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 8 of 27 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 0679 Provide activities to meet all resident's needs.

Level of Harm - Minimal harm or 41458 potential for actual harm Based on observation, interview and record review it was determined the facility failed to provide an ongoing Residents Affected - Some person-centered activity program for 3 of 3 sampled dependent residents (#s 9, 24 and 47) reviewed for activities. This placed residents at risk of a decline in psychosocial well-being and diminished quality of life. Findings include:

The facility's 2/2005 Activities Policy revealed the facility was to encourage each resident to maintain normal leisure activity. The facility would provide an activities program that addressed the intellectual, social, spiritual, creative and physical needs, capabilities and interests of each resident. The activity program would promote each resident's self-respect by providing activities that supported self-expression and choice.

1. Resident 9 was admitted to the facility in 5/2021 with diagnoses including major depressive disorder and dementia.

Resident 9's 6/11/21 and revised 11/16/21 Activities Care Plan indicated the following:

-Resident 9 liked music, pet therapy, visiting with the chaplain, gardening, flowers and birds.

-Resident 9 was to have one-on-one bedside visits and activities to include music, animal visits, bird watching discussions, manicures, hand massages and assistance looking through magazines.

-Resident 9 was Christian and the Activities Department was to provide gospel music and set-up Chaplain visits as needed.

Resident 9's 6/24/24 Significant Change MDS revealed the resident had severe cognitive impairments. Her/his activity preferences indicated it was somewhat or very important to have books, newspapers and magazines to read, do favorite activities, participate in religious services and practices and be around animals.

Resident 9's 6/16/24 through 7/16/24 Group Activity Task Log and One-On-One Activity Task Log contained no data regarding activity participation.

A review of Resident 9's electronic health record contained no evidence the resident participated in any activities.

The facility's 7/2024 Activity Calendar revealed the following scheduled activities:

Monday, 7/15/24:

-8:30 AM Morning Room Rounds

-11:00 AM Large Group: Exercises

-1:00 PM Birdhouse Building & Painting

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 27 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 0679 -3:00 PM Afternoon Rounds & Mail

Level of Harm - Minimal harm or -6:00 PM Independent Activities (CNA led) potential for actual harm Tuesday, 7/16/24: Residents Affected - Some -8:30 AM Morning Room Rounds

-11:30 AM Resident Shopping

-1:00 PM Gardening Club

-3:00 PM Afternoon Rounds & Mail

-6:00 PM Featured Movie (CNA led)

Wednesday, 7/17/24:

-8:30 AM Morning Room Rounds

-11:00 AM Large Group: Exercises

-1:00 PM Resident Council

-3:00 PM Afternoon Rounds & Mail

-6:00 PM Independent Activities (CNA led)

Observations from 7/15/24 through 7/18/24 between the hours of 8:00 AM and 7:30 PM revealed Resident 9 was in her/his room, typically with the blinds closed and the lights low, and was not engaged in any activities. No magazines, books or newspapers were observed; no music was playing and no one-on-one activities took place.

On 7/16/24 at 2:30 PM Resident 9 stated she/he liked to play bingo and the balls. Resident 9 stated she/he loved to read anything I can get my hands on.

On 7/17/24 at 7:40 AM Staff 9 (CNA) stated Resident 9 rarely got up out of bed. She stated she had not seen any activities occurring in Resident 9's room and she was not aware of any one-on-one activities being done

in residents' rooms, just group activities being conducted in the dining room.

On 7/17/24 at 8:16 AM Staff 14 (CNA) stated she had never seen Resident 9 engaged in any one-on-one activities in the resident's room.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 27 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 0679 On 7/18/24 at 8:33 AM Staff 6 (Activities Director) stated she was the only person in the activities department and she was responsible for completing all of the care conferences, Activity MDS Assessments, Activity Level of Harm - Minimal harm or Admission Profiles, shopping for the residents, delivering mail, engaging residents in group and one-on-one potential for actual harm person-centered activities; as well as assisting with many resident requests. She stated there was no one to provide activities on the weekends. Staff 6 was unable to provide dates or times of any specific activities Residents Affected - Some completed with Resident 9 and confirmed no activities documentation was completed.

On 7/19/24 at 9:40 AM Staff 1 (Administrator) stated his expectation was all residents received activities according to their person-centered care plan and he needed to work on getting additional help in the activities department.

2. Resident 24 was admitted to the facility in 10/2023 with diagnoses including dementia.

Resident 24's 10/30/23 Activity Profile indicated the resident spoke Farsi/Arabic and required a translator.

Resident 24's 11/8/23 and revised 11/16/23 Activities Care Plan indicated the following:

-Resident 24 liked visits from her/his spouse, eating ice cream and other comfort foods, watching television and reading.

-Resident 24 was to have twice weekly social visits for special updates on activities and assistance with self-directed activities.

Resident 24's 4/30/24 Significant Change MDS revealed the resident had short and long term memory deficits. Her/his activity preferences indicated it was somewhat or very important to listen to music, be around animals, go outside to get fresh air when the weather was good, do things with groups of people, do favorite activities and participate in religious services or practices.

Resident 24's 6/16/24 through 7/16/24 Group Activity Task Log and One-On-One Activity Task Log contained no data regarding activity participation.

A review of Resident 24's electronic health record revealed no evidence the resident participated in any activities.

The facility's 7/2024 Activity Calendar revealed the following scheduled activities:

Monday, 7/15/24:

-8:30 AM Morning Room Rounds

-11:00 AM Large Group: Exercises

-1:00 PM Birdhouse Building & Painting

-3:00 PM Afternoon Rounds & Mail

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 27 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 0679 -6:00 PM Independent Activities (CNA led)

Level of Harm - Minimal harm or Tuesday, 7/16/24: potential for actual harm -8:30 AM Morning Room Rounds Residents Affected - Some -11:30 AM Resident Shopping

-1:00 PM Gardening Club

-3:00 PM Afternoon Rounds & Mail

-6:00 PM Featured Movie (CNA led)

Wednesday, 7/17/24:

-8:30 AM Morning Room Rounds

-11:00 AM Large Group: Exercises

-1:00 PM Resident Council

-3:00 PM Afternoon Rounds & Mail

-6:00 PM Independent Activities (CNA led)

Observations from 7/15/24 through 7/18/24 between the hours of 8:00 AM and 8:00 PM revealed the resident was in her/his room with no music, books or materials to complete self-directed activities. Resident 24 was typically awake in bed with her/his television on without sound and closed captioning (text that reflects an audio track that can be read while watching visual content) on in English. On one occasion in the evening, Resident 24 was observed up in her/his wheelchair in a lobby area, placed in front of a television being broadcast in English, with four other residents. No one-on-one activities were observed during any

observations.

On 7/17/24 at 9:53 AM Staff 4 (CNA) stated she tried to get an I-Pad for Resident 24 to watch television on because her/his room television did not have Arabic channels but she was not successful getting an I-Pad. Staff 4 stated she had not seen any one-on-one activities occurring with Resident 24 and the resident just sits in her/his room unless her/his spouse comes to visit.

On 7/18/24 at 8:33 AM Staff 6 (Activities Director) stated she was the only person in the activities department and she was responsible for completing all of the care conferences, Activity MDS Assessments, Activity Admission Profiles, shopping for the residents, delivering mail, engaging residents in group and one-on-one person-centered activities; as well as assisting with many resident requests. She stated there was no one to provide activities on the weekends. Staff 6 was unable to provide dates or times of any specific activities completed with Resident 24 and confirmed no activities documentation was completed.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 27 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 0679 On 7/19/24 at 9:40 AM Staff 1 (Administrator) stated his expectation was all residents received activities according to their person-centered care plan and he needed to work on getting additional help in the Level of Harm - Minimal harm or activities department. potential for actual harm 47000 Residents Affected - Some 3. Resident 47 was admitted to the facility in 11/2023 with diagnoses including dementia.

Resident 47's 11/23/23 Activity Profile indicated the resident spoke Vietnamese and was unable to communicate or answer questions in English.

Resident 47's 11/27/23 Admission MDS indicated the resident experienced short-and-long-term memory loss and identified the following as activity preferences for the resident:

-Reading books, newspapers or magazines;

-Listening to music;

-Being around animals such as pets;

-Keeping up with the news;

-Doing things with groups of people;

-Participating in favorite activities; and

-Spending time outdoors.

Resident 47's 2/27/24 Social Determinants of Health Form indicated the resident spoke Vietnamese, she/he needed or wanted an interpreter to communicate with a doctor or health care staff and she/he sometimes felt lonely or isolated from those around her/him.

Resident 47's 3/17/24 Activity Care Plan revealed the following:

-The resident's activity goal was to attend/participate in activities of choice two-to-three times per week.

-The resident was dependent upon staff for activities.

-The resident's activity interests included passively participating in large group activities, watching television, one-to-one conversation and chair exercises.

-One-to-one in-room activities were needed if the resident was unable to attend out of room events.

-The resident required an escort to activity functions.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 27 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 0679 A review of Resident 47's 6/17/24 through 7/15/24 activity participation records revealed no evidence the resident participated in a group, one-to-one or self-directed activity during this timeframe. Level of Harm - Minimal harm or potential for actual harm The facility's 7/2024 Activity Calendar revealed the following scheduled activities:

Residents Affected - Some Monday, 7/15/24:

-8:30 AM Morning Room Rounds

-11:00 AM Large Group: Exercises

-1:00 PM Birdhouse Building & Painting

-3:00 PM Afternoon Rounds & Mail

-6:00 PM Independent Activities (CNA led)

Tuesday, 7/16/24:

-8:30 AM Morning Room Rounds

-11:30 AM Resident Shopping

-1:00 PM Gardening Club

-3:00 PM Afternoon Rounds & Mail

-6:00 PM Featured Movie (CNA led)

Wednesday, 7/17/24:

-8:30 AM Morning Room Rounds

-11:00 AM Large Group: Exercises

-1:00 PM Resident Council

-3:00 PM Afternoon Rounds & Mail

-6:00 PM Independent Activities (CNA led)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 27 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 0679 Observations of Resident 47 conducted from 7/15/24 to 7/17/24 between 9:41 AM through 4:28 PM revealed

the resident to be in bed in her/his room or in her/his wheelchair in her/his room or in the dining room. The Level of Harm - Minimal harm or resident's eyes were observed to be closed during each observation. When the resident was observed in potential for actual harm her/his room, no television or music played and no books, magazines or newspapers were observed. Resident 47's roommate's television could be heard from the hallway and the content was in English. When Residents Affected - Some the resident was observed in the dining room, the television was on and content played in English. On 7/15/24 at 1:04 PM, 7/17/24 at 9:41 AM and 7/17/24 at 11:31 AM the resident verbally responded to the surveyor's greeting with her/his eyes closed.

On 7/15/24 at 1:13 PM Witness 6 (Family Member) stated Resident 47's native language was Vietnamese and the resident spoke and understood limited English. Witness 6 stated the resident was able to communicate only her/his basic needs in English.

On 7/17/24 at 10:19 AM Staff 14 (CNA) stated she was unaware of any activity interests for Resident 47. Staff 14 stated since the resident came to the facility, it was just room to dining room for meals and back to [her/his] room to lay down. Staff 14 further stated the resident never participated in group activities, went outside, had the television or music on in her/his room or had books, newspapers or magazines available to read.

On 7/17/24 at 10:45 AM Staff 20 (CNA) stated Resident 47 spent all of her/his time either sleeping or eating. Staff 20 stated the resident did not participate in group activities or go outside. Staff 20 further stated she had never seen the resident with books, newspapers or magazines.

On 7/17/24 at 11:00 AM Staff 27 (CNA) stated she thought Resident 47 enjoyed listening to music and watching television but it was difficult for her/him to do either in her/his room because the resident's roommate's television was really loud. Staff 27 stated Resident 47 did not open her/his eyes often.

On 7/17/24 at 11:17 AM a group of residents was observed in the facility's dining room and participated in an exercise activity with a ball and parachute. Resident 47 was observed at this time in her/his room in bed with

the lights and television off.

On 7/17/24 at 11:31 AM Resident 47 was observed in her/his room and sat in her/his wheelchair with her/his eyes closed. The State Surveyor, with the assistance of a Vietnamese translator attempted an interview at

this time. As soon as the resident heard the translator speak in Vietnamese, the resident pulled opened her/his eyelids with her/his hand and verbally engaged in the interview. Resident 47 stated I don't do anything here. Resident 47 stated she/he would love to participate in group activities and go outside when

the weather was nice but no one offered these activities. Resident 47 further stated she/he enjoyed reading, songs, exercise and pets but no one at the facility had ever asked her/him about her/his likes and preferences.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 27 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 0679 On 7/17/24 at 4:09 PM Staff 6 (Activity Director) stated she did not attempt the Preferences for Customary Routine and Activities interview required at the time of Resident 47's 11/27/23 Admission MDS Assessment Level of Harm - Minimal harm or with the resident because she was informed the resident did not speak English, so she interviewed Witness potential for actual harm 6 instead. Staff 6 stated she typically added the resident activity preferences and interests she learned from

this interview to the resident's care plan and stated Resident 47's activity care plan needed to be updated. Residents Affected - Some Staff 6 stated she completed one-to-one visits with Resident 47 during mealtimes when she would primarily ask the resident in English about her/his meal. Staff 6 stated she did not use a translator during her interactions with Resident 47. Staff 6 stated she documented resident activity participation in each resident's clinical record which included any refusals and if the resident was sleeping. Staff 6 acknowledged Resident 47 did not have any activities, refusals or instances of sleeping documented from 6/17/24 to 7/15/24 and stated she sometimes did not get to charting at the end of the day. Staff 6 stated CNAs were responsible to turn on Resident 47's television when she/he was in her/his room and the resident watched television with English programming when in the dining room. Staff 6 further stated she did not invite Resident 47 to the group exercise activity this morning because the resident's eyes were closed and she did not like to bother residents if they were sleeping.

On 7/17/24 at 4:40 PM Staff 2 (DNS) stated she expected resident activity participation to be documented daily and staff to utilize a translation service when interacting with Resident 47. Staff 2 further stated she expected books, newspapers and magazines to be provided to Resident 47, television and music to be available to Resident 47 and one-to-one visits to be offered to Resident 47 daily, all in Vietnamese.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 27 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Level of Harm - Minimal harm or 41458 potential for actual harm Based on interview and record review it was determined the facility failed to ensure physician orders were Residents Affected - Few followed for 1 of 5 sampled residents (#24) reviewed for unnecessary medications. This placed residents at risk for adverse medication consequences. Findings include:

Resident 24 was admitted to the facility in 10/2023 with diagnoses including dementia

A 12/7/23 Physician Order indicated Resident 24 was prescribed a lidocaine 4% pain patch to be applied to

the resident's lower back, one patch once daily. The lidocaine 4% pain patch was to be on for 12 hours and off for 12 hours.

A review of Resident 24's 7/1/24 through 7/31/24 MAR indicated the resident's lidocaine 4% pain patch was not administered according to the physician orders on the following days:

-7/6/24, 7/8/24, 7/9/24 and 7/10/24.

On 7/18/24 at 12:17 PM Staff 7 (CMA) stated there were no lidocaine 4% pain patches available in the facility on 7/10/24, so she was unable to provide Resident 24 with her/his lidocaine pain patch.

On 7/18/24 at 12:27 PM Staff 8 (Maintenance Director) stated he was responsible for ordering Resident 24's lidocaine 4 % pain patches and the pain patches were not ordered timely because ordering supplies was a new task for him and he was unsure how the ordering system worked.

On 7/19/24 at 10:23 AM Staff 1 (Administrator) stated Staff 8 took over the responsibility of ordering supplies

on 7/1/24 so he was not familiar enough with the supply ordering process but that should never happen.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 27 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 0688 Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 47000

Residents Affected - Few Based on observation, interview and record review it was determined the facility failed to ensure residents with limited range of motion and/or mobility received restorative services and equipment to prevent a further decrease in range of motion for 2 of 4 sampled residents (#s 10 and 25) reviewed for position/mobility and rehab/restorative. This placed residents at risk for worsening contractures and physical decline. Findings include:

1. Resident 10 was admitted to the facility in 12/2016 with diagnoses including hemiplegia (complete paralysis on one side of the body) and hemiparesis (partial weakness on one side of the body) following a stroke.

Resident 10's 5/2/24 Annual MDS revealed the resident experienced short-and-long-term memory loss, upper and lower extremity impairment on one side of her/his body and did not utilize splint or brace assistance.

Resident 10's 7/2024 Physician Orders directed the resident to wear a right hand splint as tolerated.

Observations conducted from 7/15/24 to 7/18/24 between 7:42 AM through 8:19 PM revealed Resident 10 to be in her/his wheelchair or bed. The resident's right hand was in a fist and the resident did not wear a splint.

On 7/16/24 at 3:12 PM Resident 10 was able to partially open the four fingers on her/his right hand with visual prompting but was unable to answer any questions regarding her/his hand, a splint or pain.

On 7/17/24 at 8:07 PM Staff 10 (CNA), on 7/17/24 at 8:27 PM Staff 19 (CNA) and on 7/18/24 at 12:02 PM Staff 20 (CNA) stated they had never seen Resident 10 wear a brace and did not know she/he had one.

No evidence was found in Resident 10's clinical record to indicate the resident's upper extremity impairment was comprehensively assessed, ongoing monitoring of her/his upper extremity impairment was being provided, a care plan was developed to address the resident's upper extremity impairment or the right hand splint was available and offered to the resident.

On 7/18/24 at 12:39 PM Staff 2 (DNS) and Staff 21 (Resident Care Coordinator) acknowledged the findings of this investigation. Staff 2 stated assessments and on-going monitoring of Resident 10's right hand contracture were not completed and she was unsure if the resident's hand splint was even appropriate.

50930

2. Resident 25 admitted to the facility in 10/2022 with diagnoses including history of falls, and stroke with hemiplegia and hemiparesis (paralysis and weakness of one side of the body).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 27 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 0688 The quarterly MDS, dated [DATE REDACTED], showed a BIMS score of 15 which indicated she/he was cognitively intact, and required minimal assistance from one staff for eating and oral/personal hygiene, maximal assistance Level of Harm - Minimal harm or from one to two staff for ADLs/cares, and she/he was dependent on one to two staff for wheelchair mobility potential for actual harm and transfers.

Residents Affected - Few The resident's care plan, updated 4/6/23, revealed that she/he was at moderate risk for falls and needed a restorative care program to prevent decline in level of function. Interventions were updated on 6/6/24 to include a detailed ROM plan with monthly reviews.

On 7/15/24 at 1:11PM Resident 25 demonstrated her/his ability to move arms effectively, and inability to move their legs effectively. Resident 25 stated they were supposed to receive restorative therapy three times

a week, she/he received restorative therapy once a week on average, and during care conference on 6/13/24 a restorative therapy plan was discussed with her/him and their responsible party.

Review of 5/2/24 restorative therapy program referral for Resident 25 noted ROM and balance exercises, with interventions for upper and lower body, to be conducted in sessions three to five times per week. A care conference note on 6/13/24 indicated Resident 25 was encouraged to work with restorative therapy daily for four weeks prior to a resident requested physical therapy evaluation. Review of RA documentation for Resident 25 from 6/15/24 to 7/16/24 indicated nine therapy sessions and one resident refusal out of 13 to 22 ordered sessions.

There was no documentation to indicate Resident 25 experienced a decline in functional abilities.

On 7/17/24 at 8:55 AM Staff 15 (CNA/RA) stated RA staff had a restorative therapy plan for Resident 25 averaging three days per week, and Resident 25 had shown increased willingness to do work and participate. She stated RA staff had been pulled to the floor to work as CNA staff frequently this summer.

On 7/17/24 at 2:13 PM Staff 23 (MDS Coordinator) stated he implemented and monitored restorative therapy, and three sessions per week was a standard schedule. He stated if restorative therapy staff were pulled to the floor as CNA staff, the restorative therapy team attempted make up sessions with residents. He stated some missed days could not be made up, and he prioritized sessions for residents with multiple missed sessions.

On 7/19/24 at 1:42 PM findings were discussed with Staff 2 (DNS), and no additional information was provided.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 27 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 20 of 27 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 21 of 27 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 22 of 27 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 23 of 27 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 24 of 27 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 25 of 27 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 0805 Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. Level of Harm - Minimal harm or potential for actual harm 47000

Residents Affected - Few Based on observation, interview and record review it was determined the facility failed to ensure the appropriate diet texture was followed for 1 of 2 sampled residents (#10) reviewed for nutrition. This placed residents at risk for choking. Findings include:

Resident 10 was admitted to the facility in 12/2016 with diagnoses including dysphagia (difficulty swallowing).

The facility's 9/2019 Food Size & Testing Methods Form defined a regular, easy to chew diet as the following:

-No restrictions to food piece size.

-Normal, everyday foods of soft and tender texture.

-Foods must break apart easily and pass the fork pressure test.

Resident 10's 5/2/24 Annual MDS revealed the resident experienced short-and-long-term memory loss, was moderately impaired for decision making, required supervision or touch assistance with eating and was edentulous (without teeth).

Resident 10's 7/2024 Physician Orders directed the resident to receive a regular, easy to chew diet.

On 7/15/24 at 11:53 AM Resident 10 was observed to eat in bed. The resident's meal tray sat on top of an overbed table and the meal ticket on the tray stated beef fajitas. Resident 10 was observed to attempt a bite of the beef fajitas and was unable to bite through the tortilla with her/his gums. The contents of the fajita spilled out of the tortilla and landed on the resident's chest. The resident picked up the beef pieces which ranged from one-to-two inches in length and put them in her/his mouth. Resident 10 was unable to answer any questions about her/his diet.

On 7/17/24 at 8:27 PM Staff 19 (CNA) stated Resident 10 was not considered at risk to aspirate and thought

the resident received a regular diet.

On 7/18/24 at 12:16 PM Staff 2 (DNS) and Staff 21 (Resident Care Coordinator) along with the State Surveyor observed Resident 10 in bed with her/his meal tray on an overbed table in front of the resident. Staff 2 attempted to cut the meat on the resident's plate with a fork and could not. Staff 2 confirmed the meat Resident 10 was served was not easy to chew and should have been. Staff 2 and Staff 21 were informed of

the beef fajitas served to Resident 10 on 7/15/24, and Staff 2 stated beef fajitas and tortillas were not considered easy to chew foods.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of 27 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 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food

in accordance with professional standards. Level of Harm - Minimal harm or potential for actual harm 46053

Residents Affected - Some Based on observation, interview and record review it was determined the facility failed to ensure beverages were labeled and stored in a manner to minimize spoilage and bulk food items were stored in a manner to minimize cross contamination in 1 of 1 kitchen reviewed for sanitary conditions. This placed residents at risk of foodborne illness. Findings include:

On 7/15/24 at 9:49 AM during the initial tour of the kitchen dry storage area, a plastic scoop was observed to be partially buried in the bulk sugar. Staff 24 acknowledged the scoop was not stored appropriately and stated it should be in the provided holster above the sugar rather than in the supply of sugar, to minimize the risk of cross contamination.

On 7/15/24 at 9:57 AM the following items were observed to be stored in the snack refrigerator in the facility's 100 hallway:

-A previously-opened liter container of nectar-thick lemon water dated 6/23

-A previously-opened liter container of nectar-thick lemon water dated 6/4

-A previously-opened liter container of nectar-thick orange juice labeled Use by 6/26

Staff 24 acknowledged the manner in which these items were labeled was unclear as they did not indicate if

the dates referred to when they were opened or when they should be discarded. He stated these items should be discarded as it was unsafe to store and use juice beyond seven days after it was opened. Staff 24 stated he was not clear about who was supposed to monitor and discard outdated items in the snack refrigerator.

On 7/19/24 at 1:12 PM Staff 1 acknowledged the deficiencies observed in the kitchen's dry storage area and

in the snack refrigerator. He stated he expected the facility staff to label items when they were opened and when they should be discarded in order to reduce the risk of spoilage. He stated he also expected staff to store dry goods in a manner to avoid cross contamination.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 27 of 27 385132