Inspection Reports for Avamere at Three Fountains
835 Crater Lake Avenue, OR, 97504
Back to Facility ProfileDeficiencies per Year
28
21
14
7
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Inspection Report
Complaint Investigation
Capacity: 117
Deficiencies: 26
Oct 28, 2025
Visit Reason
State-compiled facility profile showing 9 inspections from 2021 to 2025 with deficiency history and enforcement actions
Findings
Across multiple inspections from 2021 to 2025, the facility exhibited numerous deficiencies including failures in medication administration, infection control, restorative services, staff training, resident care planning, and safety measures. Several deficiencies were corrected while others remained uncorrected at follow-up visits, indicating ongoing compliance challenges.
Deficiencies (26)
| Description |
|---|
| F0000 - INITIAL COMMENTS |
| M0000 - Initial Comments |
| F0554 - Resident Self-Admin Meds-Clinically Approp: Failed to ensure residents were assessed for self-administration of medications |
| F0688 - Increase/Prevent Decrease in ROM/Mobility: Failed to ensure restorative services were provided to maintain mobility for sampled residents |
| F0880 - Infection Prevention & Control: Failed to ensure transmission-based precautions, sanitation, and proper linen transport |
| F0881 - Antibiotic Stewardship Program: Failed to ensure antibiotic use was properly indicated and monitored |
| F0947 - Required In-Service Training for Nurse Aides: Failed to ensure CNA staff completed required annual training hours |
| F0602 - Free from Misappropriation/Exploitation: Failed to ensure residents were free from misappropriation of narcotic medications |
| F0658 - Services Provided Meet Professional Standards: Failed to adhere to professional standards resulting in medication error and hospitalization |
| F0760 - Residents are Free of Significant Med Errors: Resident hospitalized due to significant medication error |
| F0657 - Care Plan Timing and Revision: Failed to revise care plans timely for sampled residents |
| F0679 - Activities Meet Interest/Needs Each Resident: Failed to provide meaningful activity programs for sampled residents |
| F0686 - Treatment/Svcs to Prevent/Heal Pressure Ulcer: Failed to accurately assess pressure ulcers |
| F0744 - Treatment/Service for Dementia: Failed to provide adequate dementia behavior identification and monitoring |
| F0758 - Free from Unnec Psychotropic Meds/PRN Use: Failed to ensure gradual dose reduction of antipsychotic medication |
| F0791 - Routine/Emergency Dental Srvcs in NFs: Failed to ensure residents received routine dental care |
| F0812 - Food Procurement,Store/Prepare/Serve-Sanitary: Failed to ensure proper sanitation protocols in kitchen |
| F0919 - Resident Call System: Failed to ensure call system activation device was available in resident bathroom |
| F0921 - Safe/Functional/Sanitary/Comfortable Environ: Failed to ensure automatic doors were functional |
| F0838 - Facility Assessment: Failed to develop a comprehensive facility wide assessment |
| F0580 - Notify of Changes (Injury/Decline/Room, etc.): Failed to notify resident's representative and physician of change in condition |
| F0660 - Discharge Planning Process: Failed to implement effective discharge planning |
| F0684 - Quality of Care: Failed to respond to changes in condition in a timely manner |
| F0600 - Free from Abuse and Neglect: Failed to ensure residents were free from verbal abuse |
| F0661 - Discharge Summary: Failed to ensure thorough discharge summaries were completed |
| F0689 - Free of Accident Hazards/Supervision/Devices: Failed to ensure staff followed care plans to prevent falls and accidents |
Report Facts
Inspections on page: 9
Total Surveys: 9
Total Deficiencies: 26
Licensing Violations: 20
Licensed Beds: 117
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff 1 | Administrator | Named in medication error, narcotic misappropriation, infection control, and other findings |
| Staff 2 | DNS | Named in medication error, narcotic misappropriation, infection control, and other findings |
| Staff 3 | Assistant DNS / LPN Resident Care Manager | Named in restorative services, dementia care, and other findings |
| Staff 6 | LPN / Nurse Practitioner | Named in antibiotic stewardship and medication error findings |
| Staff 7 | RCM / LPN | Named in narcotic misappropriation and fall incident investigations |
| Staff 8 | LPN / RCM-LPN | Named in narcotic misappropriation and fall incident investigations |
| Staff 9 | LPN Resident Care Manager | Named in restorative services and antibiotic stewardship findings |
| Staff 10 | Activity Assistant / LPN Resident Care Manager | Named in activity program and dementia care findings |
| Staff 11 | CNA | Named in dementia care and fall incident findings |
| Staff 12 | CNA / Social Service | Named in infection control and dental care findings |
| Staff 13 | LPN | Named in pressure ulcer and infection control findings |
| Staff 14 | Activity Director | Named in activity program findings |
| Staff 16 | CNA | Named in restorative services and activity program findings |
| Staff 17 | CNA / LPN | Named in restorative services, nurse aide training, and fall incident findings |
| Staff 18 | CNA | Named in nurse aide training and activity program findings |
| Staff 21 | LPN | Named in infection control findings |
| Staff 22 | LPN | Named in fall incident findings |
| Staff 23 | Former CNA | Named in courtyard door incident |
| Staff 24 | LPN | Named in dementia care findings |
| Staff 25 | MDS Coordinator | Named in infection control findings |
| Staff 26 | CMA | Named in dementia care findings |
| Staff 27 | CNA | Named in infection control findings |
| Staff 28 | CMA | Named in infection control findings |
| Staff 31 | CNA | Named in infection control findings |
| Staff 32 | CNA | Named in medication self-administration findings |
| Staff 33 | RA | Named in restorative services findings |
| Staff 34 | LPN | Named in infection control findings |
| Staff 35 | RN | Named in infection control findings |
| Staff 36 | Laundry | Named in infection control findings |
| Staff 37 | Housekeeping Director | Named in infection control findings |
| Staff 38 | CMA | Named in infection control findings |
| Staff 39 | PT Assistant | Named in restorative services findings |
| Staff 4 | LPN Infection Preventionist / Maintenance Assistant | Named in infection control and call system findings |
| Staff 5 | Resident 24's Physician / Social Services Director / Admission Coordinator | Named in antibiotic stewardship, discharge planning, and dental care findings |
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