Avamere at Seaside on corrective action plan

Aug. 15—Avamere at Seaside is restricting admissions after a state relicensure survey found that a lack of effective administrative oversight at the care home undermined the quality of care and posed a risk of harm to residents.

The routine survey, conducted from June 27 through June 30, turned up multiple failures to follow state rules.

The care home on S. Roosevelt Drive signed a letter of agreement with the state Department of Human Services that requires Avamere to follow a corrective action plan. The 60-day plan ends Aug. 29.

Avamere agreed to "not admit any new residents until further notice," the letter said.

An outside registered nurse consultant, approved by the Department of Human Services, has been brought in to review and evaluate systems, procedures and practices and provide recommendations and staff training, the letter said.

The Astorian obtained the survey findings and other documentation through the state's public records law.

The survey coincided with a coronavirus outbreak at the care home that led to 14 virus cases and one death, according to a recent Oregon Health Authority outbreak report.

"As an organization we voluntarily decided to not admit new residents to Avamere at Seaside memory care at this time," Thomas Cloutier, the chief marketing officer at Avamere's Wilsonville-based headquarters, wrote in a statement. "We are continuing to partner with the state of Oregon to develop a staffing plan that will allow us to provide quality care to our seniors. We will open our memory care to move-ins in the near future.

"I want to thank our hardworking team members at the community and home office who have worked around the clock for the health and safety of our seniors. Avamere Communities has a long history in the state of Oregon of the best-in-class clinical systems and outcomes."

Resident monitoring

The survey, which largely focused on a sample of residents, found the care home's failure to comply with state administrative rules for assisted living and residential care facilities "placed residents at potential harm or risk of harm," the letter of agreement said.

Avamere could not show evidence that the facility had properly monitored and evaluated residents as their conditions changed, or that staff had adequately intervened when the change was for the worse.

One resident was admitted on April 7 weighing 152.6 pounds. By June 29, the resident weighed 131.8 pounds. This weight loss, the survey said, is "considered severe" — the kind of change that requires an assessment by a registered nurse, the survey noted.

"There was no documented evidence an RN completed an assessment of the weight loss," the survey said. "The severe, continued weight loss represented a serious risk to the health, safety and welfare of the resident."

For this resident, Avamere could not "provide documentation that the ongoing weight loss was evaluated, reported to the physician or that additional interventions had been identified and communicated to staff, and monitored at least weekly," the survey said. The staff had discussed "possible interventions, such as a nutritional supplement," but "none had been implemented," the survey said.

Another resident had an open pressure wound on a buttock. A pressure wound is one, such as a bedsore, that can erupt after staying in place for long periods.

Although the survey noted that a dressing was used, the facility could not show that "the wounds were monitored, at least weekly, to determine effectiveness of interventions."

This same resident experienced four falls within a month. The facility could not show it had investigated the unwitnessed incidents to rule out abuse or neglect, or that it had "reviewed the (resident's) service plan to see if it was being followed ... to prevent further falls," the survey said.

The survey noted gaps and lapses in how medication was documented, including physicians' orders. For sampled residents, the facility "failed to ensure orders were carried out as prescribed for all medications administered."

The medication administration records for a resident on multiple medications "lacked clear parameters on when to administer one versus the other and in what order," the survey said. The same was true of another resident's records.

While the survey was underway, Avamere did not offer consistent recreational and group activities to keep residents mentally, physically and socially engaged.

"Residents were observed sitting in common areas for long periods of time watching television, people-watching or remained in their rooms," the survey said. "Multiple residents were observed pacing the halls frequently without being engaged in any individual or group activities."

A handful of activities — such as chair exercises, brain boosters, chair volleyball, music and movement, coloring craft and gardening club — had been scheduled, then not offered, the survey said.

A staff member told the state that Avamere's life enrichment director and activity aide were on vacation. In their absence, no plans were made to continue activities, according to the survey.

A couple of residents "were observed pacing the halls and made comments including, 'There's nothing to do,' 'I don't know what we can be doing now' and 'I'd like to go out of here to do things.'"

Avamere employees said that staff turnover over several months led to "extended periods of time without life enrichment staff," the survey said.

The survey said that the living environment and kitchen areas were not kept clean or in good repair.

In areas of the main kitchen and kitchenette the survey found "black matter, debris, grease, food matter and dirt buildup."

The survey noted gouges in walls, piles of dirt and debris in various places. Walls and doors, from common areas to rooms, had scrapes and chipped or peeling paint. "A hallway near the dining room had eight screws protruding from the wall," the survey said. Multiple windowsills had chipped paint and collections of dead bugs.

"Pervasive urine odors were noted in halls and common areas during the survey," the survey said.

Some residents' service plans did not reflect their current needs or give clear direction to staff, the survey said.

The service plan of one resident, who "had not been out of bed for 'about' two months," did not inform staff about how the person should be cared for regarding the person's status, involvement in activities, bathing and toileting, falls, dining routine, weight monitoring and other needs, the survey said.

The facility also had trouble coordinating the resident's care with outside providers.

An outside provider had placed the resident on palliative care. The provider had visited the facility to instruct Avamere's care staff in "bed mobility and transfer training ... including using a transfer board" for this resident.

"There was no documented evidence the facility updated the resident's service plan with these instructions or communicated the bed mobility and transfer instructions to all direct care staff," the survey said. In addition, "there was no documentation of the outside provider visits and recommendations with care instructions for palliative care."

When a specialist created a behavior support plan for a resident displaying behaviors — including physical altercations, disrobing and elopement attempts — that negatively impacted other residents, Avamere did not incorporate the support plan into the resident's service plan, the survey said.

Guidance

The survey also found other issues.

For example, Avamere was not up to speed on visitation guidance for care homes in the post-public emergency phase of the pandemic. Residents were not allowed to meet freely with their visitors. In at least one case, a visitor was escorted out of the building.

Fire drills were not conducted every other month as required by the state fire code, and fire life safety instruction was not given to staff with the required regularity, the survey said.

Avamere could also not show that residents had received fire and life safety training within a day of moving in, or that the retraining was happening at least annually, per the state fire code.

Elisa Williams, a communications manager at the Department of Human Services, said in an email: "Reports provided by the RN consultant indicate the facility is making good progress on addressing issues to be resolved."