Avamere Rehabilitation Of Eugene
Avamere Rehabilitation Of Eugene in EUGENE, OR — inspection on March 30, 2026.
Found 3 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Findings included:Resident 3 was admitted to the facility in 2/2026 with diagnoses including respiratory failure and pneumonia.
The facility's [DATE] investigation documented that staff found Resident 3 and suspected the resident was deceased during routine rounds.
The nurse was notified, and the resident was confirmed as deceased . Resident 3 was not on hospice, had a Full Code status, and CPR was not initiated.
Included in the investigation on [DATE], six days after the resident's death, that upon the nurse assessment Resident 3 did not have rigor mortis and the nurse did not initiate code blue or resuscitation interventions. A Nursing Facility Reported Incident Form, dated [DATE], indicated the incident from [DATE] was reported to the State Agency on [DATE]. On [DATE] at 12:48 PM, Staff 26 (Regional Director of Quality Assurance) confirmed the facility did not report the incident to the State Agency within the required two-hour timeline.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.
For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE
385053 03/30/2026
Avamere Rehabilitation of Eugene 2360 Chambers Street Eugene, OR 97405
prepared for a safe transfer/discharge.
orderly discharge was provided for 1 of 3 sampled residents (#8) reviewed for discharge.
This placed
3/2026 with diagnoses including chronic pain, absence of left leg below the knee, and after care following a surgical amputation. A 3/10/26 admission MDS indicated Resident 8 was cognitively intact and required supervision or touching assistance with toileting, transfers, and bathing. No referrals were documented for medical equipment ordered, or home health referral submitted. A 3/11/26 Discharge Instructions documented Resident 8 was being discharged home and noted her/his current physical status required assistance and assistive devices. A 3/13/26 Nursing Note indicated at 12:23 AM, Resident 8 returned after an outing.
The facility notified the police because her/his location was unknown. Resident 8 had been out with friends and was unaware of any concern. A 3/13/26 Social Services Note documented because Resident 8 was out past midnight, she/he was discharging from the facility. NOMNC was not issued due to leaving prior to scheduled discharge and leaving on own initiative. A 3/13/26 Discharge Summary note documented the discharge instructions were reviewed with Resident 8 and she/he refused to sign leaving the facility voluntarily.
The facility's Voluntary Consent form included a handwritten statement that Resident 8 refused to sign.
On 3/26/25 at 10:58 AM, Resident 8 stated he was kicked out of the facility for coming back late. Resident 8 stated she/he was currently sleeping on a friend's couch, and it was difficult to get around. On 3/30/26 at 10:36 AM, Staff 21 (Business Office Manager) stated Resident 8 did not have any financial notes for lack of payment and she did not have any information about why she/he discharged from the facility. On 3/30/26 at 12:06 PM, Staff 19 (Social Services Coordinator) stated Resident 8 stayed out late and the facility called the police. Resident 8 returned to the facility after midnight and because she/he was a Medicare resident, insurance would not cover her/him if out of the facility past midnight.
Staff 19 stated Resident 8 was scheduled for discharge from the facility on 3/17/26. On 3/30/26 at 12:57 PM, Staff 27 (Regional Director of Operations) stated he thought it was a clerical error and confirmed the facility should have completed a normal discharge for Resident 8.
385053 03/30/2026
Avamere Rehabilitation of Eugene 2360 Chambers Street Eugene, OR 97405
color.
Staff 8 stated she did not believe CPR was needed and called Staff 2 and the physician.
Staff 8
jeopardy to resident health or CPR on anyone no matter how long they have been deceased . On [DATE] at 8:44 AM, Staff 2 (DNS) safety stated she was called by Staff 4 at 4:10 AM informing her of Resident 3's death.
Staff 2 stated she expected staff to call a code blue right away, start CPR, call 911 and get the resident's code status.
deficient practice was identified by the facility and was corrected when the facility completed a root cause analysis of the incident and determined there was a delay in initiating CPR.
The Plan of Correction included:1.
Administrator, DNS and Nursing staff would be re-educated prior to next scheduled shift, on the process for code blue, how to locate a resident's code status in PCC and POLST on file and importance of following individual resident care plans and orders.2.
Resident's code status would be crossed referenced with PCC order, POLST scanned in binder, care plan and resident dashboard.3. DNS or Designee to monitor Resident code status preferences for new admissions/returning admissions from hospitalizations for the next seven days.4.
Monitoring: DNS or designee would audit code status for all new admissions and readmissions from hospitalization or ED visits weekly for eight weeks.
Audit results would be shared with QAPI committee to ensure substantial compliance was maintained.5. DNS or designee would complete mock code on [DATE].
DNS or designee would complete mock cod monthly for three months then quarterly going forward.