Aging and People with Disabilities
Safety, Oversight and Quality
Print Violation: 00426259-AP-377944
Provider Information
Avamere at Chestnut Lane
1219 NE 6TH STREET
Gresham, OR 97030
- Provider ID
- 70A290
- Administrator
- Renee Rickard
- Phone
- (503) 674-0364
- rrickard@avamerecommunities.com
Violation Details
- Date
- 9/12/2025
- Report number
- 00426259-AP-377944
- Type
- Licensing Violation
- Level
- 2 - Minor harm or potential for moderate harm
- Allegation
- Failed to follow care plan
- Result
- Substantiated
- Rule(s) Violated
-
411-054-0025(1)(a) and (b) and (4)
- Findings
- On the morning of the incident, the Alleged Victim (AV) was having breakfast under the supervision of Alleged Perpetrator 2 (AP2), who was the staff member assigned to monitor and assist AV with meals. AV’s initial meal included a sausage patty that had been cut into small, manageable pieces. According to facility documentation and staff interviews, AV was eating well and requested a second serving of the sausage patty. AP2 went to the kitchen to request an additional portion but did not inform kitchen staff that the food was for AV. The second sausage patty was provided whole and uncut. AP2 gave the uncut patty to AV, believing it was small enough to be safely consumed. Shortly after eating the second serving, AV began exhibiting signs of distress, including abnormal behavior, cessation of breathing, and facial discoloration (turning purple). AP2 responded by patting AV on the back and calling for additional staff assistance. AP2 then performed the Heimlich maneuver, successfully dislodging and ejecting pieces of the sausage patty from AV’s airway. AP2 later acknowledged not noticing that the initial portion had been cut and believed they were adequately monitoring AV’s food intake. Although AP2 is trained in resident care, meal assistance, and dietary need, including food handling and safety, at time of incident AP2 failed to ensure that AV’s second meal portion adhered to AV’s dietary restrictions. This failure resulted in AV choking on a meal item. AP2's actions is considered neglect of care which constitutes abuse. Furthermore, the facility failed to provide adequate oversight to ensure AP2 followed AV's dietary and safety protocols. This failure is a violation of Oregon Administrative Rules.