Print Violation: 00392589-AP-343167

Provider Information

Avamere Living at St Helens

2400 GABLE RD
Saint Helens, OR 97051

Date: 3/29/2025
Report number: 00392589-AP-343167
Type: Abuse: Neglect
Level: 3 - Moderate harm or potential for serious harm
Allegation: Failed to provide safe environment
Result: Substantiated
Rule(s) Violated: External site: 411-054-0025(1)(a) and (b)
External site: 411-054-0027(1)(g) and (s)
External site: 411-054-0028(2)
External site: 411-054-0036(2)(g)
Findings: On or about March 29, 2025, Alleged Victim (AV) suffered an unwitnessed fall in his/her room, and it was unknown when the fall happened. Based on facility documentation and interviews, it was determined that day shift had not completed a timely safety check on AV when day shift started, and the last safety check was completed at 4am by NOC shift. It is not known if AV had fallen earlier in the night and then went back to bed or if the fall happened between the times of 4am and 8:40am, when AV was found by day shift staff. Facility documentation shows that AV's call pendant was not working at time of incident. The investigation determined that the facility failed to complete a safety check on AV, leaving AV almost 5 hours without a safety check and AV's call pendant was not working correctly at time of incident. The facility's failure to provide a safe environment caused AV unreasonable discomfort, which is a moderate violation of resident rights, is considered neglect of care and constitutes abuse.
Sanction: ALFCP25-00385 $375.00 fine assessed