Aging and People with Disabilities
Safety, Oversight and Quality
Print Violation: CALMS - 00086798
Provider Information
Avamere at Hillsboro Assisted Living Facility
2000 SE 30TH AVENUE
Hillsboro, OR 97123
- Provider ID
- 70M245
- Administrator
- Samantha Jimerson
- Phone
- (503) 693-9944
- sjimerson@avamerecommunities.com
Violation Details
- Date
- 8/18/2025
- Report number
- CALMS - 00086798
- Type
- Licensing Violation
- Level
- 4 - Serious harm, death, imminent danger or chronic regulatory noncompliance
- Allegation
- Failed to provide a safe medication administration system
- Result
- Substantiated
- Rule(s) Violated
-
External site: 411-054-0025(1)(a) and (b)
External site: 411-054-0055(1)(a) and (f)
- Findings
- Based on observation, interview, and record review, conducted during a site visit on August 18, 2025, the facility’s failure to exercise reasonable precautions against any condition that could threaten the health, safety, or welfare of residents was substantiated for 1 of 1 sampled resident (# 1). Resident 1, who had a signed physician’s order for a mechanical soft diet, was served a regularly textured meal. This put Resident 1 at risk of choking and constituted an immediate jeopardy situation. Findings include but are not limited to: Resident 1’s physician orders, dated May 16, 2025, indicated Resident 1 was to receive a mechanical soft diet. Resident 1 was admitted to the facility in July 2021 with a diagnosis of Parkinsons. On August 18, 2025, at approximately 11:45 am, Resident 1 was observed to have been served a firm sausage cut into approximately two to three-inch slices. This meal was inconsistent with a mechanical soft diet. On August 18, 2025, at approximately 12:00 pm, Resident 1 stated s/he could not eat the food, and staff were supposed to have cut up his/her food, but they had not. On August 18, 2025, at approximately 12:30 pm, Resident 1 was served a hamburger cut into quarters. Resident 1 stated s/he was unable to pick up and eat the hamburger. This meal was inconsistent with a mechanical soft diet. On August 18, 2025, at approximately 12:30 pm, Staff 4 stated s/he did not think Resident 1 required a special diet. On August 18, 2025, at approximately 12:45 pm, Staff 3 stated s/he did not know if Resident 1 required a special diet. Resident 1’s service plan, dated June 17, 2025, indicated s/he was to receive a “regular easy chew diet,” and did not indicate s/he required assistance with eating. On 08/18/25, at approximately 12:55 pm Staff 5 stated: - The sausage and hamburger that had been served would not be considered “mechanical soft;” - An indication of “regular easy to chew” on the facility’s meal chart meant the resident was to receive a mechanical soft diet; and - The incorrect meal chart had been available to kitchen staff. The facility’s “Nutritional and Culinary Services Food Size and Testing” reference guide (undated) indicated “regular easy chew” as: - Food piece size is not restricted; - Normal everyday foods of soft and tender texture; and - Foods must break apart easily test & pass Fork Pressure. This definition was not consistent with the requirements for a mechanical soft diet. The facility’s resident meal chart dated May 21, 2025, and posted in the kitchen at approximately 1:00pm on August 18, 2025, indicated Resident 1 was to receive a regular easy chew diet, and there were five additional unsampled residents who were to receive a regular easy chew diet. On August 18, 2025, at approximately 4:30 pm, Staff 1 stated an audit of the facility’s meal chart available to kitchen staff had failed to include diet orders for an additional three residents. The facility’s failure to exercise reasonable precautions against any condition that could threaten the health, safety, or welfare of residents was substantiated. On August 18, 2025, at 2:45pm, the LCU team requested an immediate plan of correction. An acceptable plan of correction was received from the facility on August 18, 2025, at 5:03 pm. The immediate risk was addressed; however, the facility will need to evaluate the overall system failures associated with the licensing violation to ensure adequate oversight of the operation of the facility and the quality of services rendered in the facility. The facility's failure is a serious violation of resident rights, which is a violation of Oregon Administrative Rules. Additional corrective action was taken concerning this case. ODHS issued condition, ALFCD25-00399, effective August 19, 2025.