Print Violation: 00290953-AP-244978

Provider Information

Avamere at Chestnut Lane

1219 NE 6TH STREET
Gresham, OR 97030

Date: 10/14/2023
Report number: 00290953-AP-244978
Type: Abuse: Neglect
Level: 4 - Serious harm, death, imminent danger or chronic regulatory noncompliance
Allegation: Failed to provide service
Result: Substantiated
Rule(s) Violated: 411-054-0025(1)(a) and (b)
411-054-0027(1)(f) and (r)
411-054-0028(2)
411-054-0036(2)(g)
Findings: On or about October 14, 2023, Alleged Victim (AV) was found deceased in his/her room. Based on facility documentation and interviews, AV had a diagnosis of heart failure, and care staff did not provide adequate care to AV during the night leading up to AV's death when he/she showed signs of being outside his/her baseline. Facility staff failed to notify facility nurse of AV's symptoms per instructions in AV's care plan. Facility staff did not call 911 based on the totality of AV's heart failure symptoms. The facility's failure to provide basic care and services necessary to maintain AV's health and safety is a violation of residents rights, is considered neglect of care, and constitutes abuse.
Sanction: ALFCP23-00718 $2500.00 fine assessed