbally abused AV by using profanity in conversation with AV and making derogatory comments about AV in front of AV and other facility staff. AV reported that AP2's comments made him/her feel bad and expressed "feeling like an animal" as a result of AP2's actions. AP2's actions caused AV emotional distress which constitutes verbal/emotional abuse. The facility failed to protect AV from verbal/emotional abuse by not ensuring AV was from free from staff making verbal derogatory/negative comments about AV which is a violation of Oregon Administrative Rules.

On or about March 19, 2024, Alleged Victim (AV) was administered the incorrect dosage of a newly ordered medication. AV suffered no adverse side effects of medication error. Based on interviews and facility documentation, the facility failed to administer medications to AV as ordered which is a violation of Oregon Administrative Rules. Alleged Perpetrator 2 (AP2) allegedly neglected AV. An investigation determined no abuse occurred.

The facility failed to keep a copy of the most current inspection report and any conditions placed upon the license must be posted with the facility's license in public view near the main entrance to the facility. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to provide a safe and homelike environment. An investigation determined no licensing violation or abuse occurred.

The facility failed to implement a service plan that reflects the resident's needs as identified in the evaluation in accordance with OAR 411-054-0036(2) per complaint that a resident has trauma around crowds and the facility does not take into consideration the resident's mental health/trauma, and refuses to deliver their meals, which is a violation of Oregon Administrative Rules.

The facility failed to implement a resident's right to have a safe and homelike environment in accordance with OAR 411-054-0027(1)(r) per complaint that staff are yelling and have been verbally aggressive toward residents, which is a violation of Oregon Administrative Rules.

Based on observation, interview, and record review, conducted during a site visit on 08/21/23, it was confirmed the facility took away a resident's ability to self-administer medications without reason for 1 of 1 sampled resident (Resident 1). Findings include, but are not limited to: - During an interview, 08/21/23, Resident 1 stated s/he had failed to receive medication that was supposed to come in the mail from his/her pharmacy, and the following day the facility RN had then taken all of Resident 1's medication from his/her room. - On 08/21/23, Resident 1 was observed to be sound of mind and was actively coordinating his/her own care prior to the interview. - A review of a RN assessment of Resident 1, dated 07/28/23, indicated Resident 1 was capable of self-administering medication. Staff 1 confirmed that Resident 1 could self-administer his/her medication, and his/her medications had been returned. Facility failed to allow a resident to self-administer medication which is a violation of Oregon Administrative Rules.

The facility failed to carry out medication and treatment orders as prescribed per complaint that the resident was not administered their medication as ordered, which is a violation of Oregon Administrative Rules.

The facility failed to keep an accurate MAR per complaint that staff signed off on administering medication they did not, which is a violation of Oregon Administrative Rules.

The facility failed to implement safe medication and treatment administration systems per complaint that the facility is constantly running out of the resident's allergy medication and not reordering timely, which is a violation of Oregon Administrative Rules.

The facility failed to ensure a resident's HCBS rights per complaint a resident is not delivered their meals to their room as requested and they are not allowed visitors of their choosing.

The facility failed to protect a resident in accordance with OAR , per complaint that a resident was verbally assaulted by a caregiver and was retaliated against when they reported it, which is a violation of Oregon Administrative Rules.

Based on interview and record review, conducted during a site visit on 08/21/23, it was confirmed the facility failed to carry out medication orders as prescribed for 1 of 1 sampled residents (# 1). Findings include, but are not limited to: A review of Resident 1's March 2023 MAR showed the following: * A legend indicating a check mark meant medication was administered. * An order for Trazadone, for an anxiety disorder, 12.5 mg by mouth in the morning. * An order for Metoprolol Succinate 50 mg, extended-release tablet for hypertension, by mouth once a day. Resident 1's March 2023 revealed the following. * On 03/07/23 and 03/08/23, the 6:30 am dose of Trazadone did not have check marks in the corresponding boxes. * On 03/07/23, the 6:30 am dose of Metoprolol Succinate did not have a check mark in the corresponding box. A review of Resident 1's progress note, dated 03/04/23 and 03/06/23, indicated both medications were awaiting refill. In an interview on 08/21/23, Staff 2 stated the lack of a checkmark on the MAR indicated that medication had not been administered. The facility's failure to provide a safe medication administration system for Resident #1 is a violation of Oregon Administrative Rules.

Alleged Perpetrator 2 (AP2) failed to administer the Alleged Victim’s (AV) medication as ordered, causing AV unreasonable discomfort and ongoing pain. AP2 is responsible for neglect of care which constitutes abuse. The facility failed to provide a safe medication administration system which is a violation of Oregon Administrative Rules. AP2 allegedly verbally abused AV. An investigation determined no verbal abuse occurred by AP2.

The facility failed to fully implement and update an Acuity Based Staffing Tool (ABST). An investigation determined this is a violation of Oregon Administrative Rules. Corrective Action taken on related allegation.

The facility failed to carry medication and treatment orders as prescribed. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to implement effective methods of responding to and resolving resident complaints. An investigation determined this is a violation of Oregon Administrative Rules.

Based on interview and record review, conducted during a site visit on 08/21/23, it was determined the facility failed to report abuse or suspected abuse to Seniors and People with Disabilities (SPD) office for 1 of 1 sampled resident (# 1). Findings include, but are not limited to: - Progress notes for Resident 1, dated 11/22/22, indicated s/he had been transported to the hospital on 11/22/22 for "hip pain." - There was no documented evidence the fall had been witnessed or investigated by the facility. - During an interview on 08/22/23, Staff 1 stated there was no incident report available for Resident 1's fall in November. - The findings of the investigation were reviewed with and acknowledged by Staff 1, Staff 2, and Staff 3 on 08/22/23. It was determined the facility failed to investigate and report abuse or suspected abuse to the local SPD office. The facility's failure is a violation of Oregon Administrative Rules.

The facility failed to keep all interior materials and surfaces clean in accordance with OAR 411-054-0300(4)(i). Based on facility documentation and interviews, the resident rooms are filthy. The facility's failure to provide a safe environment is a violation of Oregon Administrative Rules.

The facility failed to provide assistance with bathing in accordance with OAR 411-054-0030(1)(e)(B). Based on interviews and facility documentation, Alleged Victim (AV) was not assisted with bathing and started to have an odor. The facility's failure to follow AV's care plan is a violation of Oregon Administrative Rules.

The facility failed to develop and implement a policy on smoking in accordance with OAR 411-054-0025(7)(e). Based on facility documentation and interviews, residents smoked in their room and in the facility without staff taking an action. The facility's failure to provide a safe environment is a violation of Oregon Administrative Rules.

The allegation that the facility failed to keep the interior free from unpleasant odors and failed to keep all equipment in good repair in accordance with OAR 411-054-0300(4)(h) was investigated and finding determined that the facility failed to provide a safe environment which is a violation of Oregon Administrative Rules.

The allegation that the facility failed to carry out medication and treatment orders as prescribed in accordance with OAR 411-054-0055(1)(f) was investigated and findings determined that the facility failed to provide a safe medication administration system which is a violation of Oregon Administrative Rules.

The allegation that the facility failed to provide household services in accordance with OAR 411-054-0030(1)(g) was investigated and findings determined facility failed to provide housekeeping services which is a violation of Oregon Administrative Rules.