Avamere Rehab: Resident Breaks Arm in One-Person Transfer - OR
The June incident at Avamere Rehabilitation of Oregon City involved Resident 8, who had been admitted in May with diagnoses including a neck fracture that severely limited mobility. The resident's care plan specifically required two-person assistance for all transfers and toileting due to these limitations.
Staff 20, a certified nursing assistant, ignored this requirement on June 25 when she attempted the transfer alone. The resident slipped during the solo transfer attempt and fell to the floor, fracturing their right arm.
"Staff 20 had attempted to assist her/him from the commode when she/he slipped and fell to the floor, causing her/him to fracture her/his arm," the resident told inspectors in August, confirming that their care plan required two-person assistance for transfers and toileting.
Hospital records confirmed the severity of the injury. A discharge summary from June 27 documented that Resident 8 sustained a right arm fracture as a direct result of the fall at the nursing home.
The resident was cognitively intact with a perfect score of 15 out of 15 on mental status testing, meaning they fully understood what happened and the requirements of their care plan.
Facility managers acknowledged the violation immediately. Staff 3, the residential care manager, confirmed to inspectors that Staff 20 failed to follow the resident's care plan, directly leading to the arm fracture. The administrator and care manager both verified this account during interviews in late August.
The facility's own investigation reached the same conclusion. A June 25 internal report determined that Staff 20 had not followed Resident 8's care plan and that the two-person transfer requirement existed specifically because of the resident's limited mobility from their neck fracture.
Inspectors attempted to interview Staff 20 on August 26 and 27 but were unable to reach the nursing assistant.
The violation represented what inspectors classified as "past noncompliance" because facility managers had already identified and addressed the deficient practice through their own investigation by June 26, one day after the incident occurred.
The facility's corrective action plan included multiple components. Managers reviewed and revised Resident 8's care plan to address additional risk factors identified after the fall. They conducted a facility-wide audit of all residents with fall risk care plans to ensure current interventions were being followed by staff.
All nursing staff received re-education on following individualized resident care plans. Supervisors began conducting random spot checks to verify compliance with care plans, while the director of nursing performed weekly audits of care plan implementation for residents at risk for falls.
These monitoring efforts were scheduled to continue for three months, with results reviewed in Quality Assurance and Performance Improvement committee meetings. The facility committed to taking corrective actions as needed based on ongoing monitoring results.
The incident highlighted the consequences when basic safety protocols are ignored. Resident 8's neck fracture already severely limited their mobility and made transfers dangerous without proper assistance. The care plan's two-person requirement existed specifically to prevent exactly this type of injury.
The resident's cognitive clarity made the violation particularly troubling. Unlike residents with dementia who might not understand safety requirements, Resident 8 was fully aware of their limitations and the need for two-person assistance.
Federal inspectors classified the violation as causing "actual harm" to "few" residents, indicating the serious nature of the injury while noting it affected a limited number of people. The fracture required hospitalization and likely extended the resident's recovery time and medical complications.
The facility's quick internal response demonstrated awareness of the severity. Completing a root cause analysis within 24 hours and implementing multiple corrective measures showed recognition that the incident represented a serious breakdown in basic care protocols.
However, the violation occurred despite existing care plans designed to prevent exactly this outcome. The incident underscored how individual staff decisions to ignore safety requirements can cause immediate and serious harm to vulnerable residents who depend on proper assistance for basic activities like toileting.
Resident 8 now lives with the consequences of a fractured right arm that could have been prevented if the nursing assistant had simply followed the established care plan requiring two-person assistance.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Avamere Rehabilitation of Oregon City from 2025-08-29 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
AVAMERE REHABILITATION OF OREGON CITY in OREGON CITY, OR was cited for violations during a health inspection on August 29, 2025.
The resident's care plan specifically required two-person assistance for all transfers and toileting due to these limitations.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.