Print Violation: 00301309-AP-254490

Provider Information

Avamere at Chestnut Lane

1219 NE 6TH STREET
Gresham, OR 97030

Date: 12/12/2023
Report number: 00301309-AP-254490
Type: Abuse: Neglect
Level: 3 - Moderate harm or potential for serious harm
Allegation: Failed to provide oversight and monitoring of change of condition
Result: Substantiated
Rule(s) Violated: 411-054-0025(1)(a) and (b)
411-054-0027(1)(g) and (s)
411-054-0028
411-054-0036(2)(g)
411-054-0040(1)(a) and (d)
Findings: The facility failed to provide appropriate services according to Alleged Victim's (AV) care needs concerning AV's skin impairment. Based on facility documentation and interviews, staff did not place AV on alert monitoring and also failed to notify facility nurse when staff observed AV's perineal and abdominal fold with a rash on November 26, 2023. As a result of this failure, AV did not receive an appropriate treatment plan from AV's medical provider until after AV returned from visiting Witness 1 (W1) on December 7, 2023. The facility's failure resulted in AV's unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.
Sanction: ALFCP25-00340 $500.00 fine assessed