Aging and People with Disabilities
Safety, Oversight and Quality
Print Violation: CALMS - 00086876
Provider Information
Avamere Living at Newberg
730 FOOTHILLS DRIVE
Newberg, OR 97132
- Provider ID
- 70M208
- Administrator
- Kelci Mauser
- Phone
- (503) 554-0767
- kmauser@avamerecommunities.com
Violation Details
- Date
- 8/13/2025
- Report number
- CALMS - 00086876
- Type
- Licensing Violation
- Level
- 4 - Serious harm, death, imminent danger or chronic regulatory noncompliance
- Allegation
- Failed to provide oversight and monitoring of change of condition
- Result
- Substantiated
- Findings
- Based on interview and record review, conducted during site visits on 08/18/25 and 08/20/25, the facility's failure to have a Registered Nurse assess all residents with a significant change of condition was substantiated for 1 of 1 sampled resident (# 1). Findings include but are not limited to: Resident 1's service plan, dated 06/17/25, in the section titled personality/behaviors, indicated Resident 1 “Has been identified as experiencing hallucinations or delusions. [Resident 1] will make comments about seeing people who are not that [sic], usually happens in the evening or at night.” Progress notes for Resident 1, dated 07/17/25 through 08/13/25, indicated: - On 08/06/25, Resident 1 was suffering hallucinations, seeing children in his/her room; - On 08/10/25, Resident 1 was experiencing hallucinations, thinking s/he was a fictional character; - On 08/11/25, Resident was found on the floor of his/her apartment, confused, with unidentified pills in his/her hand, again experiencing hallucinations, that there was a man in his/her bathroom; - On 08/12/25, Resident 1 “appears agitated, restless, and [sic] hallucinations;” and - On 08/13/25, Resident 1 had hit a family member in the face with a metal water bottle, made comments about wanting “to be taken out of this world,” and staff had administered PRN Haloperidol and Olazepam. The 08/13/25 progress note also indicated on 08/11/25 Resident 1 had been combative with staff, hallucinating, and telling staff “everyone was trying to kill [him/her].” - The progress note entries on 08/06/25, 08/10/25, 08/11/25, and 08/12/25 were documented as “outside provider notes.” On 08/20/25 Staff 2 stated there were “no other interventions other than her oral pharmacological intervention meds.” On 06/13/25, Staff 5 completed a form titled Significant Change of Condition Comprehensive Assessment. There was no documented evidence interventions were made as a result of the assessment or communicated to staff. There was no documented evidence of interventions for staff on each shift to take or monitor in the event Resident 1 was experiencing suicidal ideations or hallucinations. On 06/18/25, Staff 5 completed a form titled Significant Change of Condition update. There was no documented evidence of interventions for staff on each shift to take or monitor in the event Resident 1 was experiencing suicidal ideations or hallucinations. On 08/18/25 at 12:35 PM, Staff 5 stated the last review of Resident 1's change of condition was 06/18/25, and “I don’t know if there was any changes of condition in [Resident 1].” The facility's failure to have a Registered Nurse assess all residents with a significant change of condition is a serious violation of Oregon Administrative Rules.