Print Violation: 00236214-AP-193674

Provider Information

Avamere at Chestnut Lane

1219 NE 6TH STREET
Gresham, OR 97030

Date: 12/11/2022
Report number: 00236214-AP-193674
Type: Abuse: Neglect
Level: 3 - Moderate harm or potential for serious harm
Allegation: Failed to follow care plan
Result: Substantiated
Rule(s) Violated: 411-054-0027(1)(f) and (r)
411-054-0028(2)
411-054-0036(2)(g)
Findings: On or about December 11, 2022, the facility failed to provide appropriate services according to the Alleged Victim’s (AV) care needs which resulted in AV choking on a piece of meatball, approximately 1 inch in length and width. Based on facility documentation and interviews, AV's food needs to be pureed and/or mashed due to AV's choking risk. At time of incident, AV's meatball was not pureed and/or mashed causing AV to choke. After W4's, W5's, W3's, and W6's attempt at dislodging the meatball from AV's throat, W2 was finally able to get the piece of meatball out. The failure resulted in AV’s suffering unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.
Sanction: ALFCP23-00233 $1125.00 fine assessed