Avamere at Bethany Assisted Living Facility

Last inspection

March 6, 2025

Inspections

6, 29 deficiencies cited

Substantiated abuse

9

Substantiated licensing violations

13

Regulatory actions

0

Fines assessed

$7,125.00 (9 violations)

Current owner since

August 28, 2003

Inspections

• March 6, 2025: Re-Licensure, 18 deficiencies cited report
  • C0252: Resident Move-in & Evaluation: Res Evaluation severity level 2, scope L2 Pattern
  • C0260: Service Plan: General severity level 2, scope L2 Pattern
  • C0270: Change of Condition and Monitoring severity level 2, scope L2 Pattern
  • C0280: Resident Health Services severity level 2, scope L2 Pattern
  • C0290: Res Hlth Srvc: On- and Off-Site Health Srvc severity level 2, scope L2 Pattern
  Show all 19

  • C0295: Infection Prevention & Control severity level 2, scope L2 Isolated
  • C0303: Systems: Treatment Orders severity level 2, scope L2 Pattern
  • C0305: Systems: Resident Right to Refuse severity level 2, scope L2 Isolated
  • C0340: Restraints and Supportive Devices severity level 2, scope L2 Isolated
  • C0370: Staffing Requirements and Training ? Pre-service severity level 2, scope L2 Pattern
  • C0372: Training Within 30 Days of Hire ? Direct Care Staff severity level 2, scope L2 Pattern
  • C0374: Annual and Biennial Inservice for All Staff severity level 2, scope L2 Pattern
  • C0420: Fire and Life Safety: Safety severity level 2, scope L2 Widespread
  • C0455: Inspections and Investigation: Insp Interval severity level 2, scope L2 Isolated
  • C0613: General Building: Doors-Walls, Cleanable severity level 2, scope L2 Widespread
  • C0615: Resident Units severity level 2, scope L2 Widespread
  • C0640: Heating and Ventilation severity level 2, scope L2 Widespread
  • C0645: Plumbing Systems severity level 2, scope L2 Widespread
  • L0370: Staffing Requirements and Training ? Pre-service severity level 2, scope L2 Pattern
• July 10, 2024: State Licensure, 1 deficiency cited report
  • C0000: Comment severity level 0
  • C0240: Resident Services Meals, Food Sanitation Rule severity level 2, scope L2 Widespread, corrected November 4, 2024
  • C0455: Inspections and Investigation: Insp Interval severity level 2, scope L2 Widespread, corrected November 4, 2024
• April 9, 2024: Complaint Investig., 3 deficiencies cited report
  • C0300: Systems: Medications and Treatments severity level 2, scope L2 Isolated
  • C0303: Systems: Treatment Orders severity level 2, scope L2 Isolated
  • C0361: Acuity-Based Staffing Tool severity level 2, scope L2 Widespread
• June 20, 2023: State Licensure, 1 deficiency cited report
  • C0000: Comment severity level 0
  • C0240: Resident Services Meals, Food Sanitation Rule severity level 2, scope L2 Widespread, corrected August 18, 2023
• August 8, 2022: Complaint Investig., 1 deficiency cited report
  • C0010: Licensing Complaint Investigation severity level 2, scope L2 Isolated
  • C0160: Reasonable Precautions severity level 2, scope L2 Isolated
• March 14, 2022: Validation, 5 deficiencies cited report
  • C0000: Comment severity level 0
  • C0370: Staffing Requirements and Training – Pre-Serv severity level 2, scope L2 Isolated, corrected May 15, 2022
  • C0372: Training Within 30 Days: Direct Care Staff severity level 2, scope L2 Isolated, corrected May 15, 2022
  • C0374: Annual and Biennial Inservice For All Staff severity level 2, scope L2 Pattern, corrected May 15, 2022
  • C0420: Fire and Life Safety: Safety severity level 2, scope L2 Widespread, corrected May 15, 2022
  • C0422: Fire and Life Safety: Training For Residents severity level 2, scope L2 Widespread, corrected May 15, 2022

Substantiated abuse or neglect

• September 2, 2025: Failed to provide a safe medication administration system Abuse: Neglect; Level 4 - Serious harm, death, imminent danger or chronic regulatory noncompliance; fine $1,500.00; report
  Rules: 411-054-0025 (Facility Administration); 411-054-0027 (Resident Rights and Protections); 411-054-0028 (Reporting and Investigating Abuse and Other Actions Affecting Resident Welfare); 411-054-0055 (Medications and Treatments)
  State’s findings

  On January 23, 2026, ODHS Adult Protective Services (APS) completed investigation #00429373 and issued a written investigation report, which is incorporated here by reference. Alleged Victim (AV) lived at Respondent’s facility. On September 2, 2025, AV returned from a medical appointment with a new prescription for treatment of an infection. Facility records and staff interviews confirm the medication was delivered to the facility but not entered in AV’s Medication Administration Record (MAR) and not administered as ordered. Staff reported they were unaware of the new order until September 12, 2025, when Witness 3 followed up. At that time, the facility began the prescribed 7-day treatment. Following completion of the medication, AV exhibited hallucinatory behaviors and was transferred to the hospital. On September 25, 2025, AV was admitted to the ICU due to complications related to the infection diagnosed on September 2, 2025. The facility’s failure to follow physician orders and maintain an accurate MAR caused a 10-day delay in treatment, contributing to AV’s health decline and hospitalization which is a violation of resident rights, is considered neglect of care, and constitutes abuse.

• October 2, 2024: Failed to properly plan care Abuse: Neglect; Level 3 - Moderate harm or potential for serious harm; fine $500.00; report
  Rules: 411-054-0027 (Resident Rights and Protections); 411-054-0028 (Reporting and Investigating Abuse and Other Actions Affecting Resident Welfare); 411-054-0036 (Service Plan – General)
  State’s findings

  On or about October 2, 2024, the facility failed to provide appropriate services according to the Alleged Victim’s (AV) care needs. The failure resulted in AV being left unchecked and without access to their call light for over twelve hours while sick with gastroenteritis. Based on facility documentation and interviews, AV was discovered the next morning with vomit on his/her clothing, his/her bedroom window was open, and the room temperature was cold due to window being left open all night. AV was also observed to not have a blanket or access to his/her call pendant to call for help. The facility's failure to appropriately monitor AV's nighttime care needs during NOC shift resulted in AV not receiving appropriate services according to his/her care needs which caused AV unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

• July 21, 2023: Failed to provide a safe medication administration system Abuse: Neglect; Level 3 - Moderate harm or potential for serious harm; fine $1,500.00; report
  Rules: 411-054-0027 (Resident Rights and Protections); 411-054-0028 (Reporting and Investigating Abuse and Other Actions Affecting Resident Welfare); 411-054-0055 (Medications and Treatments)
  State’s findings

  The facility failed to provide a safe medication administration system to ensure The Alleged Victim’s (AV) medications were available for AV to self administer. Based on facility documentation and interviews, AV suffers from ongoing pain and mental health issues that require medication support from the facility. AV administers his/her own medication but requires facility to order medication from the pharmacy and to ensure delivery. AV's medication was received from the pharmacy on July 20, 2023, but facility failed to deliver the medication directly to AV. AV went without two significant medications for a total of 14 days which equates up to 45 missed dosages. AV reported the missed medication caused severe pain/anxiety issues that impacted their overall health and well being. The failure resulted in unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

• February 28, 2023: Failed to provide a safe medication administration system Abuse: Neglect; Level 2 - Minor harm or potential for moderate harm; fine $500.00; report
  Rules: 411-054-0027 (Resident Rights and Protections); 411-054-0028 (Reporting and Investigating Abuse and Other Actions Affecting Resident Welfare); 411-054-0055 (Medications and Treatments)
  State’s findings

  The facility failed to provide a safe medication administration system to ensure the Alleged Victim’s (AV) medications were administered as ordered. Based on facility documentation and interviews, AV has a complex medication regiment and facility failed to administer AV's medication as ordered by AV's medical provider causing AV to suffer adverse effects including behavioral disturbances. The facility's failure to provide a safe medication administration system resulted in unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

• December 6, 2022: Failed to follow care plan Abuse: Neglect; Level 2 - Minor harm or potential for moderate harm; fine $500.00; report
  Rules: 411-054-0027 (Resident Rights and Protections); 411-054-0028 (Reporting and Investigating Abuse and Other Actions Affecting Resident Welfare); 411-054-0036 (Service Plan – General)
  State’s findings

  The facility failed to update and follow Alleged Victim's (AV) care plan by allowing AV to sleep through and not be aware of AV’s meals. Without appropriate intervention, this continued level of care could have resulted in substantial negative consequences to AV’s health and safety due to AV's medical condition. Based on facility documentation, AV's blood sugar was impacted at least once during AV's time at the facility due to AV not being properly monitored during meal time. The facility failure to follow AV's care plan placed AV at risk of potential harm which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Substantiated licensing violations

• June 26, 2026: Failed to use an ABST Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0037 (Acuity-Based Staffing Tool)
  State’s findings

  The facility failed to have an Acuity-Based Staffing Tool (ABST) that accurately reflected the resident population, their needs, and all required Activities of Daily Living (ADL). Inconsistencies were identified between the resident roster, care plans, and the data entered into the ABST. Facility was not staffed to the levels as indicated by the ABST to meet the scheduled and unscheduled needs of residents. An investigation determined this is a violation of Oregon Administrative Rules.

• June 20, 2026: Failed to submit timely or adequate staffing documentation Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0105 (Inspections and Investigations)
  State’s findings

  The facility failed to provide records to the Department upon request in accordance with OAR 411-054-0105(1)(a), which is a violation of Oregon Administrative Rules.

• June 14, 2026: Failed to provide a safe medication administration system Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0055 (Medications and Treatments)
  State’s findings

  The facility failed to provide a safe medication administration system to ensure resident's medications were administered as ordered. The failure resulted is a violation of Oregon Administrative Rules.

• February 21, 2026: Failed to submit timely or adequate staffing documentation Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0105 (Inspections and Investigations)
  State’s findings

  The facility failed to provide records to the Department upon request in accordance with OAR 411-054-0105(1)(a), which is a violation of Oregon Administrative Rules.

• February 10, 2026: Failed to use an ABST Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0037 (Acuity-Based Staffing Tool)
  State’s findings

  The facility failed to have an updated Acuity-Based Staffing Tool (ABST) that accurately reflected the resident population and their care needs. Inconsistencies were identified between the resident roster, care plans, and the data entered into the ABST. An investigation determined this is a violation of Oregon Administrative Rules.

Read the full record on the state’s site →

ODHS lists only substantiated violations: “either a substantiated instance of abuse or a licensing violation. Open investigations and complaints that are being appealed by the provider are not listed.” Oregon counts neglect as a form of abuse; see the state’s definitions of abuse. Each violation shows the level ODHS gives it, in the state’s words (for example “2 - Minor harm or potential for moderate harm”), and any fine ODHS assessed. Inspection citations show the state’s severity level and scope, and the date ODHS recorded the problem as corrected when it lists one. Rule names come from the Oregon Administrative Rules. ODHS: “Formal regulatory actions can range from a condition placed upon a license due to non-compliance or a notice to revoke a license.” This community is licensed for 90 residents; larger communities are inspected and reported on more often, so read counts with size in mind. Source: Oregon Department of Human Services, Long-Term Care Licensing, data as of October 15, 2026, showing the last five years. Always visit in person and ask the community about anything listed here.