Inspection Reports for
Avamere at Hillsboro

2000 SE 30th Ave, Hillsboro, OR 97123, USA, OR, 97123

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Deficiencies (last 5 years)

Deficiencies (over 5 years) 21.4 deficiencies/year

Deficiencies are regulatory violations found during state inspections.

219% worse than Oregon average
Oregon average: 6.7 deficiencies/year

Deficiencies per year

80 60 40 20 0
2021
2022
2023
2024
2025

Inspection Report

Routine
Capacity: 24 Deficiencies: 2 Date: Jul 1, 2025

Visit Reason
Facility failed to ensure kitchen was maintained in accordance with Food Sanitation Rules including cleaning and repair needs. Staff beverages were improperly stored and alcohol wipes were unavailable. Staff did not cover beverages during meal delivery.

Findings
Facility failed to ensure kitchen was maintained in accordance with Food Sanitation Rules including cleaning and repair needs. Staff beverages were improperly stored and alcohol wipes were unavailable. Staff did not cover beverages during meal delivery.

Deficiencies (2)
OAR 411-054-0030 (1)(a) Resident Services Meals, Food Sanitation Rule
OAR 411-057-0140(2) Administration Compliance

Inspection Report

Complaint Investigation
Capacity: 127 Deficiencies: 2 Date: Mar 3, 2025

Visit Reason
No deficiencies were cited during this complaint licensure survey.

Findings
No deficiencies were cited during this complaint licensure survey.

Deficiencies (2)
F0000 - INITIAL COMMENTS with no deficiencies noted.
M0000 - Initial Comments with no deficiencies noted.

Inspection Report

Complaint Investigation
Capacity: 127 Deficiencies: 2 Date: Dec 2, 2024

Visit Reason
No deficiencies were cited during this complaint licensure survey.

Findings
No deficiencies were cited during this complaint licensure survey.

Deficiencies (2)
F0000 - INITIAL COMMENTS with no deficiencies noted.
M0000 - Initial Comments with no deficiencies noted.

Inspection Report

Complaint Investigation
Capacity: 127 Deficiencies: 26 Date: Sep 13, 2024

Visit Reason
Multiple deficiencies were cited related to resident dignity, informed consent, self-determination, environment safety, abuse reporting and investigation, assessment accuracy, PASARR coordination, baseline care planning, care plan revisions, discharge summaries, activities, hearing/vision treatment, pressure ulcer care, tube feeding, trauma informed care, nursing staff competency, social services, medication storage, dental services, food sanitation, infection control, and staffing.

Findings
Multiple deficiencies were cited related to resident dignity, informed consent, self-determination, environment safety, abuse reporting and investigation, assessment accuracy, PASARR coordination, baseline care planning, care plan revisions, discharge summaries, activities, hearing/vision treatment, pressure ulcer care, tube feeding, trauma informed care, nursing staff competency, social services, medication storage, dental services, food sanitation, infection control, and staffing.

Deficiencies (26)
F0000 - INITIAL COMMENTS with deficiencies not corrected on revisit.
F0550 - Resident Rights/Exercise of Rights: Facility failed to ensure dignity for a resident by using Styrofoam dishware, placing residents at risk for lack of dignity.
F0552 - Right to be Informed/Make Treatment Decisions: Facility failed to obtain consent prior to administering antipsychotic medication for a resident, risking uninformed medication use.
F0561 - Self-Determination: Facility failed to honor a resident's preference to get dressed, risking lack of choices and self-determination.
F0584 - Safe/Clean/Comfortable/Homelike Environment: Facility failed to maintain a homelike environment with multiple maintenance issues, risking unkempt environment.
F0609 - Reporting of Alleged Violations: Facility failed to report an allegation of abuse to the State Survey Agency, risking abuse and neglect.
F0610 - Investigate/Prevent/Correct Alleged Violation: Facility failed to investigate an allegation of abuse, risking abuse and neglect.
F0641 - Accuracy of Assessments: Facility failed to ensure accurate assessments for residents, risking inaccurate assessments.
F0644 - Coordination of PASARR and Assessments: Facility failed to incorporate PASARR Level II recommendations into assessments and care plans, risking delayed care.
F0655 - Baseline Care Plan: Facility failed to complete a baseline care plan within 48 hours of admission, risking unmet needs.
F0657 - Care Plan Timing and Revision: Facility failed to revise care plans for residents, risking unmet needs.
F0661 - Discharge Summary: Facility failed to ensure accurate discharge summaries, risking unmet discharge needs.
F0676 - Activities Daily Living (ADLs)/Mntn Abilities: Facility failed to provide appropriate treatment and services in communication and activities, risking diminished quality of life.
F0685 - Treatment/Devices to Maintain Hearing/Vision: Facility failed to ensure treatment and services to maintain hearing abilities, risking unmet hearing needs.
F0686 - Treatment/Svcs to Prevent/Heal Pressure Ulcer: Facility failed to assess pressure ulcers and update care plans, risking worsening ulcers.
F0693 - Tube Feeding Mgmt/Restore Eating Skills: Facility failed to provide appropriate care related to tube feeding, risking nutritional complications.
F0699 - Trauma Informed Care: Facility failed to ensure trauma-informed care for residents, risking re-traumatization and decreased quality of life.
F0726 - Competent Nursing Staff: Facility failed to provide staff with appropriate competencies and skills, risking unmet resident needs.
F0745 - Provision of Medically Related Social Service: Facility failed to provide medically-related social services, risking unmet needs and decreased dignity.
F0761 - Label/Store Drugs and Biologicals: Facility failed to ensure proper storage of biologicals, risking unsafe access.
F0791 - Routine/Emergency Dental Srvcs in NFs: Facility failed to ensure routine dental services were provided, risking unmet dental needs.
F0812 - Food Procurement,Store/Prepare/Serve-Sanitary: Facility failed to maintain a clean and sanitary kitchen environment, risking infections.
F0880 - Infection Prevention & Control: Facility failed to follow infection control precautions, risking cross contamination and infection.
M0000 - Initial Comments with deficiencies not corrected on revisit.
M0182 - Nursing Services:Minimum Licensed Nurse Staff: Facility failed to ensure RN coverage for required hours, risking lack of oversight.
M9999 - STATE OF OREGON ADMINISTRATIVE RULES: Multiple OAR references related to cited deficiencies.

Inspection Report

Capacity: 24 Deficiencies: 5 Date: Sep 12, 2024

Visit Reason
Facility failed to complete and document fire drills on alternate months and provide fire and life safety instruction to staff on alternate months. Grounds and building exterior were not maintained orderly and clean. Interior doors, walls, and surfaces were not kept clean and in good repair. Administration compliance and staff training requirements were not met.

Findings
Facility failed to complete and document fire drills on alternate months and provide fire and life safety instruction to staff on alternate months. Grounds and building exterior were not maintained orderly and clean. Interior doors, walls, and surfaces were not kept clean and in good repair. Administration compliance and staff training requirements were not met.

Deficiencies (5)
OAR 411-054-0090 (1-2) Fire and Life Safety: Safety
OAR 411-054-0200 (3) General Building Exterior
OAR 411-054-0200 (4)(d-i) Doors, Walls, Elevators, Odors
OAR 411-057-0140(2) Administration Compliance
OAR 411-057-0155(1-6) Staff Training Requirements

Inspection Report

Capacity: 24 Deficiencies: 2 Date: Jun 20, 2024

Visit Reason
Kitchen inspection found multiple sanitation and food storage issues. Dishwashing machine temperature was inadequate initially. Staff failed to follow licensing rules for administration compliance.

Findings
Kitchen inspection found multiple sanitation and food storage issues. Dishwashing machine temperature was inadequate initially. Staff failed to follow licensing rules for administration compliance.

Deficiencies (2)
OAR 411-054-0030 Resident Services Meals, Food Sanitation Rule
OAR 411-057-0140(2) Administration Compliance

Inspection Report

Complaint Investigation
Capacity: 127 Deficiencies: 6 Date: Jan 25, 2024

Visit Reason
Deficiencies included failure to ensure resident safety with mechanical lift, urinary incontinence care, sufficient nursing staff, and thorough abuse investigations. Some deficiencies were corrected on revisit but others remained uncorrected.

Findings
Deficiencies included failure to ensure resident safety with mechanical lift, urinary incontinence care, sufficient nursing staff, and thorough abuse investigations. Some deficiencies were corrected on revisit but others remained uncorrected.

Deficiencies (6)
F0000 - INITIAL COMMENTS with deficiencies not corrected on revisit.
F0689 - Free of Accident Hazards/Supervision/Devices: Facility failed to ensure safe use of mechanical lift causing resident injury.
F0690 - Bowel/Bladder Incontinence, Catheter, UTI: Facility failed to provide adequate urinary incontinence care, risking unmet bladder care needs.
F0725 - Sufficient Nursing Staff: Facility failed to provide adequate qualified staff, risking unmet resident needs.
M0000 - Initial Comments with deficiencies not corrected on revisit.
M9999 - STATE OF OREGON ADMINISTRATIVE RULES: Multiple OAR references related to cited deficiencies.

Inspection Report

Complaint Investigation
Capacity: 127 Deficiencies: 4 Date: Oct 16, 2023

Visit Reason
Deficiencies included medication errors with insulin administration and failure to ensure residents were free from unnecessary drugs. Some deficiencies were corrected on revisit but others remained uncorrected.

Findings
Deficiencies included medication errors with insulin administration and failure to ensure residents were free from unnecessary drugs. Some deficiencies were corrected on revisit but others remained uncorrected.

Deficiencies (4)
F0000 - INITIAL COMMENTS with deficiencies not corrected on revisit.
F0757 - Drug Regimen is Free from Unnecessary Drugs: Facility failed to ensure residents were free from unnecessary medication, risking adverse consequences.
M0000 - Initial Comments with deficiencies not corrected on revisit.
M9999 - STATE OF OREGON ADMINISTRATIVE RULES: Multiple OAR references related to cited deficiencies.

Inspection Report

Complaint Investigation
Capacity: 127 Deficiencies: 6 Date: Oct 10, 2023

Visit Reason
Deficiencies included failure to protect residents from verbal and mental abuse by a visitor, failure to conduct thorough abuse investigations, and failure to provide trauma-informed care. Some deficiencies were corrected on revisit but others remained uncorrected.

Findings
Deficiencies included failure to protect residents from verbal and mental abuse by a visitor, failure to conduct thorough abuse investigations, and failure to provide trauma-informed care. Some deficiencies were corrected on revisit but others remained uncorrected.

Deficiencies (6)
F0000 - INITIAL COMMENTS with deficiencies not corrected on revisit.
F0600 - Free from Abuse and Neglect: Facility failed to protect resident from verbal and mental abuse by a visitor, risking abuse.
F0610 - Investigate/Prevent/Correct Alleged Violation: Facility failed to ensure thorough investigation of abuse allegations, risking incomplete investigations.
F0699 - Trauma Informed Care: Facility failed to provide trauma-informed care for a resident with trauma history, risking re-traumatization.
M0000 - Initial Comments with deficiencies not corrected on revisit.
M9999 - STATE OF OREGON ADMINISTRATIVE RULES: Multiple OAR references related to cited deficiencies.

Inspection Report

Complaint Investigation
Capacity: 127 Deficiencies: 20 Date: Jun 15, 2023

Visit Reason
Multiple deficiencies were cited related to resident dignity, environment, care planning, quality of care, activities, hearing/vision treatment, staffing, medication management, infection control, and safety. Some deficiencies were corrected on revisit but many remained uncorrected.

Findings
Multiple deficiencies were cited related to resident dignity, environment, care planning, quality of care, activities, hearing/vision treatment, staffing, medication management, infection control, and safety. Some deficiencies were corrected on revisit but many remained uncorrected.

Deficiencies (20)
F0000 - INITIAL COMMENTS with deficiencies not corrected on revisit.
F0550 - Resident Rights/Exercise of Rights: Facility failed to treat residents in a dignified manner, risking undignified existence.
F0584 - Safe/Clean/Comfortable/Homelike Environment: Facility failed to exercise reasonable care for protection of resident property, risking unhomelike environment.
F0655 - Baseline Care Plan: Facility failed to provide baseline care plan timely, risking uninformed residents.
F0656 - Develop/Implement Comprehensive Care Plan: Facility failed to implement care plans, risking unmet needs.
F0657 - Care Plan Timing and Revision: Facility failed to revise care plans comprehensively, risking unmet needs.
F0684 - Quality of Care: Facility failed to follow physician orders, risking increased swelling and discomfort.
F0685 - Treatment/Devices to Maintain Hearing/Vision: Facility failed to provide treatment to maintain vision, risking unmet vision needs.
F0689 - Free of Accident Hazards/Supervision/Devices: Facility failed to prevent falls and secure smoking materials, risking accidents and injuries.
F0690 - Bowel/Bladder Incontinence, Catheter, UTI: Facility failed to ensure appropriate urinary catheterization, risking infections.
F0692 - Nutrition/Hydration Status Maintenance: Facility failed to intervene promptly for significant weight loss, risking increased risk.
F0695 - Respiratory/Tracheostomy Care and Suctioning: Facility failed to follow physician orders for respiratory care, risking adverse effects.
F0725 - Sufficient Nursing Staff: Facility failed to ensure sufficient nursing staff, risking unmet care needs.
F0732 - Posted Nurse Staffing Information: Facility failed to maintain accurate staffing reports, risking inaccurate information.
F0758 - Free from Unnec Psychotropic Meds/PRN Use: Facility failed to limit PRN antipsychotic orders, risking adverse side effects.
F0761 - Label/Store Drugs and Biologicals: Facility failed to secure medications on carts, risking misappropriation.
F0880 - Infection Prevention & Control: Facility failed to ensure infection control precautions, resulting in immediate jeopardy.
M0000 - Initial Comments with deficiencies not corrected on revisit.
M0183 - Nursing Services: Minimum CNA Staffing: Facility failed to maintain minimum CNA staffing ratios, risking delayed treatment.
M9999 - STATE OF OREGON ADMINISTRATIVE RULES: Multiple OAR references related to cited deficiencies.

Inspection Report

Capacity: 24 Deficiencies: 3 Date: May 9, 2023

Visit Reason
Kitchen sanitation issues including uncovered food, improper storage, and lack of aprons for staff. Administration compliance and inspection interval requirements were not met initially but corrected on later visits.

Findings
Kitchen sanitation issues including uncovered food, improper storage, and lack of aprons for staff. Administration compliance and inspection interval requirements were not met initially but corrected on later visits.

Deficiencies (3)
OAR 411-054-0030 Resident Services Meals, Food Sanitation Rule
OAR 411-054-0455 Inspections and Investigation: Insp Interval
OAR 411-057-0140(2) Administration Compliance

Inspection Report

Complaint Investigation
Capacity: 127 Deficiencies: 4 Date: Mar 2, 2023

Visit Reason
Deficiencies included failure to administer medications as ordered resulting in significant medication error. Facility took immediate corrective actions and implemented audits.

Findings
Deficiencies included failure to administer medications as ordered resulting in significant medication error. Facility took immediate corrective actions and implemented audits.

Deficiencies (4)
F0000 - INITIAL COMMENTS with deficiencies not corrected on revisit.
F0760 - Residents are Free of Significant Med Errors: Facility failed to administer medications as ordered causing significant medication error.
M0000 - Initial Comments with deficiencies not corrected on revisit.
M9999 - STATE OF OREGON ADMINISTRATIVE RULES: Multiple OAR references related to cited deficiencies.

Inspection Report

Complaint Investigation
Capacity: 127 Deficiencies: 8 Date: Jan 10, 2023

Visit Reason
Deficiencies included failure to notify resident representative of injury, failure to report verbal abuse allegations, failure to follow physician orders, failure to prevent falls, failure to maintain accurate resident records, and failure to follow infection control precautions. Some deficiencies were corrected on revisit but others remained uncorrected.

Findings
Deficiencies included failure to notify resident representative of injury, failure to report verbal abuse allegations, failure to follow physician orders, failure to prevent falls, failure to maintain accurate resident records, and failure to follow infection control precautions. Some deficiencies were corrected on revisit but others remained uncorrected.

Deficiencies (8)
F0000 - INITIAL COMMENTS with deficiencies not corrected on revisit.
F0580 - Notify of Changes (Injury/Decline/Room, etc.): Facility failed to notify resident representative of injury, risking increased injury risk.
F0609 - Reporting of Alleged Violations: Facility failed to report verbal abuse allegation to state agency, risking verbal abuse.
F0684 - Quality of Care: Facility failed to follow physician orders for insulin administration, risking diabetic complications.
F0689 - Free of Accident Hazards/Supervision/Devices: Facility failed to implement care plan interventions to prevent falls, risking resident injury.
F0842 - Resident Records - Identifiable Information: Facility failed to ensure accurate resident medical records, risking missed treatments.
M0000 - Initial Comments with deficiencies not corrected on revisit.
M9999 - STATE OF OREGON ADMINISTRATIVE RULES: Multiple OAR references related to cited deficiencies.

Inspection Report

Complaint Investigation
Capacity: 24 Deficiencies: 3 Date: Nov 15, 2022

Visit Reason
Facility failed to notify emergency contact in an emergency, failed to ensure residents with dementia had proper diagnosis for memory care placement, and failed to comply with resident services requirements.

Findings
Facility failed to notify emergency contact in an emergency, failed to ensure residents with dementia had proper diagnosis for memory care placement, and failed to comply with resident services requirements.

Deficiencies (3)
OAR 411-054-0010 Licensing Complaint Investigation
OAR 411-054-0252 Resident Move-In and Eval: Res Evaluation
OAR 411-057-0160 Resident Services

Inspection Report

Complaint Investigation
Capacity: 127 Deficiencies: 4 Date: Sep 13, 2022

Visit Reason
Deficiencies included failure to follow care planned interventions causing resident injury, failure to ensure safe transfers, and failure to follow care plans for transfers and staffing. Some deficiencies were corrected on revisit but others remained uncorrected.

Findings
Deficiencies included failure to follow care planned interventions causing resident injury, failure to ensure safe transfers, and failure to follow care plans for transfers and staffing. Some deficiencies were corrected on revisit but others remained uncorrected.

Deficiencies (4)
F0000 - INITIAL COMMENTS with deficiencies not corrected on revisit.
F0689 - Free of Accident Hazards/Supervision/Devices: Facility failed to follow care planned interventions for transfers, resulting in resident injury.
M0000 - Initial Comments with deficiencies not corrected on revisit.
M9999 - STATE OF OREGON ADMINISTRATIVE RULES: Multiple OAR references related to cited deficiencies.

Inspection Report

Capacity: 24 Deficiencies: 10 Date: Mar 31, 2021

Visit Reason
Multiple deficiencies including failure to report and investigate abuse, failure to provide assistance with ADLs, incomplete resident evaluations and service plans, failure to conduct and document fire drills, and inadequate staff training.

Findings
Multiple deficiencies including failure to report and investigate abuse, failure to provide assistance with ADLs, incomplete resident evaluations and service plans, failure to conduct and document fire drills, and inadequate staff training.

Deficiencies (10)
OAR 411-054-0231 Reporting & Investigating Abuse-Other Action
OAR 411-054-0243 Resident Services: Adls
OAR 411-054-0260 Service Plan: General
OAR 411-054-0270 Change of Condition and Monitoring
OAR 411-054-0420 Fire and Life Safety: Safety
OAR 411-054-0422 Fire and Life Safety: Training For Residents
OAR 411-054-0455 Inspections and Investigation: Insp Interval
OAR 411-057-0140 Administration Compliance
OAR 411-057-0155 Staff Training Requirements
OAR 411-057-0162 Compliance With Rules Health Care

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