Avamere Rehabilitation Of King City

F-F725 and M183.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 3 of 9 385132 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 385132 B. Wing 07/19/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Avamere Rehabilitation of King City 16485 SW Pacific Highway Tigard, OR 97224

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0725 Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Level of Harm - Minimal harm or potential for actual harm 41458

Residents Affected - Many Based on interview and record review it was determined the facility failed to ensure there were sufficient nursing staff available to provide the necessary care and services to meet residents' needs in 1 of 1 facility reviewed for staffing. This placed residents at risk for unmet care needs. Findings include:

On 7/25/24 the facility had a census of 62 residents. On 7/18/24, Staff 1 (Administrator) provided a list of residents who:

-Required two-person mechanical lift transfers: 23;

-Required one or two-person extensive or total assistance for bathing: 47;

-Required one or two-person extensive or total assistance for toileting: 47;

-Required one or two-person extensive or total assistance for dressing: 49;

-Required two person assistance at all times for all care: 11;

-Had behavioral healthcare needs which required monitoring: 28;

-Were at risk for elopement: 5 and

-Were considered high fall risks: 14

1. On 2/1/24 a public complaint was received by the State Agency which alleged the facility was short staffed CNAs on all shifts resulting in residents not being toileted timely, long call light response times and basic care not being met. The complaint indicated the facility had been short staffed for months.

On 2/12/24 a public complaint was received by the State Agency which alleged the facility was short staffed CNAs on all shifts but evening shift was impacted the most, staff were unable to provide showers and, in general, resident care was diminished.

On 4/8/24 a public complaint was received by the State Agency which alleged the facility was short staffed CNAs which resulted in residents not receiving showers and staff not being able to properly monitor residents who required supervision when eating.

On 5/20/24 a public complaint was received by the State Agency which alleged the facility was short staffed CNAs, especially on night shift which resulted in residents not getting needed care.

On 6/17/24 two public complaints were received by the State Agency which alleged the facility was short staffed CNAs for the past several months resulting in staff not being able to properly monitor and supervise residents during meals and some residents were unable to be showered.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 4 of 9 385132 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 385132 B. Wing 07/19/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Avamere Rehabilitation of King City 16485 SW Pacific Highway Tigard, OR 97224

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0725 On 7/15/24 at 11:16 AM Resident 35 stated she/he sometimes waited over 30 minutes, pretty much daily, for someone to answer her/his call light. Resident 35 stated long call light times occurred across all shifts. Level of Harm - Minimal harm or potential for actual harm On 7/15/24 at 1:15 PM Resident 22 stated call light response times could take up to one hour. Resident 22 stated the facility was short-handed, especially on the weekends. Resident 22 stated, I filled my diaper a Residents Affected - Many couple of times because they didn't get here in time.

On 7/15/24 at 1:24 PM Resident 36 stated the facility needed more staff. Resident 36 stated she/he required two persons using a mechanical lift to transfer her/him and sometimes she/he was told there were not enough staff to transfer her/him to the chair.

On 7/16/24 at 8:34 AM Witness 4 (Complainant) reported since 2/2024 there was constant low CNA staffing. Witness 4 stated the facility was often three to four CNA staff short. Witness 4 stated staffing was bad which resulted in increased falls, residents missing showers and residents having to remain up in their chairs longer than they should.

On 7/16/24 at 8:21 AM Witness 3 (Complainant) reported CNA staffing was bad, especially on weekends, since approximately 2/2024. Witness 3 stated the facility was three or four CNA staff short on many shifts in 2/2024 and 3/2024 and now CNA staffing was often one to two CNAs short on many shifts. Witness 3 stated when CNA staffing was low, call light response times were longer and CNA staff did not have time to provide showers to residents.

On 7/16/24 at 1:28 PM Witness 1 (Complainant) stated the facility did not staff CNAs to meet the mandatory CNA minimum staffing ratio requirements. Witness 1 stated CNAs were frequently working one to two CNAs short, especially on the weekends. Witness 1 stated low staffing occurred off and on for months. Witness 1 stated low CNA staffing impacted staff's ability to monitor residents which resulted in increased falls. Witness 1 stated the facility continued to admit new residents even though they were unable to meet CNA staffing ratios, which had the potential to result in injuries to the resident and/or staff.

On 7/16/24 at 2:58 PM Witness 2 (Complainant) stated low CNA staffing was ongoing since 1/2024, especially on the weekends. Witness 2 stated staff were unable to provide showers to residents or properly supervise residents who were identified to be at high risk for aspiration (inhaling food or liquids into the lung). Witness 2 stated she was concerned residents might choke. Witness 2 stated the facility had many residents who required two person assistance with transfers but many times transfers were completed with only one person due to a lack of available staff. Witness 2 reported the facility continued to accept new admits even when they knew they were unable to adequately staff CNAs.

On 7/17/24 at 4:51 PM Witness 5 (Complainant) stated staffing was horrible and many CNA staff quit. Witness 5 stated when CNA staffing was low, staff could not provide showers, staff were unable to complete two person mechanical lift transfers and staff were unable to toilet residents in a timely manner which resulted in a lack of dignity for the residents. Witness 5 stated CNA staffing was a dumpster fire since 1/2024. Witness 5 reported many staff did not get their breaks. Witness 5 stated the facility did not have the right staffing for the level of acuity of the residents.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 5 of 9 385132 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 385132 B. Wing 07/19/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Avamere Rehabilitation of King City 16485 SW Pacific Highway Tigard, OR 97224

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0725 On 7/17/24 at 7:52 AM, 8:08 AM and 8:16 AM Staff 16 (CNA), Staff 10 (CNA) and Staff 14 (CNA) reported

the facility was consistently short staffed one to two CNAs, especially on the weekends. Staff 16 and Staff 14 Level of Harm - Minimal harm or reported CNA staff often did not get their breaks or lunches. Staff 16 and Staff 14 stated residents who potential for actual harm required two person mechanical lift transfers often had to wait a long time, showers got bumped and staff were unable to provide supervision to residents who ate in their rooms. Staff 10 reported the facility had Residents Affected - Many difficulty retaining CNA staff.

On 7/18/24 at 9:14 AM Staff 18 (Staffing Coordinator) stated she staffed CNAs based on the census and by

the CNA mandatory minimum staffing ratios. Staff 18 stated she heard there were staffing concerns. Staff 8 confirmed, from 2/2024 through 7/14/24, CNA staffing was short on many shifts.

On 7/19/24 at 9:14 AM Staff 1 (Administrator) stated he was aware the facility had staffing issues and struggled to maintain adequate staffing levels.

2. Resident 22 was admitted to the facility in 1/2024 with diagnoses including a fractured hip.

A 6/23/24 5-Day MDS indicated Resident 22 had no cognitive impairment and assistance levels ranged from moderate to maximal assistance from staff for multiple ADLs.

Review of Resident 22's 6/1/24 through 7/17/24 Call Light Tracking Sheet revealed the following call light response times:

-6/1/24 at 9:37 PM: call light response time 38 minutes;

-6/4/24 at 5:54 AM: call light response time 32 minutes;

-6/6/24 at 3:00 AM: call light response time 24 minutes;

-6/6/24 at 5:27 PM: call light response time 23 minutes;

-6/6/24 at 3:54 PM: call light response time 16 minutes;

-6/8/24 at 9:58 AM: call light response time 20 minutes;

-6/9/24 at 3:37 AM: call light response time 20 minutes;

-6/9/24 at 9:09 PM: call light response time 18 minutes;

-6/10/24 at 5:38 AM: call light response time 40 minutes;

-6/10/24 at 2:33 PM: call light response time 37 minutes;

-6/12/24 at 12:23 AM: call light response time 17 minutes;

-6/12/24 at 5:37 AM: call light response time 18 minutes;

-6/12/24 at 11:50 AM: call light response time 17 minutes;

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 9 385132 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 385132 B. Wing 07/19/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Avamere Rehabilitation of King City 16485 SW Pacific Highway Tigard, OR 97224

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0725 -6/19/24 at 1:24 PM: call light response time 23 minutes;

Level of Harm - Minimal harm or -6/19/24 at 8:18 PM: call light response time 40 minutes; potential for actual harm -6/20/24 at 6:22 AM: call light response time 27 minutes; Residents Affected - Many -6/20/24 at 2:23 PM: call light response time 16 minutes;

-6/23/24 at 8:03 PM: call light response time one hour;

-6/23/24 at 9:19 PM: call light response time 21 minutes;

-6/24/24 at 3:58 PM: call light response time 18 minutes;

-6/24/24 at 9:38 PM: call light response time 19 minutes;

-6/27/24 at 5:03 AM: call light response time 22 minutes;

-6/27/24 at 9:44 AM: call light response time 16 minutes;

-6/29/24 at 10:40 AM: call light response time 24 minutes;

-7/2/24 at 2:38 PM: call light response time 20 minutes;

-7/3/24 at 7:17 AM: call light response time 21 minutes;

-7/6/24 at 8:14 AM: call light response time 29 minutes;

-7/9/24 at 10:30 AM: call light response time 19 minutes;

-7/10/24 at 3:51 PM: call light response time 17 minutes;

-7/11/24 at 8:21 AM: call light response time 24 minutes;

-7/15/24 at 7:44 AM: call light response time 16 minutes and

-7/15/24 at 9:56 AM: call light response time 20 minutes.

On 7/15/24 at 1:15 PM Resident 22 stated call light response times could take up to one hour. Resident 22 stated the facility was short-handed, especially on the weekends. Resident 22 stated, I filled my diaper a couple of times because they didn't get here in time.

On 7/19/24 at 9:14 AM and 12:45 PM Staff 1 (Administrator) stated he was aware the facility had staffing issues and struggled to maintain adequate staffing levels. Staff 1 stated he would like to see call light response times no longer than 15 minutes and anything longer than 15 minutes would be an issue.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 9 385132 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 385132 B. Wing 07/19/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Avamere Rehabilitation of King City 16485 SW Pacific Highway Tigard, OR 97224

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0725 3. Resident 25 was admitted to the facility in 10/2022 with diagnoses including a stroke with hemiplegia and hemiparesis (paralysis and weakness of one side of the body). Level of Harm - Minimal harm or potential for actual harm Resident 25's 10/31/22 Fall Prevention Care Plan instructed staff to remind the resident to wait for staff assistance when she/he was up in her/his chair and to ensure the call light was within Resident 25's reach. Residents Affected - Many

A 5/30/24 Quarterly MDS indicated Resident 25 had no cognitive impairment and assistance levels ranged from maximal to dependent assistance from staff for multiple ADLs.

Review of Resident 25's 6/1/24 through 7/17/24 Call Light Tracking Sheet revealed the following call light response times:

-6/2/24 at 11:46 AM: call light response time 16 minutes;

-6/3/24 at 5:00 PM: call light response time 40 minutes;

-6/5/24 at 4:20 AM: call light response time 43 minutes;

-6/6/24 at 2:47 AM: call light response time 24 minutes;

-6/9/24 at 1:22 PM: call light response time 22 minutes;

-6/13/24 at 2:04 PM: call light response time 21 minutes;

-6/15/24 at 2:40 AM: call light response time 23 minutes;

-6/16/24 at 1:28 PM: call light response time 16 minutes;

-6/17/24 at 10:39 PM: call lighte response time 29 minutes;

-6/18/24 12:06 AM: call light response time 17 minutes;

-6/18/24 at 1:50 AM: call light response time 17 minutes;

-6/18/24 at 9:41 PM: call light response time 16 minutes;

-6/25/24 at 7:42 AM: call light response time 25 minutes;

-6/25/24 at 11:21 AM: call light response time 29 minutes;

-6/26/24 at 5:28 PM: call light response time 32 minutes;

-6/30/24 at 12:04 PM: call light response time 22 minutes;

-7/1/24 at 7:13 AM: call light response time 17 minutes;

-7/2/24 at 6:02 AM: call light response time 36 minutes;

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 9 385132 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 385132 B. Wing 07/19/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Avamere Rehabilitation of King City 16485 SW Pacific Highway Tigard, OR 97224

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0725 -7/2/24 at 2:54 PM: call light response time 18 minutes;

Level of Harm - Minimal harm or -7/4/24 at 11:33 AM: call light response time 21 minutes; potential for actual harm -7/4/24 at 6:39 PM: call light response time 17 minutes; Residents Affected - Many -7/6/24 at 10:52 AM: call light response time 16 minutes;

-7/6/24 at 6:00 PM: call light response time 24 minutes;

-7/7/24 at 6:54 PM: call light response time 49 minutes;

-7/10/24 at 11:18 AM: call light response time 36 minutes;

-7/11/24 at 9:25 AM: call light response time 26 minutes;

-7/11/24 at 6:48 PM: call light response time 18 minutes;

-7/12/24 at 10:55 AM: call light response time 17 minutes;

-7/12/24 at 4:47 PM: call light response time 22 minutes;

-7/16/24 at 4:53 AM: call light response time 16 minutes and

-7/16/24 at 6:32 PM: call light response time 20 minutes.

On 7/15/24 at 1:11 PM Resident 25 stated her/his call light response times were up to 30 to 40 minutes, at times.

On 7/19/24 at 9:14 AM and 12:45 PM Staff 1 (Administrator) stated he was aware the facility had staffing issues and struggled to maintain adequate staffing levels. Staff 1 stated he would like to see call light response times no longer than 15 minutes and anything longer than 15 minutes would be an issue.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 9 385132