Below average — CMS composite of the measures below.
A standard survey is most likely before around September 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 Transitional Care At Sunnyside during CMS and state inspections, most recent first.
A medical assistant, not certified as a medication aide, administered medications to residents after being scheduled through an agency to fill a CMA shift. The error was discovered only after the shift ended, when nursing staff questioned her qualifications and confirmed she was not permitted to administer medications under state law or facility policy.
Staff did not consistently sign narcotic log books to verify controlled drug counts on multiple medication carts, resulting in numerous missed verifications. The DNS confirmed that narcotic counts should always be verified and signed by two nurses or CMAs, but this was not done as required.
Staff and residents reported ongoing shortages of bariatric sheets and towels, resulting in delays in bed changes and care for multiple bariatric residents. The issue persisted for several months despite being reported to management, with staff often unable to find appropriate linens and residents experiencing discomfort due to lack of proper bedding.
A resident who primarily speaks Spanish was not provided with adequate translation services during care interactions, resulting in communication barriers and the resident being unable to fully participate in health care decisions. Staff did not consistently use translation devices as outlined in the care plan, and the resident's preferences regarding blood pressure monitoring were not understood or respected.
A resident with chronic pain and PTSD reported delayed administration of pain medication and felt disrespected after voicing concerns to the DNS, who responded dismissively. The resident completed a grievance form, but did not receive any follow-up or written resolution, and key staff were unaware of the grievance, indicating the facility did not follow its grievance policy.
A resident with multiple chronic conditions was transferred to the hospital, but neither the resident nor their representative received the required written bed hold notification, including information about reserved bed hold payment, at the time of transfer. Facility staff confirmed the omission, citing the resident's Medicaid payer status, despite policy requiring written notice for all residents.
A resident with COPD and diabetes was repeatedly observed receiving oxygen via nasal cannula without any documented physician orders or instructions for equipment maintenance. Staff confirmed the absence of current orders, resulting in a failure to provide respiratory care and services under physician direction.
A resident with chronic pain and severe osteoarthritis experienced ongoing, inadequately managed pain despite receiving scheduled gabapentin and acetaminophen. The resident reported frequent breakthrough pain and stated that requests for additional pain relief were not addressed, with no documentation or provider communication found regarding these concerns.
The facility experienced significant staffing shortages, leading to prolonged call light response times and inadequate care for residents. Several residents reported sitting in wet and soiled briefs due to delays in assistance, with staff confirming that the facility had been short-staffed since the summer. The issue affected residents' ADL care, particularly on weekends and during shifts with high acuity residents.
Several residents in the facility were provided with improperly sized incontinence briefs, leading to discomfort and potential skin breakdown. Despite complaints, the facility continued to use briefs based on height and weight, disregarding individual needs. Additionally, a resident with a Stage 4 pressure wound was not provided with necessary wet wipes for gentle care, leading to further discomfort.
Two residents experienced violations of dignity and privacy in a facility. One resident waited nearly an hour for assistance after using a commode, causing distress. Another resident faced an unauthorized room and body search, leading to feelings of humiliation. These incidents highlight a failure to respect residents' rights.
A resident with CHF experienced significant weight gains over several days, which were not reported to the physician as required by facility policy. Despite the facility's guidelines and the American Heart Association's recommendations, nursing staff failed to notify the physician of these changes, leading to the resident being sent to the hospital for evaluation after a delayed report.
A resident with morbid obesity and diabetes did not receive their requested meals on multiple occasions. On one occasion, the resident ordered specific items but did not receive all of them, and on another, the resident was not given a menu to select meals, resulting in receiving unwanted food. A CNA confirmed this was a frequent issue, and the Dietary Manager was unaware of the resident's preferences due to being new to the position.
Unqualified Staff Administered Medications
Penalty
Summary
The facility failed to ensure that only qualified staff administered medications to residents, as required by state regulations and facility policy. Specifically, a staffing coordinator posted a request for Certified Medication Aides (CMAs) to pass medications, but an agency medical assistant, who was not a CMA and not permitted by Oregon law to administer medications in a nursing facility, signed up for the shift and administered medications on two floors. The error was discovered only at the end of the shift when nursing staff questioned the individual's qualifications and verified her credentials, revealing she was a medical assistant, not a CMA. The facility's policy stated that only licensed or state-permitted individuals could prepare, administer, and document medication administration. Despite this, the medical assistant worked an entire eight-hour shift administering medications under the mistaken belief that she was allowed to do so if supervised by a nurse or physician. The incident was triggered by a public complaint and confirmed through staff interviews and record review, establishing that unqualified personnel had administered medications to residents.
Failure to Maintain Accurate Narcotic Drug Records
Penalty
Summary
Facility staff failed to ensure that narcotic drug records were properly maintained and that an account of all controlled drugs was accurately kept for all four medication carts reviewed. During the review of narcotic log books on multiple medication carts across both the South and North halls, it was found that staff did not sign to verify the accuracy of the narcotic count on numerous occasions. Specifically, there were multiple instances where required signatures were missing, with counts ranging from 36 to 94 missed signatures out of 180 to 186 counting opportunities per log book. At the time of the survey, the Director of Nursing Services (DNS) confirmed the absence of required signatures in the narcotic log books and acknowledged that the narcotic count should always be verified and signed by two nurses or Certified Medication Aides (CMAs). The lack of proper verification and documentation was observed and confirmed during the survey process.
Ongoing Shortage of Bariatric Linens and Towels
Penalty
Summary
The facility failed to ensure sufficient supplies, specifically bariatric sheets and towels, were available to meet the needs of residents on one of two floors reviewed. Multiple staff members, including CNAs and the Maintenance Director, reported ongoing shortages of bariatric linens and towels since February 2025. Staff described frequent situations where they were unable to find appropriate linens in the North Hall linen closet, resulting in delays in changing residents' beds and providing care. These shortages were reported to management and housekeeping, but the issues persisted over several months. Residents affected by the shortage reported discomfort and inconvenience, such as not having the correct size sheets for bariatric beds, sheets slipping off mattresses, and waiting extended periods before their bedding could be changed. Staff confirmed that the problem was particularly acute on weekends and during times when multiple bedbound bariatric residents required care. The facility administrator acknowledged awareness of the ongoing issue with insufficient linens to meet all residents' needs.
Failure to Ensure Communication in Resident's Preferred Language
Penalty
Summary
A deficiency occurred when a Spanish-speaking resident with hypertension was not fully informed about their health status and care in a language they could understand. The resident's care plan indicated that translation services would be available, but multiple incidents showed that staff did not consistently use these services. The resident reported that some staff were impatient and did not take the time to understand or communicate with them effectively. On one occasion, a CNA told the resident to stop talking while attempting to take their blood pressure, and did not use the tablet translator as required. The resident expressed frustration at not being respected or understood, particularly regarding their preference for a manual blood pressure cuff instead of the tower monitor. Staff interviews confirmed that translation devices were not used during these interactions, and the CNA involved acknowledged being blunt and not utilizing the translator. The Director of Nursing Services stated that staff were expected to use translator tablets but had not provided recent training on communicating with non-English speaking residents, assuming it was covered during orientation. These actions and inactions resulted in the resident not being able to fully participate in their own health care decisions due to language barriers.
Failure to Communicate Grievance Resolution to Resident
Penalty
Summary
A resident with chronic pain and PTSD, who was cognitively intact at admission, reported that nursing staff failed to administer prescribed pain medication in a timely manner. After waiting for an extended period and missing a physical therapy session due to pain, the resident attempted to voice concerns to the Director of Nursing Services (DNS), who responded dismissively and directed the resident to leave her office. The resident described the DNS as rude and disrespectful, and subsequently completed a grievance form with the assistance of staff, which was submitted to the administrator's office. Despite the facility's grievance policy requiring prompt action and communication of grievance resolutions to residents, the resident did not receive any follow-up or written resolution regarding the grievance. Multiple staff members, including the Social Service Director and the Administrator, were unaware of the grievance submission until after the fact. The grievance process was not followed, and the resident's concerns about pain management and staff conduct were not addressed in accordance with facility policy.
Failure to Provide Written Bed Hold Notification at Hospital Transfer
Penalty
Summary
The facility failed to provide a written bed hold notification, including information about reserved bed hold payment, to a resident or the resident's representative at the time of transfer to the hospital. The facility's policy, dated 10/2022, requires that all residents, regardless of payer source, receive written notice about bed hold and return policies at the time of transfer. The resident involved had a history of congestive heart failure, COPD, and respiratory failure, and was transferred to the hospital. Review of the clinical record showed no evidence that the required written notice was given at the time of transfer. Facility staff confirmed that the notification was not provided because the resident's payer source was Medicaid, and acknowledged that the written policy should have been followed.
Failure to Provide Physician-Ordered Respiratory Care
Penalty
Summary
The facility failed to provide respiratory care and services in accordance with physician orders for a resident with COPD and diabetes. The resident was admitted with a care plan indicating the need for oxygen via nasal cannula as needed, along with interventions to monitor for signs of respiratory compromise. Observations over several days showed the resident receiving oxygen through a nasal cannula on multiple occasions, both in bed and during routine care. Staff interviews confirmed that the resident regularly used oxygen while in bed. Despite the ongoing administration of oxygen, a review of the clinical record revealed there were no documented physician orders for oxygen administration, nor were there orders specifying how often the oxygen filter should be cleaned, checked, or how often the tubing should be changed. Staff confirmed the absence of current physician orders for oxygen. This lack of documentation and physician oversight constituted a failure to provide respiratory care and services as required.
Failure to Address Resident's Breakthrough Pain and Provider Communication
Penalty
Summary
The facility failed to provide appropriate pain management for a resident with chronic pain and severe osteoarthritis. The resident was admitted with diagnoses including osteoarthritis of the hip and knee, and chronic pain. Physician documentation recommended continuing pain management with PRN acetaminophen, and the care plan included non-pharmaceutical interventions and reporting pain complaints to nursing staff. The resident's quarterly assessment indicated almost constant pain affecting sleep, daily activities, and therapy, with a self-reported pain level of seven out of ten. Medication orders for gabapentin and scheduled acetaminophen were administered as prescribed. Despite these interventions, the resident reported ongoing breakthrough pain and stated that requests for additional pain relief had not been addressed. The resident indicated that topical creams were ineffective and that a request for additional medication made weeks prior had not resulted in any action. Review of the clinical record revealed no documentation or communication with the provider regarding the resident's pain management needs or clarification of the PRN acetaminophen order. The Director of Nursing confirmed that there was no evidence the physician had been contacted for clarification, as would be expected.
Staffing Shortages Lead to Prolonged Call Light Response Times
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents, resulting in prolonged call light response times and inadequate care for several residents. Resident 1, who was admitted with diagnoses including diabetes and renal disease, required assistance for all ADL care needs and a mechanical lift for transfers. Despite these needs, Resident 1 experienced call light response times of 30 minutes or longer, leading to instances of sitting in wet and soiled briefs. Staff and the resident reported ongoing concerns about staffing shortages and long wait times, which had been an issue since the summer months. Resident 2, admitted with a stroke and depression, was on a toileting program due to incontinence and required assistance for ADL care. The resident reported sitting in a wet and soiled brief for over 20 minutes on multiple occasions due to long call light response times. Staff confirmed these concerns, attributing the delays to a lack of sufficient staffing. Similarly, Resident 3, who required assistance with toileting hygiene, reported sitting on a bedside commode for extended periods without assistance, sometimes up to an hour, due to staffing shortages. Resident 13, with a history of stroke and anxiety, also experienced long call light response times, sometimes upwards of 40 minutes, resulting in sitting in wet briefs. The facility's staffing issues were further highlighted by a review of Direct Care Staff Daily Reports, which showed that state minimum staffing requirements were not met for 74 out of 90 days. Staff interviews consistently indicated that the facility had been short-staffed since July 2024, affecting the quality of care provided to residents, particularly on weekends and during shifts with high acuity residents.
Improper Sizing of Incontinence Briefs and Inadequate Wound Care
Penalty
Summary
The facility failed to accommodate the needs and preferences of several residents by providing incontinence briefs that were improperly sized, leading to discomfort and potential skin breakdown. Resident 1, who was admitted with diagnoses including diabetes and renal disease, was switched to a smaller brief size that was too tight and caused red marks on the skin. Despite complaints from the resident and observations from staff that the new briefs were uncomfortable and did not fit properly, the facility continued to use the briefs based solely on height and weight measurements, disregarding the resident's specific needs and preferences. Similarly, Resident 13, who had a history of stroke and anxiety, was also provided with a new brief size that was too small and tight around the thighs and crotch area. The resident expressed dissatisfaction with the new briefs, but was informed that the size was appropriate based on height and weight. The facility's management did not consider the resident's waist or lower body size, and residents were told to purchase their own briefs if they were unhappy with the provided size. Resident 15, diagnosed with morbid obesity and anxiety, experienced similar issues with the new brief size, which was too small and caused discomfort. The resident reported these concerns to management but was advised to buy personal supplies. Additionally, Resident 6, who had a Stage 4 pressure wound, was not provided with wet wipes for incontinence care, despite the need for gentle care due to skin breakdown. The facility had moved to using washcloths instead of wet wipes, and Resident 6 was not initially included on the list of residents approved for wet wipes, leading to further discomfort and potential harm.
Violation of Resident Dignity and Privacy
Penalty
Summary
The facility failed to ensure the dignity and respect of two residents, leading to a deficiency in their care. Resident 3, who was admitted with diagnoses including morbid obesity and depression, experienced a delay in receiving assistance after using the bedside commode. Despite turning on the call light, the resident waited nearly an hour for help, causing physical discomfort and emotional distress. The delay was attributed to staff being occupied with other duties, and the resident expressed frustration and upset over the repeated occurrences of such incidents. Resident 15, admitted with morbid obesity and anxiety, faced a violation of privacy and dignity when staff conducted a room and body search without proper consent. The resident, who had a history of non-compliance with smoking paraphernalia, was found with a lighter and a pill in her possession. Following this, staff searched the resident's room and conducted a body search without obtaining permission, leading to the resident feeling humiliated and targeted. The staff involved were uncomfortable with the search, and the resident was extremely upset by the invasion of privacy. Both incidents highlight the facility's failure to uphold residents' rights to a dignified existence and self-determination. The lack of timely assistance for Resident 3 and the unauthorized search of Resident 15's room and person demonstrate a disregard for the residents' dignity and respect. These actions resulted in emotional distress and a diminished quality of life for the residents involved.
Failure to Notify Physician of Significant Weight Gain in Resident with CHF
Penalty
Summary
The facility failed to notify the physician regarding a significant change in condition for a resident diagnosed with Congestive Heart Failure (CHF) and a below-the-knee amputation. The resident experienced multiple instances of significant weight gain over a short period, which were not reported to the physician as required by the facility's policy. Specifically, the resident had a 4.9-pound weight gain in 24 hours, a 10.2-pound weight gain over seven days, a 4-pound weight gain in 24 hours, and a 3.2-pound weight gain in 24 hours, none of which were communicated to the physician. Interviews with staff revealed that the nursing staff did not notify the physician of these weight changes, despite the facility's policy and the American Heart Association's recommendations to report such changes. The Director of Nursing Services (DNS) and the Medical Director confirmed that the physician was not notified as expected. The resident was eventually sent to the hospital for evaluation of lower extremity swelling after a significant weight gain was finally reported.
Failure to Honor Resident Food Preferences
Penalty
Summary
The facility failed to honor the food preferences of a resident, identified as Resident 3, who was admitted in 2020 with diagnoses including morbid obesity and diabetes. On December 27, 2024, Resident 3 ordered a meal that included barbecue country ribs, scalloped potatoes, mixed vegetables, fruit salad, two strawberry kiwi juices, and two diet lemon sodas. However, the resident received only one of each beverage and no fruit salad. The resident expressed that this was a frequent issue, and a Certified Nursing Assistant (CNA) confirmed that the resident often did not receive what was requested. Further observations on December 31, 2024, revealed that Resident 3 received a breakfast that was not ordered, as the resident was not provided with a menu on the previous day to make selections. The CNA confirmed that this was a common occurrence. The Dietary Manager, identified as Staff 25, stated that CNAs were responsible for ensuring residents completed menus for the next day's meals. Staff 25 was unaware of the resident's unmet requests and preferences, as she was new to the position and still learning the dietary meal ticket system.
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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 Salem
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Salem Transitional Care | 2.5 mi | ★★★★★ | 2 | 0 |
| Windsor Health And Rehabilitation | 3.9 mi | ★★★★★ | 6 | 0 |
| Tierra Rose Care Center | 4.8 mi | ★★★★★ | 2 | 0 |
| Keizer Nursing And Rehabilitation | 6.6 mi | ★★★★★ | 3 | 0 |
| Avamere Court At Keizer | 7.7 mi | ★★★★★ | 19 | 0 |
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