Inspection Reports for Avamere Court at Keizer RCF
5210 RIVER ROAD N, KEIZER, OR, 97303
Back to Facility ProfileInspection Report Summary
The most recent inspection on April 7, 2025, identified deficiencies related to severe sanitation and safety concerns in the satellite kitchen area, resulting in immediate jeopardy and closure of kitchen operations for cleaning and repair. Earlier inspections showed a pattern of issues including ineffective oversight of resident care, incomplete records, medication administration problems, infection control deficiencies, staffing and training noncompliance, and fire and life safety violations. Prior reports also noted recurring kitchen sanitation problems and incomplete investigations of abuse allegations, but enforcement actions such as fines or license suspensions were not listed in the available reports. Complaint investigations were not substantiated according to the available information. The inspection history indicates ongoing challenges with facility administration and food service oversight, with some periods of substantial compliance following revisits, but recent findings suggest these issues have not been fully resolved.
Deficiencies (last 5 years)
Deficiencies (over 5 years)
7.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
16% worse than Oregon average
Oregon average: 6.7 deficiencies/yearDeficiencies per year
28
21
14
7
0
Inspection Report
Routine
Capacity: 63
Deficiencies: 2
Date: Apr 7, 2025
Visit Reason
Immediate jeopardy identified due to severe sanitation and safety concerns in the satellite kitchen area. Kitchen and food storage areas were closed for cleaning and repair. Facility administration failed to provide adequate oversight of food service operations. Multiple sanitation and repair issues noted with no designated Person In Charge during food operations.
Findings
Immediate jeopardy identified due to severe sanitation and safety concerns in the satellite kitchen area. Kitchen and food storage areas were closed for cleaning and repair. Facility administration failed to provide adequate oversight of food service operations. Multiple sanitation and repair issues noted with no designated Person In Charge during food operations.
Deficiencies (2)
OAR 411-054-0025 (1) Facility Administration: Operation — Facility administration failed to ensure adequate oversight of food service operations.
OAR 411-054-0030 (1)(a) Resident Services Meals, Food Sanitation Rule — Facility failed to maintain kitchen in sanitary manner, in good repair, and have a designated Person In Charge, posing immediate jeopardy.
Inspection Report
Capacity: 63
Deficiencies: 25
Date: Nov 21, 2024
Visit Reason
Multiple deficiencies identified including ineffective oversight of resident care and services, incomplete and inaccurate records, failure to conduct abuse investigations, incomplete resident evaluations and service plans, inadequate monitoring of changes of condition, medication administration issues, infection control deficiencies, staffing and training noncompliance, and fire and life safety violations.
Findings
Multiple deficiencies identified including ineffective oversight of resident care and services, incomplete and inaccurate records, failure to conduct abuse investigations, incomplete resident evaluations and service plans, inadequate monitoring of changes of condition, medication administration issues, infection control deficiencies, staffing and training noncompliance, and fire and life safety violations.
Deficiencies (25)
OAR 411-054-0025 (1) Facility Administration: Operation — Failed to provide effective oversight to ensure quality of care and services.
OAR 411-054-0025 (8) Facility Administration: Records — Failed to maintain complete and accurate records for sampled residents.
OAR 411-054-0025 (9) Facility Administration: Quality Improvement — Failed to develop and conduct ongoing quality improvement programs.
OAR 411-054-0028 (1-3) Reporting & Investigating Abuse-Other Action — Failed to conduct investigations of injuries of unknown cause and report suspected abuse.
OAR 411-054-0034 (1-6) Resident Move-in & Evaluation: Res Evaluation — Failed to ensure all required elements addressed in move-in evaluations and quarterly evaluations completed timely.
OAR 411-054-0036 (1-4) Service Plan: General — Failed to ensure service plans reflected residents' current care needs and preferences and were implemented.
OAR 411-054-0036 (5) Service Plan: Service Planning Team — Failed to ensure service plans were developed by a Service Planning Team including required members.
OAR 411-054-0040 (1-2) Change of Condition and Monitoring — Failed to ensure resident-specific interventions were determined, communicated, and monitored through resolution.
OAR 411-054-0045 (1)(a-f)(A)(C-F) Resident Health Services — Failed to assess residents with significant change of condition.
OAR 411-054-0045 (1)(f)(B) RN Delegation and Teaching — Failed to ensure delegation and supervision of nursing tasks per OSBN Division 47 rules.
OAR 411-054-0050(1-5) Infection Prevention & Control — Failed to establish and maintain effective infection prevention and control protocols and designate qualified Infection Control Specialist.
OAR 411-054-0055 (1)(a) Systems: Medications and Treatments — Failed to ensure safe medication system and adequate professional oversight.
OAR 411-054-0055 (1)(e) Systems: Tracking Control Substances — Failed to have system for accurately tracking controlled substances.
OAR 411-054-0055 (2) Systems: Medication Administration — Failed to ensure accurate MARs and clear instructions for PRN medications.
OAR 411-054-0055 (4) Systems: Medication & Treatment-General — Failed to maintain legible signatures of staff administering medications and treatments.
OAR 411-054-0055 (5) Systems: Self-Administration of Meds — Failed to evaluate residents self-administering medications upon move-in and quarterly.
OAR 411-054-0037 (1)(b-g) Acuity Based Staffing Tool - ABST Time — Failed to accurately capture care minutes on ABST for sampled residents.
OAR 411-054-0037 (4-6) Acuity Based Staffing Tool - Updates & Staffing Plan — Failed to ensure all residents had ABST evaluations updated quarterly and upon admission.
OAR 411-054-0070 (5 & 9-10) Training Within 30 Days of Hire – Direct Care Staff — Failed to ensure newly hired direct care staff demonstrated competency within 30 days.
OAR 411-054-0070 (6-8) Annual and Biennial Inservice for All Staff — Failed to ensure required annual in-service training and designation of employees for LGBTQIA2S+ training.
OAR 411-054-0090 (1-2) Fire and Life Safety: Safety — Failed to conduct fire drills per Oregon Fire Code and provide fire and life safety instruction on alternate months.
OAR 411-054-0090 (5) Fire and Life Safety: Training for Residents — Failed to ensure residents were instructed on fire and life safety procedures within 24 hours of admission and annually.
OAR 411-054-0200 (4)(d-i) Doors, Walls, Elevators, Odors — Failed to ensure interior and exterior environment were clean and in good repair.
OAR 411-054-0200 (11-13) Call Sys, Exit Dr Alarm, Phones, TV, or Cable — Failed to ensure exit doors had alarms or acceptable systems to alert staff.
OAR411-004-0020(2)(b) Physical Setting: Individual Accessible — Failed to ensure outside courtyard area was physically accessible to residents without staff assistance.
Inspection Report
Capacity: 63
Deficiencies: 2
Date: Dec 19, 2023
Visit Reason
Kitchen inspection identified deficiencies related to food sanitation rules. Facility was determined to be in substantial compliance upon revisit in April 2024.
Findings
Kitchen inspection identified deficiencies related to food sanitation rules. Facility was determined to be in substantial compliance upon revisit in April 2024.
Deficiencies (2)
OAR 411-054-0030 (1)(a) Resident Services Meals, Food Sanitation Rule — Failed to ensure kitchen was maintained in accordance with Food Sanitation Rules.
OAR 411-054-0030 (1)(a) Resident Services Meals, Food Sanitation Rule — Revisit showed substantial compliance with food sanitation rules.
Inspection Report
Complaint Investigation
Capacity: 63
Deficiencies: 4
Date: Oct 24, 2023
Visit Reason
Licensing complaint investigation identified deficiencies related to treatment orders, medication and treatment review, and acuity-based staffing tool.
Findings
Licensing complaint investigation identified deficiencies related to treatment orders, medication and treatment review, and acuity-based staffing tool.
Deficiencies (4)
OAR 411-054-0000 - Licensing Complaint Investigation — Findings documented in report.
OAR 411-054-0055 (1) Systems: Treatment Orders — Deficiency noted.
OAR 411-054-0055 (1) Systems: Medication and Treatment Review — Deficiency noted.
OAR 411-054-0037 (1) Acuity-Based Staffing Tool — Deficiency noted.
Inspection Report
Capacity: 63
Deficiencies: 2
Date: Dec 15, 2022
Visit Reason
Kitchen inspection identified deficiencies related to refrigeration temperatures and hood vent cleanliness. Facility was determined to be in substantial compliance upon revisit in March 2023.
Findings
Kitchen inspection identified deficiencies related to refrigeration temperatures and hood vent cleanliness. Facility was determined to be in substantial compliance upon revisit in March 2023.
Deficiencies (2)
OAR 411-054-0030 (1)(a) Resident Services Meals, Food Sanitation Rule — Failed to maintain appropriate refrigeration temperatures and clean hood vents.
OAR 411-054-0030 (1)(a) Resident Services Meals, Food Sanitation Rule — Revisit showed substantial compliance with food sanitation rules.
Inspection Report
Capacity: 63
Deficiencies: 1
Date: Jun 21, 2021
Visit Reason
COVID-19 Preparedness Follow up Questionnaire completed.
Findings
COVID-19 Preparedness Follow up Questionnaire completed.
Deficiencies (1)
OAR 411-054-0000 - Comment — COVID-19 Preparedness Follow up Questionnaire.
Inspection Report
Capacity: 63
Deficiencies: 3
Date: Jun 21, 2021
Visit Reason
Re-licensure survey and subsequent revisits identified deficiencies related to kitchen sanitation and repair, staffing requirements and training, and annual inservice training. Facility was determined to be in substantial compliance after second revisit.
Findings
Re-licensure survey and subsequent revisits identified deficiencies related to kitchen sanitation and repair, staffing requirements and training, and annual inservice training. Facility was determined to be in substantial compliance after second revisit.
Deficiencies (3)
OAR 411-054-0030 (1)(a) Resident Services Meals, Food Sanitation Rule — Failed to ensure kitchen was clean and in good repair; repeat citation.
OAR 411-054-0370 Staffing Requirements and Training – Pre-Serv — Failed to ensure newly hired staff completed required pre-service training prior to job responsibilities.
OAR 411-054-0374 Annual and Biennial Inservice For All Staff — Failed to ensure required annual in-service training completed.
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