Above average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Avamere Court At Keizer during CMS and state inspections, most recent first.
Care Plan Not Updated for Meal Supervision Needs: A resident with a swallowing problem had therapy notes and nursing progress notes indicating the need for supervision and assistance with meals, but the care plan and Kardex were not updated to reflect that need. Staff confirmed the meal supervision order was not included, and the resident was observed eating lunch in bed with no staff present in the room.
The facility failed to ensure a system was in place to receive and resolve grievances. Residents were unaware of how to file grievances, and no information or forms were readily available in common areas. A resident reported a lost mechanical lift sling with no resolution and was not offered a grievance form. The administrator confirmed the lack of signage and verbal reminders about the grievance process.
The facility neglected to ensure the availability of mechanical lift slings and briefs, leading to significant issues for residents. Multiple residents reported being unable to get out of bed due to the lack of slings, and staff confirmed frequent shortages of briefs and wipes, particularly on weekends. The Administrator acknowledged the issue, highlighting the facility's failure to provide necessary equipment and supplies, compromising residents' independence and well-being.
The facility failed to respond to resident council concerns expressed at three meetings, including issues with laundry services, food quality, supply shortages, and improper handling of clothes by aides. Staff confirmed the lack of responses, and the Administrator acknowledged the issue, which placed residents at risk for unmet needs and lessened quality of life.
The facility failed to ensure residents were notified of their rights both orally and in writing on an ongoing basis. A review of Resident Council Meeting minutes and staff interviews revealed no system to track and review resident rights, and no resident rights were posted in the facility. The Administrator acknowledged these deficiencies.
The facility failed to maintain RN coverage for at least eight consecutive hours a day for 9 out of 62 days reviewed. This deficiency was identified through a review of staffing reports for February 2023, September 2023, and May 2024. During an interview, the Staffing Coordinator and Human Resources acknowledged the struggle with RN coverage in February and September 2023, but no additional information was provided for May 2024.
The facility failed to ensure medications were secured and only accessible to authorized persons. An LPN found Ozempic stored in the DNS's office refrigerator, which was unlocked and in plain view. The DNS's office door was also observed propped open with the DNS not present. Both the Administrator and DNS acknowledged that medications should be locked and secured in the designated medication storage room.
The facility failed to properly label and store food, maintain complete temperature logs, ensure staff wore hair restraints, and maintain correct bleach concentration in cleaning solutions, leading to potential infection risks.
The facility failed to properly disinfect a shared glucometer between uses for four residents with type II diabetes, and did not maintain sanitary conditions for a resident's grab bars, which were worn and dirty. An LPN acknowledged the improper disinfection due to being busy, and an RNCM confirmed the grab bars needed replacement.
The facility failed to provide a dignified dining experience by not delivering meals to all residents at a table simultaneously. A resident with dysphagia waited 28 minutes for lunch while others ate and had their tables cleared. Staff acknowledged ongoing issues with meal delivery timeliness and incorrect meal cart placements.
The facility failed to revise the care plan for a resident with Huntington's disease receiving hospice care. Despite a significant change in condition indicating the resident was expected to live six months or less, the care plan was not updated to reflect hospice care needs. The administrator acknowledged the need for revision.
The facility failed to follow physician orders and implement bowel care timely for three residents, leading to missed medications and inadequate bowel management. One resident missed multiple doses of alpha-lipoic acid, another did not receive sevelamer carbonate during dialysis, and a third did not receive appropriate bowel care and had medications improperly crushed.
A resident with mild cognitive impairment was administered Quetiapine Fumarate without an appropriate diagnosis or documented behaviors justifying its use. Staff confirmed the diagnosis was inappropriate and that the resident did not exhibit behaviors indicating the need for the medication.
The facility failed to maintain a medication pass error rate below 5%, resulting in a 7.14% error rate. One resident received crushed extended-release metformin tablets, and another received a house stock multivitamin instead of the prescribed PreserVision AREDS supplement. Both errors were acknowledged by the facility's DNS and Administrator.
Care Plan Not Updated for Meal Supervision Needs
Penalty
Summary
The facility failed to revise Resident 7’s plan of care to reflect current nutrition-related needs. Resident 7 was admitted in 6/2025 with diagnoses including a urinary tract infection, and a 9/2/25 care plan identified a swallowing problem and the need for assistance with meals. A 9/6/25 Speech Therapy progress note and a 9/7/25 progress note both stated Resident 7 was to receive supervision and assistance with meals, but the care plan and Kardex were not updated to include supervision. Staff 5 stated the Kardex did not indicate supervision for meals, Staff 4 reviewed the care plan and confirmed it did not show the need for meal supervision, Staff 3 stated speech therapy had provided orders to nursing for supervision during meals, and Staff 2 confirmed the care plan was not updated to include supervision for meals. Resident 7 was observed eating lunch in bed with the privacy curtain drawn and no staff present in the room.
Failure to Ensure Grievance System in Place
Penalty
Summary
The facility failed to ensure a system was in place to receive and resolve resident and/or resident representative grievances. The facility's grievance policy indicated that residents and their family members should be able to express their concerns formally in writing. However, a review of the facility's grievance binder revealed no written grievances had been completed since September 2023. During a Resident Council meeting, residents stated they did not know how to file a grievance, and one resident mentioned that grievance forms used to be available in the front reception area but were no longer there. Observations confirmed that there was no information available in common areas about how to file a grievance, the timeframe for review, or the contact information for the grievance official and independent entities. Additionally, grievance forms were not readily available in the reception area or other common areas of the facility. A resident reported that a mechanical lift sling purchased for personal use had been lost months ago, and despite informing multiple staff members, no resolution was provided. The resident was not offered a grievance form and did not know how to file a grievance. The facility administrator acknowledged the lack of signage or verbal reminders about the grievance process and confirmed that instructions were only given in the Resident handbook upon admission. The administrator also confirmed that grievance forms were available at nursing stations but required residents to ask for them, which contributed to the lack of grievances filed since September 2023.
Neglect in Providing Mechanical Lift Slings and Briefs
Penalty
Summary
The facility neglected to ensure the availability of mechanical lift slings and briefs for residents, leading to significant issues for four sampled residents. Resident 29 reported that the facility often lacked mechanical lift slings and briefs, resulting in her/his spouse having to purchase briefs. On multiple occasions, Resident 29 was unable to get out of bed due to the unavailability of mechanical lift slings. The Resident Council Meeting minutes revealed ongoing concerns about the lack of mechanical lift slings and supplies, with residents expressing that the slings took three days to dry when laundered, causing them to remain in bed. Staff members confirmed the frequent shortages of briefs and wipes, particularly on weekends, and the necessity to borrow slings from other residents in emergencies. Resident 23 and Resident 27 also confirmed their inability to get out of bed due to the lack of slings, and Resident 27 had to wear the wrong size or no brief at all due to supply shortages. Staff 1, the Administrator, acknowledged the issue, stating that she had previously purchased mechanical lift slings but was unaware that the problem persisted. The deficiency was evident as residents were unable to perform activities of daily living (ADLs) and experienced social isolation and potential ADL decline due to the lack of necessary equipment and supplies. The facility's failure to provide adequate mechanical lift slings and briefs compromised the residents' independence and well-being.
Failure to Address Resident Council Concerns
Penalty
Summary
The facility failed to effectively respond to resident council concerns expressed at three resident council meetings. The facility's Resident Council Policy indicated that a Quality Assurance form should be used to track the council's concerns and suggestions, and a staff designee should fill out the Resident Council Response/Grievances forms immediately following the meetings. However, during the 5/29/24 Resident Council meeting, residents stated they did not feel heard about their concerns or suggestions and often did not receive a response from administration or departments regarding their reported issues. Specific concerns included delays and missing items in laundry services, food quality, supply shortages, and improper handling of clothes by aides, with no adequate responses or resolutions provided by the facility departments. Staff 13, who assisted the residents with Resident Council and wrote the response forms, confirmed the lack of responses from facility departments and acknowledged the residents' frustration. Staff 1, the Administrator, also acknowledged the lack of response to the Resident Council concerns and expected all concerns to be appropriately addressed in written form and given to the Resident Council for review. The failure to respond to resident council concerns placed residents at risk for unmet needs concerning issues of resident care and lessened quality of life.
Failure to Inform Residents of Their Rights
Penalty
Summary
The facility failed to ensure residents were notified of their rights both orally and in writing on an ongoing basis. The facility's revised 2021 Resident Rights policy indicated that copies of the resident rights were to be posted throughout the facility and that residents were to be informed about their rights and responsibilities upon admission and periodically thereafter. However, a review of past Resident Council Meeting minutes revealed no indication that resident rights were provided to residents during the meetings. The Resident Council stated they were not informed of resident rights on an ongoing basis and were unsure if any were posted in the facility or where to obtain them. Observations of the reception area and common areas confirmed that no resident rights were posted. Staff interviews revealed a lack of a system to track and review resident rights during Resident Council and no clear method for providing ongoing resident rights communication to residents who did not attend the meetings. The Administrator acknowledged the lack of ongoing resident rights information and the absence of posted resident rights in the facility.
Failure to Maintain RN Coverage
Penalty
Summary
The facility failed to use the services of a registered nurse (RN) for at least eight consecutive hours a day for 9 out of 62 days reviewed. This deficiency was identified through a review of the Direct Care Staff Daily Reports for the months of February 2023, September 2023, and May 2024. Specifically, there was no RN coverage on 2/4/2023, 2/11/2023, 9/1/2023, 9/3/2023, 9/10/2023, 9/11/2023, 5/6/2024, 5/10/2024, and 5/12/2024. During an interview on 5/31/2024, the Staffing Coordinator and Human Resources acknowledged the facility's struggle with RN coverage in February and September 2023. The Staffing Coordinator mentioned that RN schedules were adjusted to ensure appropriate coverage, but no additional information was provided regarding the lack of RN coverage in May 2024.
Failure to Secure Medications in Designated Storage Room
Penalty
Summary
The facility failed to ensure medications were secured and only accessible to authorized persons. During an observation, an LPN removed a box of Ozempic from the medication room refrigerator and stated it was not supposed to be stored there. Instead, the Ozempic was stored in the Director of Nursing Services' (DNS) office refrigerator. The DNS's office was located near the facility's entrance and adjacent to the reception desk. The refrigerator in the DNS's office was small, unlocked, and in plain view. The DNS stated that the Ozempic had been stored in her office refrigerator since the middle of the previous month and that her office door was locked when she was not present. However, the office door was observed propped open with the DNS not in the room, and the refrigerator was not locked. Upon review of the findings, both the Administrator and the DNS acknowledged that all medications were supposed to be locked and secured in the designated medication storage room to prevent unauthorized access. The facility's policy specified that medications should be stored properly and accessible only to licensed nursing personnel or staff members authorized to administer medications. The failure to secure the medications in the appropriate storage room placed residents at risk for drug diversion.
Food Storage and Sanitation Deficiencies
Penalty
Summary
The facility failed to ensure proper labeling and storage of food, as well as maintaining a clean and sanitary kitchen environment. During an initial kitchen observation, several containers of facility-made food items were found in the refrigerator with dates indicating they were kept beyond the maximum allowable period. Specifically, potato salad, chicken gravy, and country gravy were labeled with dates from April, well past the seven-day limit. The Dietary Manager acknowledged these items should have been discarded after three days. Additionally, the temperature logs for the snack refrigerator in the satellite kitchen were found to be incomplete on multiple dates, and the Dietary Manager confirmed that refrigerator temperatures were not monitored on weekends. Furthermore, a Dietary Aide was observed assisting with the lunchtime tray line without wearing a hair restraint, which is required when in the kitchen area. The Dietary Manager confirmed that staff are expected to wear hair restraints. Additionally, when the surveyor requested the Dietary Manager to test the bleach buckets for the correct chemical solution concentration, the test strips indicated zero bleach concentration, revealing that the wrong test strips were used and the chemical solution dispenser needed servicing.
Inadequate Disinfection of Glucometer and Unsanitary Grab Bars
Penalty
Summary
The facility failed to ensure appropriate disinfection of a shared glucometer for four residents observed for capillary blood glucose (CBG) monitoring. An LPN was observed using the same glucometer for multiple residents without thoroughly disinfecting it between uses. The LPN quickly flipped the glucometer side-to-side over the same disinfectant wipe between uses, failing to clean all areas and surfaces of the device. This practice was observed for four residents with type II diabetes, placing them at risk for bloodborne infections. The LPN acknowledged the failure to properly disinfect the glucometer, citing being busy and running behind as reasons for the oversight. The facility's policy required thorough disinfection of the glucometer between each use, which was not followed in this instance. Additionally, the facility failed to maintain sanitary conditions for a resident's bilateral grab bars. The grab bars, covered with coban adhesive, were observed to be worn, dirty, and stained. The resident, who had dementia and anxiety, used the grab bars to assist with repositioning in bed. The condition of the grab bars was acknowledged by a registered nurse case manager (RNCM), who confirmed that the coban adhesive was worn and needed replacement. The duration of the coban adhesive's placement was unknown.
Failure to Ensure Timely Meal Delivery
Penalty
Summary
The facility failed to ensure a dignified dining experience by not providing meals to all residents at a table at the same time. Resident 20, who has dysphagia, was observed waiting for her/his lunch for 28 minutes while other residents were eating and having their tables cleared. Staff acknowledged that Resident 20's meal was not delivered timely and that this was an ongoing issue, with meals often being late or placed on the incorrect meal cart. Both CNAs and the RNCM confirmed the delay and the failure to serve Resident 20's meal with the other residents in the dining hall.
Failure to Revise Care Plan for Hospice Resident
Penalty
Summary
The facility failed to ensure care plans were revised to accurately reflect the needs of a resident receiving hospice care. Resident 7, diagnosed with Huntington's disease, began hospice services on March 9, 2024. A Significant Change of Condition MDS on March 18, 2024, indicated the resident was expected to live six months or less and was receiving hospice services. However, the resident's care plan, last revised on December 15, 2023, did not reflect the anticipated decline in health condition or individual hospice care needs. The care plan focused on maintaining the current level of function for activities of daily living (ADLs) and mobility, without addressing the resident's hospice care requirements. The facility administrator acknowledged the need for care plan revision on May 31, 2024.
Failure to Follow Physician Orders and Implement Bowel Care Timely
Penalty
Summary
The facility failed to follow physician orders and implement bowel care timely for three residents, leading to missed medications and inadequate bowel management. Resident 151, diagnosed with diabetes, did not receive alpha-lipoic acid as prescribed on multiple occasions due to the medication being marked as unavailable. Staff acknowledged the missed doses but were unsure why the medication was not accessible, despite it being available through the facility's central supply system. This oversight resulted in the resident missing essential supplements for several days. Resident 8, who has end-stage renal disease and undergoes dialysis, did not receive sevelamer carbonate as prescribed on several occasions because the medication was not sent with the resident to dialysis. Staff admitted that there were times when the medication was not available, and the resident's family member confirmed that the medication was not always sent. The RNCM acknowledged that the resident should not have gone without the medication on dialysis days, indicating a lapse in medication management. Resident 20, with diagnoses including pneumonia, chronic constipation, and stroke, did not receive appropriate bowel care as per the facility's protocol. The resident went six and a half days without a bowel movement, and there was no documentation that bowel medications were offered or administered as required. Additionally, the resident's medications, including duloxetine and bisacodyl, were crushed despite being delayed-release, which could decrease their efficacy. Staff admitted to crushing these medications without proper verification, and the pharmacist confirmed that this practice was not recommended. The DNS acknowledged that staff failed to follow proper procedures for medication administration and bowel care.
Failure to Ensure Appropriate Use of Psychotropic Medications
Penalty
Summary
The facility failed to ensure residents were free of unnecessary psychotropic medications, specifically for one resident diagnosed with mild cognitive impairment. The facility's Psychoactive Medication Management Guideline required staff to review admission orders for psychotropic medications, ensure an appropriate diagnosis for their use, and notify the provider if no supporting diagnosis was present. However, Resident 303 was administered 25 mg of Quetiapine Fumarate at bedtime without an appropriate diagnosis. The resident's health record did not document any behaviors or target behaviors that would justify the use of this antipsychotic medication. Staff interviews confirmed that the diagnosis of mild cognitive impairment was not appropriate for the use of Quetiapine Fumarate and that the resident did not exhibit behaviors indicating the need for such medication. The Director of Nursing Services (DNS) stated that all residents should be assessed for the appropriateness of medications upon admission and that behavior monitors should be put in place to monitor medication effectiveness. Despite these guidelines, Resident 303 was administered Quetiapine Fumarate without an appropriate diagnosis or documented behaviors, leading to the deficiency.
Medication Administration Errors
Penalty
Summary
The facility failed to ensure a medication pass error rate of less than 5%, resulting in a 7.14% error rate. One incident involved a resident with type 2 diabetes who was prescribed metformin HCl extended-release (ER) tablets. During medication administration, an LPN crushed the ER tablets and mixed them with pudding before administering them to the resident. The LPN later acknowledged that ER medications should not be crushed and confirmed that she should have notified the provider if the resident preferred their medications crushed. The facility's Director of Nursing Services (DNS) stated that staff were expected to know that ER medications should not be crushed. Another incident involved a resident with spinal stenosis who was prescribed PreserVision AREDS, a specific eye health supplement. During medication administration, an LPN administered a house stock multivitamin with mineral instead of the prescribed PreserVision AREDS. The LPN stated it was preferred to administer the house stock multivitamin. Upon review, the DNS confirmed that the house stock multivitamin was not an alternative to PreserVision AREDS and that staff should have administered the prescribed supplement. Both incidents were reported to the facility's Administrator and DNS, who acknowledged the errors and the failure to follow physician orders.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Keizer
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Keizer Nursing And Rehabilitation | 1.2 mi | ★★★★★ | 3 | 0 |
| Windsor Health And Rehabilitation | 3.7 mi | ★★★★★ | 6 | 0 |
| Tierra Rose Care Center | 4.5 mi | ★★★★★ | 2 | 0 |
| Avamere Transitional Care At Sunnyside | 7.7 mi | ★★★★★ | 0 | 0 |
| Salem Transitional Care | 8.4 mi | ★★★★★ | 2 | 0 |
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