AVAMERE REHABILITATION OF HILLSBORO Nursing Home


AVAMERE REHABILITATION OF HILLSBORO (CCN: 385251) is a For profit - Corporation facility located in HILLSBORO, OR (97123). The facility has an overall rating of 3/5, health inspection rating of 3/5, and a staffing rating of 4/5. It offers 87 certified beds and maintains an average of 59.6 residents per day. The nursing staff includes Nurse Aides, LPNs, and RNs working 4.60716 total hours per resident per day. It has been certified since April 19, 1996 and the last listed health inspection was on July 31, 2023, The facility is located in Washington county and provides senior and nursing home care.

AVAMERE REHABILITATION OF HILLSBORO Summary


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Provider Name: AVAMERE REHABILITATION OF HILLSBORO

Address: 650 SE OAK STREET, HILLSBORO, OR 97123

Phone: (503) 648-8588

County: Washington (330)

Ownership Type: For profit - Corporation

Certified Beds: 87

Average Residents Per Day: 59.6 ()

Provider Type: Medicare and Medicaid, Resides in Hospital: No

Legal Business Name: PECKHAM-MILLER, INC

First Approved Date: April 19, 1996

Affiliated Entity: AVAMERE (58)

Retirement Community: N, Special Focus Status:

Ownership Change in Last 12 Months: N

Resident Family Council: Resident

Sprinkler System Status: Yes

Overall Rating: 3 ()

Health Inspection Rating: 3 ()

QM Rating: 4 ()

Long Stay QM Rating: 2 ()

Short Stay QM Rating: 5 ()

Staffing Rating: 4 ()

Staffing Report Note:

PT Staffing Note:

Nurse Aide Staff Hours Per Day, per resident: 3.01445, LPN Staff Hours Per Day: 1.1090, RN Staff Hours Per Day: 0.4836, Licensed Staff Hours Per Day: 1.5927

Total Nurse Staff Hours Per Day, per resident: 4.60716

Weekend Nurse Staff Hours: 3.99011, Weekend RN Staff Hours: 0.2776

PT Staff Hours Per Day, per resident: 0.1345

Nurse Staff Turnover: 36.6, Nurse Turnover Note:

RN Turnover: 33.3, RN Turnover Note:

Admin Left Number: 0, Admin Turnover Note:

Case Mix Nurse Aide Hours Per Day, per resident: 2.1880, Case Mix LPN Hours Per Day: 0.7412, Case Mix RN Hours Per Day: 0.3737

Adjusted Nurse Aide Hours Per Day, per resident: 2.80672, Adjusted LPN Hours Per Day: 1.1040, Adjusted RN Hours Per Day: 0.4876

Total Adjusted Nurse Hours Per Day, per resident: 4.39654

Adjusted Weekend Nurse Hours Per Day, per resident: 3.80770

Health Survey Dates and Scores: Cycle 1: 2023-07-31 (Score: 68), Cycle 2: 2019-07-15 (Score: 16), Cycle 3: 2017-12-18 (Score: 94)

Total Weighted Health Score: 55.000

Reported Incidents: 1, Substantiated Complaints: 1

Infection Control Citations: 0

Fines and Penalties: Number of Fines: 2, Total Fines in Dollars: 48126.00, Payment Denials Number: 0, Total Penalties Number: 2

Location and GPS: 650 SE OAK STREET,HILLSBORO,OR,97123 (45.5188, -122.980)

Process Date: 2024-03-01


Health Inspection Citations Details

Each record details specific health deficiencies found during inspections, categorized by type, severity, and whether they were corrected. Below are the severity levels and their implications:

Citation on 2023-07-31

Type: Health, Deficiency: Ensure that residents are fully informed and understand their health status, care and treatments.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2023-08-31

Citation on 2023-07-31

Type: Health, Deficiency: Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2023-08-31

Citation on 2023-07-31

Type: Health, Deficiency: Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2023-08-31

Citation on 2023-07-31

Type: Health, Deficiency: Provide care and assistance to perform activities of daily living for any resident who is unable.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2023-08-31

Citation on 2023-07-31

Type: Health, Deficiency: Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Severity: G - Level 3: Actual harm that is not immediate jeopardy. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2023-08-31

Citation on 2023-07-31

Type: Health, Deficiency: Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2023-08-31

Citation on 2023-07-31

Type: Health, Deficiency: Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2023-08-31

Citation on 2023-07-31

Type: Health, Deficiency: Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2023-08-31

Citation on 2023-07-31

Type: Health, Deficiency: Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2023-08-31

Citation on 2023-07-31

Type: Health, Deficiency: Provide and implement an infection prevention and control program.

Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2023-08-31

Citation on 2023-07-31

Type: Health, Deficiency: Ensure that residents are free from significant medication errors.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Past Non-Compliance on 2023-07-31

Citation on 2019-07-15

Type: Health, Deficiency: Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2019-08-16

Citation on 2019-07-15

Type: Health, Deficiency: Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2019-08-16

Citation on 2019-07-15

Type: Health, Deficiency: Provide activities to meet all resident's needs.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2019-08-16

Citation on 2019-07-15

Type: Health, Deficiency: Have the Quality Assessment and Assurance group have the required members and meet at least quarterly

Severity: C - Level 1: No actual harm with potential for minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2019-08-16

Citation on 2019-07-15

Type: Health, Deficiency: Provide and implement an infection prevention and control program.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2019-08-16

Citation on 2021-03-11

Type: Health, Deficiency: Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2021-03-12

Citation on 2021-03-11

Type: Health, Deficiency: Plan the resident's discharge to meet the resident's goals and needs.

Severity: J - Level 4: Immediate jeopardy to resident health or safety. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2021-03-12

Citation on 2021-03-11

Type: Health, Deficiency: Provide medically-related social services to help each resident achieve the highest possible quality of life.

Severity: G - Level 3: Actual harm that is not immediate jeopardy. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2021-03-12

Citation on 2017-12-18

Type: Health, Deficiency: Allow residents to self-administer drugs if determined clinically appropriate.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2018-01-30

Citation on 2017-12-18

Type: Health, Deficiency: Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2018-01-30

Citation on 2017-12-18

Type: Health, Deficiency: Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2018-01-30

Citation on 2017-12-18

Type: Health, Deficiency: Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2018-01-30

Citation on 2017-12-18

Type: Health, Deficiency: Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2018-01-30


Fire Safety Citations Details

Each record details specific fire safety deficiencies found during inspections, categorized by type, severity, and whether they were corrected. Below are the severity levels and their implications:

Citation on 2023-07-25

Type: Fire Safety, Tag: 0353, Version: New

Description: Inspect, test, and maintain automatic sprinkler systems.

Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2023-08-25

Citation on 2023-07-25

Type: Fire Safety, Tag: 0372, Version: New

Description: Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2023-08-25

Citation on 2023-07-25

Type: Fire Safety, Tag: 0712, Version: New

Description: Have simulated fire drills held at unexpected times.

Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2023-08-25

Citation on 2023-07-25

Type: Fire Safety, Tag: 0761, Version: New

Description: To conduct inspection, testing and maintenance of fire doors by qualified individuals.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2023-08-25

Citation on 2017-12-12

Type: Fire Safety, Tag: 0036, Version: New

Description: Establish emergency prep training and testing.

Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2018-01-31

Citation on 2017-12-12

Type: Fire Safety, Tag: 0037, Version: New

Description: Establish staff and initial training requirements.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2018-01-31

Citation on 2017-12-12

Type: Fire Safety, Tag: 0281, Version: New

Description: Install proper backup exit lighting.

Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2018-01-31

Citation on 2017-12-12

Type: Fire Safety, Tag: 0918, Version: New

Description: Have generator or other power source capable of supplying service within 10 seconds.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2018-01-31