Federal inspectors determined this infection control failure at Avamere Rehabilitation of Clackamas constituted an immediate jeopardy to resident safety, placing all residents requiring blood sugar monitoring at significant risk for bloodborne illness.
The violation came to light on July 17, 2024, when a state surveyor observed Staff 3 performing blood glucose checks. After testing Resident 299, the nursing assistant exited the room and cleaned the glucometer with alcohol wipes. She then started walking toward Resident 296's room to use the same meter.
The surveyor intervened.
Staff 3 returned to her treatment cart and used a bleach wipe to clean the glucometer. But she immediately started down the hall again without waiting for the disinfectant to work. Manufacturer instructions required a three-minute contact time for proper disinfection.
The surveyor stopped her again. Staff 3 finally checked the contact time on the bleach wipes, set the glucometer down, and grabbed a different meter from her cart.
The facility's own policy from September 2014 required staff to follow manufacturer instructions for blood sampling equipment. The Evencare G2 blood glucose monitoring system manual specified using EPA-registered wipes for disinfection.
Fifteen residents at the facility required blood glucose checks, including Resident 15, who had been admitted with diagnoses that included HIV. This resident needed blood sugar testing three times daily using shared glucometers.
Records showed Staff 3 had performed Resident 15's blood glucose checks twice on June 14, 2024. Staff 3 told inspectors she worked on all resident halls throughout the facility.
The nursing assistant acknowledged she "primarily used alcohol wipes to clean the glucometer." Alcohol wipes alone do not meet the manufacturer's disinfection requirements for bloodborne pathogens.
Staff 2, the Director of Nursing Services, told inspectors the facility's expectation was for staff to use microkill bleach wipes between every glucometer use and rotate devices to ensure proper contact times. But this protocol clearly wasn't being followed.
When confronted with the immediate jeopardy finding on July 17 at 2:15 PM, facility administrators scrambled to implement emergency measures. By 5:30 PM that evening, they submitted an acceptable removal plan to federal inspectors.
The facility immediately collected all glucometers and disinfected them with EPA-approved disinfectants for bloodborne pathogens before the next round of blood sugar checks. Staff 3 was suspended pending retraining on proper disinfection procedures and education about dedicated equipment for residents with bloodborne pathogens.
All licensed nurses received emergency education on proper blood glucose monitor disinfection procedures before their next shifts. They were required to complete a Blood Glucose Monitoring Competency assessment.
Resident 15 received dedicated blood glucose monitoring equipment that would not be shared with other residents. The facility audited all residents for bloodborne pathogen diagnoses to identify others who needed dedicated equipment.
The Medical Director was notified of the potential exposure. Residents who may have been affected were also informed, and the facility offered testing as requested.
To monitor ongoing compliance, the Director of Nursing Services committed to observing blood glucose monitor disinfection during routine checks for one week, then weekly for three weeks, then monthly for two months.
The immediate jeopardy status was removed on July 18 at 2:30 PM after inspectors verified completion of the emergency measures.
But the facility's problems extended beyond infection control. Inspectors also found failures in dementia care that affected resident well-being.
Resident 18, admitted in 2020 with dementia, agitation, and depression, had been living at the facility for four years. By May 2024, assessments showed severe cognitive impairment. The resident's behavioral care plan from July 18, 2024, described someone who was "confrontational, rude, demanding, suspicious, manipulative and anxious."
The care plan documented behaviors including verbal aggression, physical aggression, yelling, hitting, interference with their roommate's care, and a history of making false accusations. Staff interventions were limited to giving chocolate when the resident became agitated, separating them from other residents, approaching calmly, and leaving the room when behaviors escalated.
Resident 18 refused activities of daily living and showers. The care plan's only intervention was to document refusals and try again later.
Staff 10, a certified nursing assistant, told inspectors she relied on care plans and shift reports for guidance on resident care. She confirmed Resident 18 "had behaviors often" and ate meals alone in their room because of these behaviors. Staff kept the resident "away from people."
When asked about other interventions to prevent negative behaviors, Staff 10 provided none.
The Director of Nursing Services acknowledged during the inspection that Resident 18's care plan "was not resident centered." She admitted the interventions were written for staff convenience rather than being specific to Resident 18 as an individual.
Staff 2 reported some interventions had been attempted but were never documented or included in the resident's care plan. She provided no further details about what those undocumented interventions might have been.
The facility's own 2018 Dementia Clinical Protocol required the interdisciplinary team to identify resident-centered care plans that would maximize remaining function and quality of life for individuals with confirmed dementia.
For Resident 18, after four years in the facility, the care plan remained focused on managing staff workload rather than supporting the resident's psychosocial well-being or addressing the root causes of behavioral expressions.
The inspection found the facility failed to implement meaningful interventions for a resident whose severe cognitive impairment and behavioral challenges required specialized, individualized approaches to maintain their highest practicable level of well-being.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Avamere Rehabilitation of Clackamas from 2024-07-19 including all violations, facility responses, and corrective action plans.
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