Avamere Rehabilitation Of King City
AVAMERE REHABILITATION OF KING CITY in TIGARD, OR — inspection on February 20, 2026.
Found 2 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
Summary Report documented Resident 4's blood pressure was 86/53 at 5:00 AM by Staff 6 (LPN). Resident 4's 11/25/25 Progress Note at 6:50 AM, indicated Staff 6 charted Resident 4's blood pressure as 70/50.
Staff 6 called provider and 911. No additional information was documented. On 2/18/26 at 2:32 PM, Staff 6 (LPN) stated she had cared for Resident 4 during the night shift on 11/24/25 through 11/25/25.
Staff 6 stated the morning of 11/25/25 staff was unable to wake Resident 4.
Staff 6 stated Resident 4's blood pressure was abnormal and low.
Staff 6 called the provider then called 911. A Fire and Rescue Public Incident Report documented that a call from the facility was received on 11/25/25 at 6:46 AM stating Resident 4 was found with altered mental status.
Paramedics arrived at the facility at 6:50 AM.
Staff 6 (LPN) reported to the paramedics that Resident 4 was found altered at 5:00 AM.
Paramedics administered Narcan (an antidote for opioids), and Resident 4's vital signs improved. Resident 4 was transported to the hospital. On 2/20/26 at 10:19 AM, Staff 14 (CNA) stated she had cared for Resident 4 during the night shift on 11/24/25 through 11/25/25.
Staff 14 stated Resident 4 appeared to be sleeping through-out the night.
Staff 14 stated when she took Resident 4's blood pressure at 5:00 AM it was very low.
Staff 14 alerted Staff 6 (LPN) and Resident 4's blood pressure was rechecked and continued to be low.
Staff 14 stated Staff 6 assisted her in providing incontinence care to Resident 4.
Staff 14 stated it was odd Resident 4 did not wake up during care because the resident usually woke up when staff laid the resident flat.
Staff 14 stated Resident 4 sometimes would stay awake for three days and then slept hard.
Staff 14 stated Resident 4 did not respond to them.
Staff 14 stated Staff 6 called the provider and 911.The 12/2/25 Hospital Discharge Summary revealed Resident 4 was admitted to the hospital for septic shock due to UTI, acute kidney injury, acute metabolic encephalopathy and acute hypoxic/hypercapnic respiratory failure.On 2/20/26 at 2:46 PM, Staff 1 (Administrator) acknowledged there was a delay by staff in responding to Resident 4's change of condition and Resident 4's progress notes did not include the baseline information regarding her/his change of condition.
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
385132 02/20/2026
Avamere Rehabilitation of King City 16485 SW Pacific Highway Tigard, OR 97224
services of a licensed pharmacist.
correct route for an emergency (Narcan) medication for 1 of 3 sampled residents (#4) reviewed for
emergency medication.
Findings include: Resident 4 was re-admitted to the facility in 12/2025 with diagnoses including multiple sclerosis, diabetes and opioid use. Resident 4's 11/2025 Physician Orders included an order for naloxone HCL (Narcan-an antidote medication for opioids) nasal liquid 4mg/0.1ML to be administered in both nostrils as needed for decreased responsiveness. On 2/19/26 at 12:34 PM, observations of the facility's emergency kit found Narcan as an intravenous route rather than the nasal route as prescribed for Resident 4. On 2/20/26 at 2:46 PM, Staff 1 (Administrator) acknowledged the facility did not have the correct Narcan route administration (nasal) for Resident 4.