Above average — CMS composite of the measures below.
The next survey window likely opens around November 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 Rehabilitation Of King City during CMS and state inspections, most recent first.
A resident with multiple sclerosis, opioid use, and chronic pain, who was cognitively intact, experienced very low blood pressure and altered responsiveness during a night shift. A CNA noted the resident’s unusually deep sleep and lack of response during incontinence care and alerted an LPN, who confirmed low BP and later called the provider and 911. EMS records showed the resident was found altered earlier than the call time, and Narcan administration improved vital signs before hospital transfer, where the resident was treated for septic shock due to UTI and related complications. Facility policy required comprehensive baseline assessment and documentation of vital signs, neuro status, pain, level of consciousness, and onset/severity of condition, but the progress notes contained only limited information, and the Administrator acknowledged a delay in response and incomplete documentation.
A resident with multiple sclerosis, diabetes, and opioid use had a PRN order for naloxone (Narcan) nasal spray to be given in both nostrils for decreased responsiveness. During a surveyor observation of the emergency kit, only IV Narcan was found instead of the ordered nasal formulation. The facility Administrator confirmed that the correct nasal route Narcan was not available for this resident.
Failure to Provide Person-Centered Activity Program: The facility did not provide an ongoing resident-centered activity program for 3 residents with varied needs, including dementia, depression, and hospice care. One resident with severe cognitive impairment had no documented one-on-one activity participation despite a care plan for bedside visits, music, pet therapy, and other individualized interventions. Another resident on hospice was observed in a dark room without TV or music, while staff were unaware of the hospice status and could not describe meaningful activity engagement. A third resident with depression and intact cognition was repeatedly observed in bed without diversional activities, reported boredom and lack of reading glasses/books, and had no documented self-directed or one-on-one activity participation.
A resident with depression and anxiety was involved in a heated argument with a former MR staff member in the garden over a plant that was allegedly uprooted and discarded. Witnesses reported the staff member called the resident a liar and used profane language, and the resident said he or she was blamed for something he or she did not do. The Administrator acknowledged the lack of dignity and respect.
A resident with a diagnosis of atherosclerosis of the left leg with rest pain was cognitively intact, but the facility changed morphine from TID to BID without evidence the resident was informed in advance or included in the decision. The resident later reported frustration that the pain med reduction was made without consent, and an LPN Resident Care Manager acknowledged the resident was not included or informed.
Failure to provide ordered bed mobility bars: A cognitively intact resident with type 2 DM had a physician order and care plan for bilateral bed mobility bars to support bed mobility, but observations showed only one bar on the bed. The resident said two bars had been promised but only one was provided, and staff gave conflicting information before the LPN Resident Care Manager and Administrator confirmed the resident was supposed to have two bars.
Failure to document nonpharmacological interventions before PRN lorazepam use: A resident with dementia had a PRN lorazepam order for agitation, anxiety, restlessness, or nausea that was given 20 times, but the record did not show a rationale for use or evidence that nonpharmacological interventions were tried first. Staff described redirection methods such as TV, music, DVDs, hot cocoa, and care choices, and the LPN RCM acknowledged the expectation to document behaviors and use nonpharmacological interventions before giving the PRN med.
Failure to Evaluate and Manage Increased Pain After Morphine Reduction: A resident with chronic, almost constant neuropathic pain had morphine reduced from TID to BID and then reported increased pain, phantom pain, restless leg symptoms, and difficulty sleeping. Progress notes documented ongoing pain complaints and the resident requested to speak with a provider, but there was no documented provider follow-up after the pain increase was reported.
Failure to assess and care plan suicidal ideations: A resident with major depressive disorder and documented suicidal ideations had no behavior interventions in the care plan. CNAs were unaware of the suicidal ideations despite mood and behavior changes, and Social Services staff acknowledged the ideations were noted but no follow-up occurred.
A resident’s methadone was found missing after staff counted narcotics and identified 18 tablets unaccounted for. The controlled substance record showed the medication remaining, but there was no documented disposition for the doses, and staff stated they did not compare the narcotic pages to the narcotic cards during the count. The DON acknowledged the doses were unaccounted for and that the narcotic medication was not reconciled.
The facility experienced significant staffing shortages, particularly for CNAs, from September to December 2024, leading to unmet care needs for residents. Resident Council notes and public complaints highlighted issues such as long call light response times and missed showers. Several residents, including those requiring substantial assistance, were directly affected, with staff confirming that evening and night shifts often ran short-staffed, resulting in incomplete ADL tasks.
The facility experienced significant staffing shortages, particularly with CNAs, leading to unmet care needs for residents. Many residents required extensive assistance, but persistent staffing issues resulted in long call light response times and delays in essential care. Complaints highlighted the impact on resident care, including missed showers and inadequate supervision during meals. The administrator acknowledged the staffing challenges, which were documented through interviews and call light tracking sheets.
Three residents in a LTC facility did not receive person-centered activities as per their care plans, leading to a deficiency. One resident with major depressive disorder and dementia was not engaged in any activities, despite a care plan including music and pet therapy. Another resident, speaking Farsi/Arabic, had no documented activity participation, and staff failed to provide necessary resources. A third resident, speaking Vietnamese, also lacked engagement in activities, with staff not utilizing translation services. The Activities Director confirmed the lack of documentation and activities.
The facility failed to properly label and store beverages and bulk food items, risking foodborne illness. A scoop was improperly stored in bulk sugar, and opened juice containers in a refrigerator had unclear labeling, leading to potential spoilage. Staff were unclear on monitoring responsibilities.
A facility failed to implement a care plan for a resident with dysphagia, who required upright positioning during meals to prevent aspiration. Despite the care plan's directive, the resident was observed eating in bed with the head-of-bed elevated only to 45 degrees. Staff were unaware of the required positioning, leading to the resident's difficulty in eating and food spillage.
A resident with dementia, whose preferred language is Vietnamese, was not provided an interpreter during cognition assessments, leading to inaccurate evaluations. Despite documentation indicating the need for an interpreter, staff conducted assessments in English, resulting in the resident feeling misunderstood. The DNS acknowledged the expectation for staff to use translators during such interactions.
A facility failed to complete a Level I PASARR screening for a resident admitted with stroke and schizophrenia. The resident's electronic health record showed no evidence of the required screening prior to admission, and staff confirmed the absence of the screening.
The facility failed to update care plans for two residents, leading to potential unmet needs. One resident, initially requiring assistance with eating, was observed to eat independently, yet the care plan was not revised. Another resident required mobility bars for bed mobility and fall prevention, but the care plan lacked interventions for their use. Staff confirmed these discrepancies, highlighting the need for accurate care plan updates.
A resident with dementia and a preferred language of Vietnamese did not receive appropriate communication services at the facility. Despite a care plan indicating the need for a translator and translation service, staff did not utilize these resources, leading to ineffective communication. Staff were unaware of the resident's language needs, and interactions were conducted in English, which the resident struggled to understand.
A resident with dementia did not receive their prescribed lidocaine 4% pain patch on multiple occasions due to a failure in the supply ordering process. The Maintenance Director, who was newly responsible for ordering supplies, did not order the patches in time, leading to their unavailability. This resulted in the resident not receiving the medication as per the physician's orders.
The facility failed to provide necessary restorative services and equipment for two residents with limited mobility, leading to potential risks of further decline. One resident did not receive the prescribed hand splint for hemiplegia, and staff were unaware of its necessity. Another resident, requiring restorative therapy for stroke-related impairments, received fewer sessions than ordered due to staff being reassigned to CNA duties. Despite these deficiencies, no decline in functional abilities was documented.
A resident with dysphagia and no teeth was served beef fajitas, which did not meet the facility's guidelines for an easy-to-chew diet. The resident struggled to eat the meal, and staff later confirmed the food was not appropriate for the resident's dietary needs. A CNA was unaware of the resident's risk for aspiration, highlighting a lack of adherence to dietary requirements.
The facility failed to assist two residents with ADLs, leading to unmet needs. A resident with cognitive impairment was not assisted with shaving despite expressing a desire for hair removal. Another resident requiring two staff for bed baths was not bathed as scheduled, reportedly due to staffing shortages. The DNS acknowledged the issue but could not confirm resolution.
Failure to Timely Respond and Document Resident Change of Condition
Penalty
Summary
The deficiency involves staff failure to respond timely and completely to a resident’s change of condition and to document required baseline assessment data. The facility’s Acute Condition Changes-Clinical Protocol, revised 3/2018, required nurses to assess and document/report baseline information including vital signs, neurological status, current pain level, level of consciousness, and onset, duration, and severity of the condition. Resident 4, who had multiple sclerosis, opioid use, and chronic pain, was cognitively intact per a Quarterly MDS with a BIMS score of 15. On 11/25/25, a Blood Pressure Summary Report showed the resident’s blood pressure was 86/53 at 5:00 AM as taken by an LPN (Staff 6). A progress note at 6:50 AM documented the blood pressure as 70/50, and that Staff 6 called the provider and 911, but no additional assessment information was recorded. Interviews and external records showed that staff recognized abnormal findings and altered responsiveness but did not promptly act or fully document the change of condition. A CNA (Staff 14) reported that during the night the resident appeared to be sleeping, and at 5:00 AM the resident’s blood pressure was very low, prompting her to alert Staff 6. Staff 14 and Staff 6 provided incontinence care and noted it was unusual that the resident did not wake up during care and did not respond, despite typically waking when laid flat. Staff 6 stated the resident was unable to be awakened and had an abnormally low blood pressure, after which she called the provider and then 911. A Fire and Rescue Public Incident Report documented that the facility reported the resident was found with altered mental status at 5:00 AM, with EMS called at 6:46 AM and arrival at 6:50 AM, when Narcan was administered and vital signs improved. A subsequent hospital discharge summary documented admission for septic shock due to UTI, acute kidney injury, acute metabolic encephalopathy, and acute hypoxic/hypercapnic respiratory failure. The Administrator (Staff 1) acknowledged there was a delay in staff response to the change of condition and that the progress notes lacked the required baseline information.
Failure to Stock Correct Route of Ordered Emergency Narcan
Penalty
Summary
Surveyors found that the facility failed to provide the correct route of administration for an ordered emergency opioid antidote medication. A resident who was re-admitted in 12/2025 with multiple sclerosis, diabetes, and opioid use had a physician’s order dated 11/2025 for naloxone HCL (Narcan) nasal liquid 4 mg/0.1 mL to be administered in both nostrils as needed for decreased responsiveness. During an observation of the facility’s emergency kit on 2/19/26 at 12:34 PM, surveyors identified that Narcan was stocked only in an intravenous (IV) form rather than the prescribed nasal route for this resident. On 2/20/26 at 2:46 PM, the Administrator acknowledged that the facility did not have the correct nasal route formulation of Narcan available for the resident. This deficiency reflects the facility’s failure to obtain and maintain the ordered nasal formulation of naloxone in its emergency supply for a resident with an active PRN order for nasal Narcan for decreased responsiveness, as confirmed by observation of the emergency kit contents and staff acknowledgment.
Failure to Provide Person-Centered Activity Program
Penalty
Summary
The facility failed to provide an ongoing person-centered activity program for 3 residents reviewed for activities. The activities policy stated the program was to support resident well-being and address intellectual, social, spiritual, creative, and physical needs, capabilities, and interests. However, the activities director stated she was the only person in the department and was responsible for multiple duties, including care conferences, MDS activity assessments, resident profiles, shopping, mail delivery, and both group and one-on-one activities, and she stated there was no one to provide activities on weekends or when she was not in the facility. She also stated she did not have enough time to meet all residents' activity needs and could not provide dates or times of specific activities completed with the residents. Resident 4 had diagnoses including major depressive disorder and dementia, with severe cognitive impairment on the most recent MDS. Her activity care plan identified preferences such as music, pet therapy, one-on-one conversations, reminiscing, stuffed animals, gardening, flowers, birds, and gospel music, and directed bedside visits and individualized activities. Records showed no evidence of activity participation, the activity logs contained no data for one-on-one visits, and the resident was observed multiple times awake in the room with the blinds closed and not engaged in activities. Staff stated the resident spent the day in bed, got confused when out of the room, and would benefit from one-on-one activity visits. Resident 20 was admitted with brain cancer and was on hospice/end-of-life care, with preferences for music, family visits, reminiscing, and religious services. The resident was observed in a dark room with no television or music playing and was unresponsive to verbal stimuli, and family reported the television was broken and there were no music opportunities in the room. Staff stated the resident listened to music on the television and was sometimes taken to the activity room, but the activities director was unaware of hospice services and could not describe meaningful one-on-one or group activities. Resident 5 had major depression and was cognitively intact, with interests including fishing, camping, outdoor activities, music, reading, card games, bingo, mechanics, art, drawing, painting, and bible studies. The resident was repeatedly observed lying in bed in a dark, quiet room without diversional activities, stated she/he had asked for reading glasses months earlier and had not received them, and said she/he was bored often and wanted more leisure items. The care plan directed one-on-one activities, supplies for independent activities, and sitting outside, but the activity task record showed no self-directed or one-on-one activities and two refused group activities.
Failure to Treat a Resident with Dignity and Respect
Penalty
Summary
The facility failed to ensure a resident was treated with dignity and respect when an argument occurred between a resident with diagnoses including depression and anxiety and a former Medical Records staff member in the garden area. The incident involved a dispute about a plant that was allegedly uprooted and thrown away, which the resident denied. During the exchange, staff and resident were heard yelling, and multiple witnesses reported that the staff member called the resident a liar and used profane language toward the resident. Facility interviews confirmed that the resident said he or she was blamed for something he or she did not do and was called a name by the staff member. An Activities Director stated the staff member called the resident a liar, and a Housekeeping Manager stated she heard the staff member call the resident a goddamn fucking liar and later heard either shut the fuck up or shut the hell up directed to the resident. The Administrator acknowledged the lack of dignity and respect between the staff member and the resident.
Resident Not Included in Pain Medication Change
Penalty
Summary
The facility failed to include and inform a cognitively intact resident in advance of a change in pain medication. Resident 60 was admitted with a diagnosis of atherosclerosis of the left leg with rest pain, and the quarterly MDS dated 7/15/25 indicated the resident was cognitively intact. A physician order dated 11/10/25 changed the resident’s morphine from TID to BID, but the health record contained no evidence that the decrease was discussed with the resident. A progress note dated 11/15/25 by an RN documented that the resident expressed frustration about recent medication changes and stated they were made without consent. During interview on 12/1/25, the resident reported the morphine pain medication had recently been reduced and that the resident was not included in the decision. On 12/3/25, the LPN Resident Care Manager reviewed the record and acknowledged the resident was not included and informed in the decision to change the pain medication.
Failure to Provide Ordered Bed Mobility Bars
Penalty
Summary
The facility failed to provide mobility bars as ordered for Resident 16, who was admitted in 1/2024 with diagnoses including type 2 diabetes mellitus. A physician order dated 8/5/25 directed the use of bilateral bed mobility bars, and the resident’s care plan revised on 9/3/25 stated that bilateral mobility bars were to be used to increase participation with bed mobility. The 11/2025 annual MDS indicated the resident was cognitively intact and required one-person assistance with mobility. Multiple observations from 12/1/25 through 12/4/25 showed only one mobility bar on the right side of the resident’s bed. The resident stated on 12/1/25 and 12/3/25 that he/she had been told two mobility bars would be placed on the bed, but only one was provided, and that the bars would help with repositioning in bed. A CNA stated the resident used the mobility bar to assist with transfers and had only seen one bar. Another CNA stated the resident needed help adjusting in bed when weak and referenced the Kardex as indicating one mobility bar. The LPN Resident Care Manager confirmed the resident was supposed to have two mobility bars, and the Administrator later confirmed the resident only had one mobility bar on the bed.
Failure to Document Nonpharmacological Interventions Before PRN Lorazepam Use
Penalty
Summary
The facility failed to provide nonpharmacological interventions before administering a PRN psychotropic medication and failed to document a rationale for the use of the PRN lorazepam ordered for agitation, anxiety, restlessness, or nausea for one resident with dementia. The resident was admitted in 4/2025 with diagnoses including dementia, and the care plan updated on 8/9/25 identified behavioral disturbance and anxiety with interventions such as assessing needs, creating a safe environment, offering activities, and reassuring the resident. The 10/9/25 Quarterly MDS identified no behaviors, yet the 11/2025 MAR showed PRN lorazepam was administered 20 times, with no evidence in the record showing nonpharmacological interventions were used first or that a rationale for the medication use was documented. During observations from 12/2/25 through 12/5/25, the resident was seen in the room either sleeping in a wheelchair or awake without behaviors. Staff interviews identified behaviors such as screaming, hitting, yelling out, repeatedly asking for ice cream, and putting the resident on the floor, and staff described redirection methods including television, hot cocoa, care choices, music, DVDs, and braiding hair. The LPN Resident Care Manager stated nurses were expected to document each time behaviors occurred and resulted in PRN lorazepam administration, and acknowledged the need for staff to use nonpharmacological interventions prior to giving the medication.
Failure to Evaluate and Manage Increased Pain After Morphine Reduction
Penalty
Summary
The facility failed to evaluate and manage increased pain after a morphine dose change for one resident with a diagnosis of atherosclerosis of the left leg with rest pain. The resident was admitted in 7/2025, was cognitively intact, and had almost constant pain with scheduled and PRN pain medication documented on the quarterly MDS. The pain care plan directed staff to attempt non-medication interventions, provide pain medications per physician orders, provide diversional activities, and report complaints of pain to the nurse. The pain evaluation described neuropathic, aching, and burning pain in the lower back and left lower extremity that was almost constant and rated 7/10. A physician order changed the resident’s morphine from TID to BID, and progress notes from 11/11/25 through 12/4/25 documented complaints of increased pain. The resident expressed that the pain was not adequately controlled and requested to speak with a provider, but there was no documentation that the provider followed up regarding the ongoing pain complaints. The resident reported that after the morphine reduction, phantom pain, restless leg symptoms, and difficulty sleeping increased. Staff later acknowledged the resident complained of pain while using the bed pan or turning in bed, and the LPN Resident Care Manager confirmed the provider was notified of the increased pain but there was no follow-up after that date.
Failure to Assess and Care Plan Suicidal Ideations
Penalty
Summary
The facility failed to comprehensively assess and develop mood and behavior interventions specific to a resident’s expression of suicidal ideations. The resident was admitted with diagnoses including major depressive disorder, and the hospital history and physical exam documented suicidal ideations. The resident’s social history evaluation also stated the resident had a history of suicidal ideations, but the care plan did not include interventions for suicidal ideations. During interviews, a CNA stated she was unaware of the resident’s suicidal ideations, and another CNA described fluctuating mood and behaviors including dysregulation, yelling, rude and sexual comments, and demanding behaviors, but was also unaware of the suicidal ideations. The Social Services Director stated she did not know the resident had suicidal ideations and had not reviewed the social history evaluation closely enough to notice them, while the Social Services Coordinator stated suicidal ideations were noted on the evaluation but no follow-up occurred. The Administrator stated residents with a diagnosis or statements of suicidal ideation were expected to be immediately and comprehensively assessed and have needed services determined.
Unaccounted Methadone in Controlled Substance Count
Penalty
Summary
The facility failed to ensure an account of all controlled drugs was maintained for one sampled resident who was reviewed for drug diversion. On 10/11/25, it was discovered that the resident was missing methadone, a narcotic medication. The facility investigation found that on 10/12/25 two staff members counted narcotic medication at the end of their shift and determined the resident had 18 tablets of methadone missing. A staff member stated she may have thrown the medication away, and the facility was unable to locate the missing medication. The controlled substance record for the 300 hall showed methadone with 18 tablets remaining on 10/11/25, but there was no indication of the disposition of the remaining medication. Staff stated they did not compare the narcotic pages to the narcotic cards when counting, and the Director of Nursing acknowledged that the resident had 18 doses of methadone that were unaccounted for and that the staff failed to reconcile the narcotic medication.
Staffing Shortages Lead to Unmet Resident Care Needs
Penalty
Summary
The facility failed to ensure sufficient nursing staff was available to meet the needs of residents, leading to unmet care needs. The facility's staffing policy from October 2019 indicated an ongoing review of resident acuity to ensure adequate staffing. However, from September to December 2024, the facility was understaffed for CNAs on 39 out of 116 days, failing to meet state minimum staffing requirements. Resident Council notes from this period highlighted concerns about call light wait times, deactivated call lights without care, and delays in food tray removal, particularly in the 300 Hall, which required heavy care. Multiple public complaints were received by the State Agency, alleging short staffing of CNAs, resulting in long call light response times, unmet basic care needs, and increased resident anxiety and agitation. Specific incidents on September 28, October 6, October 7, December 24, and December 26, 2024, were reported, with residents not receiving showers and experiencing long call light response times. Staff interviews confirmed that evening and night shifts often ran short-staffed, leading to incomplete ADL tasks and missed showers. Several residents were directly affected by the staffing shortages. Resident 6, admitted in 2019, required substantial assistance with showering and did not receive a scheduled shower on December 26, 2024, due to staffing shortages. Similarly, Resident 15, admitted in June 2024, missed scheduled showers due to staffing issues, going seven days between showers on two occasions. Resident 10, admitted in 2014, also missed a scheduled shower on December 24, 2024, due to understaffing. Staff confirmed that showers were not provided to any residents on that day, and the facility's expectation was to offer showers as scheduled or the next day if missed due to staffing issues.
Staffing Shortages Lead to Unmet Resident Needs
Penalty
Summary
The facility failed to ensure sufficient nursing staff was available to meet the needs of its residents, as evidenced by multiple complaints and interviews. The facility had a census of 62 residents, with a significant number requiring extensive assistance for daily activities such as bathing, toileting, and dressing. Despite these needs, the facility was consistently short-staffed, particularly with CNAs, leading to unmet care needs. Residents reported long call light response times, sometimes waiting over 30 minutes for assistance, which resulted in delays in toileting and other essential care. Numerous complaints were filed with the State Agency, highlighting the persistent staffing shortages across all shifts, with the evening and night shifts being particularly affected. These shortages led to residents not receiving timely showers, inadequate supervision during meals, and increased fall risks. Witnesses and staff confirmed the ongoing staffing issues, noting that the facility was often short by three to four CNAs, which compromised the quality of care provided to residents. Specific residents, such as those admitted with conditions like fractured hips and strokes, experienced significant delays in call light responses, sometimes up to an hour. These delays were documented in call light tracking sheets, showing response times frequently exceeding the facility's target of 15 minutes. The administrator acknowledged the staffing challenges and the impact on care delivery, indicating an awareness of the issues but a struggle to maintain adequate staffing levels.
Failure to Provide Person-Centered Activities for Residents
Penalty
Summary
The facility failed to provide an ongoing person-centered activity program for three residents, leading to a deficiency in meeting their psychosocial and quality of life needs. Resident 9, admitted with major depressive disorder and dementia, had a care plan that included activities such as music, pet therapy, and religious services. However, observations revealed that Resident 9 was not engaged in any activities, and there was no documentation of participation in the activity logs or electronic health records. Staff interviews confirmed the lack of one-on-one activities and the absence of documentation. Resident 24, who spoke Farsi/Arabic and had dementia, also did not participate in any documented activities despite having a care plan that included social visits and self-directed activities. Observations showed that Resident 24 was often in their room with the television on mute and no materials for activities. Staff attempts to provide an iPad for Arabic channels were unsuccessful, and no one-on-one activities were observed. The Activities Director confirmed the lack of documentation and activities for Resident 24. Resident 47, who spoke Vietnamese and had dementia, was similarly affected. The resident's care plan included preferences for group activities and outdoor time, but there was no evidence of participation in any activities. Observations showed the resident in their room or dining area with no engagement in activities. Staff interviews revealed a lack of awareness of the resident's activity interests and the absence of translation services during interactions. The Activities Director acknowledged the failure to document activities and the need to update the resident's care plan.
Improper Food Storage and Labeling in Kitchen
Penalty
Summary
The facility failed to ensure proper labeling and storage of beverages and bulk food items, which could lead to foodborne illness. During an inspection of the kitchen's dry storage area, a plastic scoop was found partially buried in bulk sugar, which staff acknowledged was not stored appropriately. The scoop should have been placed in a holster above the sugar to minimize the risk of cross-contamination. Additionally, in the snack refrigerator located in the facility's 100 hallway, several previously-opened liter containers of nectar-thick lemon water and orange juice were found with unclear labeling. The dates on the containers did not specify whether they referred to the opening date or the discard date. Staff acknowledged that these items should be discarded as it was unsafe to store and use juice beyond seven days after opening. There was also a lack of clarity among staff regarding who was responsible for monitoring and discarding outdated items in the refrigerator.
Failure to Implement Nutritional Care Plan for Resident with Dysphagia
Penalty
Summary
The facility failed to implement care plan interventions for a resident with dysphagia, placing them at risk for unmet nutritional needs. The resident, admitted in December 2016, was identified as having short-and-long-term memory loss, moderate impairment in decision-making, and was edentulous. The care plan required the resident to be positioned upright at 75 to 90 degrees during meals to prevent aspiration. However, observations on multiple occasions revealed the resident eating in bed with the head-of-bed elevated only to approximately 45 degrees. Staff members, including CNAs and the Resident Care Coordinator, were unaware or did not ensure the correct positioning during mealtimes, as evidenced by the resident's difficulty in eating and food spillage.
Failure to Use Interpreter for Cognition Assessment
Penalty
Summary
The facility failed to accurately assess a resident's cognition due to not utilizing an interpreter, despite the resident's preferred language being Vietnamese and the need for an interpreter being documented. The resident, who was admitted with a diagnosis of dementia, had multiple MDS assessments indicating the need for an interpreter to communicate effectively. However, these assessments were conducted without an interpreter, and the BIMS interview was not attempted as the resident was noted to be rarely or never understood. Observations and interviews revealed that the resident felt misunderstood at the facility. The Social Services Director admitted to completing a staff assessment without a translator, and another staff member was unaware of the resident's preference for an interpreter, conducting all MDS interviews in English. The DNS acknowledged these findings and stated that staff were expected to use a translator during interactions with the resident, especially for MDS interviews.
Failure to Complete Level I PASARR Screening
Penalty
Summary
The facility failed to ensure a Level I PASARR (Preadmission Screening for Individuals with a Mental Disorder and Individuals with Intellectual Disability) was completed for a resident reviewed for PASARR. The resident was admitted in June 2023 with diagnoses including stroke and schizophrenia, a mental disorder. A review of the resident's electronic health record revealed no evidence that a Level I PASARR screening was completed prior to admission. On July 17, 2024, staff members confirmed they were unable to locate the required screening for the resident.
Care Plan Deficiencies for ADLs and Fall Prevention
Penalty
Summary
The facility failed to ensure care plans were revised to accurately reflect the needs of two residents, leading to potential risks for unmet needs. Resident 45, admitted with diagnoses including stroke and schizophrenia, was observed to eat meals independently, contrary to the care plan which indicated a need for one-person assistance. Staff confirmed that Resident 45 was independent with eating, yet the care plan was not updated to reflect this change in the resident's level of functioning. Resident 48, admitted with osteomyelitis and muscle weakness, required bilateral mobility bars for bed mobility and fall prevention, as indicated by a fall investigation and physician order. However, the care plan did not include interventions for the use of these mobility bars, despite observations confirming their presence on the resident's bed. The Director of Nursing Services acknowledged the care plan's failure to reflect the resident's current needs for bed mobility and fall prevention.
Failure to Provide Adequate Communication Services for Non-English Speaking Resident
Penalty
Summary
The facility failed to provide appropriate communication services for a resident whose preferred language was Vietnamese. Despite the resident's care plan indicating the need for a translator and the use of an iPad translation service, staff members did not utilize these resources. Instead, they relied on asking yes or no questions, which the resident often answered affirmatively, regardless of understanding. This lack of effective communication tools and strategies led to the resident feeling misunderstood and unable to express their preferences or interests. Staff members were unaware of the resident's language needs, with some mistakenly believing the resident spoke other languages such as Taiwanese or Cantonese. The Social Services Director conducted check-ins exclusively in English, which the resident struggled to understand due to dementia. The Director of Nursing Services acknowledged the communication care plan was unclear, contributing to the deficiency in providing adequate communication support for the resident.
Failure to Administer Prescribed Medication
Penalty
Summary
The facility failed to ensure physician orders were followed for a resident who was prescribed a lidocaine 4% pain patch for pain management. The resident, diagnosed with dementia, was to have the patch applied to the lower back once daily, with it being on for 12 hours and off for 12 hours. However, the Medication Administration Record (MAR) for July 2024 indicated that the patch was not administered according to the physician's orders on several days. Staff 7, a Certified Medication Aide (CMA), reported that there were no lidocaine patches available on one of the days, preventing her from administering the medication. Staff 8, the Maintenance Director, was responsible for ordering the patches but failed to do so in a timely manner due to unfamiliarity with the ordering system, as this was a new task for him. The facility's Administrator acknowledged that Staff 8 had recently taken over the responsibility of ordering supplies and was not yet familiar with the process, which contributed to the oversight.
Failure to Provide Restorative Services for Residents with Limited Mobility
Penalty
Summary
The facility failed to provide appropriate restorative services and equipment to prevent further decline in range of motion for two residents with limited mobility. Resident 10, who was admitted with hemiplegia and hemiparesis following a stroke, was observed without the prescribed right hand splint, which was intended to assist with her/his upper extremity impairment. Staff members, including CNAs, were unaware of the resident's need for a splint, and there was no evidence of a comprehensive assessment, ongoing monitoring, or a care plan addressing the resident's impairment. The DNS and Resident Care Coordinator acknowledged the lack of assessments and monitoring, and uncertainty about the appropriateness of the hand splint. Resident 25, admitted with a history of falls and stroke-related hemiplegia and hemiparesis, was supposed to receive restorative therapy three times a week as part of a care plan to prevent functional decline. However, the resident reported receiving therapy only once a week on average. Documentation showed that out of 13 to 22 ordered sessions, only nine therapy sessions were conducted, with one resident refusal. Staff indicated that restorative therapy staff were frequently reassigned to CNA duties, impacting the delivery of therapy sessions. Despite the missed sessions, there was no documentation of a decline in the resident's functional abilities.
Failure to Provide Appropriate Diet Texture for Resident with Dysphagia
Penalty
Summary
The facility failed to ensure that the appropriate diet texture was followed for a resident with dysphagia, placing them at risk for choking. The resident, who was admitted in December 2016, had diagnoses including dysphagia and was edentulous. According to the facility's guidelines, a regular, easy-to-chew diet should consist of foods that break apart easily and pass the fork pressure test. However, during an observation, the resident was served beef fajitas, which did not meet these criteria. The resident struggled to bite through the tortilla, causing the contents to spill, and attempted to eat large pieces of beef, which were not easy to chew. Staff interviews revealed a lack of awareness regarding the resident's dietary needs. A CNA believed the resident was not at risk for aspiration and was on a regular diet. During a subsequent observation with the DNS and Resident Care Coordinator, it was confirmed that the meat served was not easy to chew, contradicting the resident's dietary requirements. The staff acknowledged that beef fajitas and tortillas were not considered easy-to-chew foods, indicating a failure to adhere to the prescribed diet texture for the resident.
Failure to Assist Residents with ADLs Due to Staffing Issues
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) for two residents, leading to unmet needs and potential loss of dignity. Resident 19, admitted with severe cognitive impairment and requiring substantial assistance for personal hygiene, was observed over several days with facial hair that she/he expressed a desire to have removed. Despite this, staff members, including a CNA and an LPN, confirmed that they had not been instructed to assist with shaving, and the resident's request for hair removal was not fulfilled. Resident 28, with normal cognitive function and requiring assistance from two staff members for bed baths, was documented to have refused multiple bed baths over several months. However, the resident stated that she/he had only refused two baths and was informed by CNAs that baths could not be provided due to staffing shortages. The DNS confirmed that missed showers and bed baths were a problem, potentially due to staffing levels, but could not confirm if the issue had been resolved.
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What surveyors actually found near you
We read the 579 citations issued within 25 miles in the last 12 months — including the 5 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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 Tigard
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Tigard Rehabilitation And Care | 1.3 mi | ★★★★★ | 19 | 2 |
| Marquis Tualatin Post Acute Rehab | 2.2 mi | ★★★★★ | 9 | 1 |
| Pearl At Kruse Way, The | 4.1 mi | ★★★★★ | 3 | 0 |
| Beaverton Post Acute Care Of Cascadia | 5.3 mi | ★★★★★ | 1 | 0 |
| West Hills Health & Rehabilitation | 5.5 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.