Aging and People with Disabilities
Safety, Oversight and Quality
Print Violation: CALMS - 00095721
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 - 00095721
- Type
- Licensing Violation
- Level
- 2 - Minor harm or potential for moderate harm
- Allegation
- Failed to provide safe environment
- Result
- Substantiated
- Rule(s) Violated
-
External site: 411-054-0300(5)(c)(C)
- Findings
- Based on observation and interview, the facility’s failure to have operable windows designed to prevent accidental falls when sill heights are lower than 36 inches and above the first floor was substantiated for 1 of 1 sampled resident (# 1). Windows on the second floor of the facility were not secured and were able to open freely. Resident 1 suffered a fall from a second story window resulting in serious injury. This constituted an immediate jeopardy situation which put the health and safety of residents at risk. Findings include, but are not limited to: An incident report, dated 08/15/25, indicated on 08/13/25 at 05:08 pm Resident 1 had fallen from a second story window. On 08/13/25 at approximately 5:08 pm, Staff 1 heard someone yelling for help. S/He found Resident 1 beneath an open second story window. Resident 1 was sent to the hospital and diagnosed with “multiple fractures.” Resident 1 died at the hospital on 08/14/25. A safety plan obtained by the Department from the facility on 08/18/25 indicated the “All top floor windows have window locks not exceeding 4 inches for the opening. This was audited and verified by Executive Director and Maintenance director on 8/13/25.” On 08/18/25, at approximately 10:00 am, Staff 1 stated the facility had ensured all second story windows had locks on them. An observation, on 08/18/25 at approximately 12:00 pm, of a second story window in the same room Resident 1 had fallen from, revealed: - The windowsill was 25 inches in height; - The window did not have a lock; and - The window was able to be fully opened. When shown the window by the on-site investigator, Staff 1 acknowledged the window did not meet requirements for resident units. The facility’s failure to have operable windows designed to prevent accidental falls when sill heights are lower than 36 inches and above the first floor was substantiated. On 08/18/25, at 3:08 pm, the Licensing Complaint Unit requested an immediate plan of correction. The on-site investigator and Staff 1 audited every second-floor window and found four additional windows were not secured to prevent accidental falls. At approximately 5:46 pm, windows in the facility were observed to be properly secured. An acceptable written plan of correction was received from the facility on 08/19/25 at 10:23 am. The immediate risk was addressed; however, the facility will need to Amended Notice & Order Imposing License Condition evaluate the overall system failures associated with the licensing violation. The facility's failure is a serious violation of Oregon Administrative Rules. Corrective Action taken on related allegation.