Avamere at Bethany

Last inspection

March 6, 2025

Inspections

6, 40 deficiencies cited

Substantiated abuse

7

Substantiated licensing violations

23

Regulatory actions

1

Fines assessed

$4,501.00 (7 violations)

Current owner since

August 29, 2003

License conditions and other regulatory actions

• July 17, 2023 to March 18, 2025: License Condition, Failed to use an ABST RCFCD23-00841; incident: OR0003914101
  The facility failed to fully implement and update an Acuity Based Staffing Tool (ABST) in accordance with OAR 411-054-0037.
  Rules: 411-054-0037 (Acuity-Based Staffing Tool)

Inspections

• March 6, 2025: Re-Licensure, 13 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 3, scope L3 Isolated
  • C0280: Resident Health Services severity level 3, scope L3 Isolated
  • C0290: Res Hlth Srvc: On- and Off-Site Health Srvc severity level 2, scope L2 Pattern
  Show all 13

  • C0303: Systems: Treatment Orders severity level 2, scope L2 Isolated
  • C0340: Restraints and Supportive Devices severity level 2, scope L2 Isolated
  • C0372: Training Within 30 Days of Hire ? Direct Care Staff severity level 2, scope L2 Pattern
  • C0422: Fire and Life Safety: Training for Residents severity level 2, scope L2 Widespread
  • C0555: Call Sys, Exit Dr Alarm, Phones, TV, or Cable severity level 2, scope L2 Widespread
  • Z0142: Administration Compliance severity level 2, scope L2 Widespread
  • Z0155: Staff Training Requirements severity level 2, scope L2 Pattern
  • Z0162: Compliance with Rules Health Care severity level 3, scope L3 Isolated
• July 10, 2024: State Licensure, 2 deficiencies 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
  • Z0142: Administration Compliance severity level 2, scope L2 Widespread, corrected November 4, 2024
• June 20, 2023: State Licensure, 2 deficiencies cited report
  • C0000: Comment severity level 0
  • C0240: Resident Services Meals, Food Sanitation Rule severity level 2, scope L2 Widespread, corrected August 18, 2023
  • Z0142: Administration Compliance severity level 2, scope L2 Widespread, corrected August 18, 2023
• April 27, 2023: Licensure Complaint, 6 deficiencies cited report
  • C0010: Licensing Complaint Investigation severity level 2, scope L2 Isolated
  • C0154: Facility Administration: Policy & Procedure severity level 2, scope L2 Isolated
  • C0260: Service Plan: General 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
  • C0372: Training Within 30 Days: Direct Care Staff severity level 2, scope L2 Isolated
  • C0513: Doors, Walls, Elevators, Odors severity level 2, scope L2 Isolated
• August 8, 2022: Complaint Investig., 2 deficiencies cited report
  • C0010: Licensing Complaint Investigation severity level 2, scope L2 Isolated
  • C0160: Reasonable Precautions severity level 2, scope L2 Isolated
  • C0513: Doors, Walls, Elevators, Odors severity level 2, scope L2 Isolated
• March 14, 2022: Validation, 15 deficiencies cited report
  • C0000: Comment severity level 0
  • C0231: Reporting & Investigating Abuse-Other Action severity level 2, scope L2 Isolated, corrected May 15, 2022
  • C0252: Resident Move-In and Eval: Res Evaluation severity level 2, scope L2 Pattern, corrected May 15, 2022
  • C0260: Service Plan: General severity level 2, scope L2 Pattern, corrected May 15, 2022
  • C0270: Change of Condition and Monitoring severity level 3, scope L3 Isolated, corrected May 15, 2022
  Show all 16

  • C0290: Res Hlth Srvc: On- and Off-Site Health Srvc severity level 2, scope L2 Pattern, corrected May 15, 2022
  • C0303: Systems: Treatment Orders severity level 2, scope L2 Pattern, corrected May 15, 2022
  • C0310: Systems: Medication Administration severity level 2, scope L2 Pattern, corrected May 15, 2022
  • C0330: Systems: Psychotropic Medication severity level 2, scope L2 Isolated, 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
  • C0513: Doors, Walls, Elevators, Odors severity level 2, scope L2 Widespread, corrected May 15, 2022
  • Z0142: Administration Compliance severity level 2, scope L2 Widespread, corrected May 15, 2022
  • Z0155: Staff Training Requirements severity level 2, scope L2 Pattern, corrected May 15, 2022
  • Z0162: Compliance With Rules Health Care severity level 3, scope L3 Isolated, corrected May 15, 2022
  • Z0164: Activities severity level 2, scope L2 Pattern, corrected May 15, 2022

Substantiated abuse or neglect

• November 21, 2025: Failed to assure food safety Abuse: Neglect; Level 2 - Minor harm or potential for moderate harm; fine $188.00; 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); 411-054-0030 (Resident Services); 411-054-0036 (Service Plan – General)
  State’s findings

  On or about November 21, 2025, Alleged Victim (AV), a resident of a secure residential care facility, was served and consumed food containing shellfish despite having a documented shellfish allergy. AV did not recall having this allergy when food was served and had already eaten some of the food before staff identified the error. Upon discovery, staff monitored AV for signs of an allergic reaction (e.g., hives, swelling, respiratory distress). Based on facility documentation and interviews, AV’s shellfish allergy was known and documented in his/her care plan. Staff interviews indicated AV’s dietary restrictions were not adequately supervised during mealtime which placed AV at risk of harm. The facility's failure to ensure proper oversight and monitoring of AV’s dietary needs, is a violation of resident rights, is considered neglect of care which constitutes abuse.

• November 17, 2025: Failed to provide safe environment Abuse: Neglect; Level 2 - Minor harm or potential for moderate harm; fine $188.00; 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); 411-054-0036 (Service Plan – General)
  State’s findings

  On or about November 17, 2025, the facility failed to provide appropriate supervision to the Alleged Victim (AV) according to his/her care needs. The failure resulted in AV eloping the secured building, without staff knowledge, placing him/her at risk of harm which is a violation of resident rights, is considered neglect of care and constitutes abuse.

• August 10, 2024: Failed to properly plan care Abuse: Neglect; Level 4 - Serious harm, death, imminent danger or chronic regulatory noncompliance; 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); 411-054-0036 (Service Plan – General); 411-054-0040 (Change of Condition and Monitoring)
  State’s findings

  The facility failed to implement interventions and appropriately care plan related to the Alleged Victim's (AV) fall history. On or about August 10, 2024, AV was found on the floor of their room crying out in pain and holding their head and hip. AV was transferred to the hospital and was diagnosed with a fractured left femur. AV was admitted to the hospital from August 10, 2024, and discharged on August 19, 2024. According to hospital records, AV had a surgical procedure to treat AV's broken thigh bone in which a metal rod was inserted with screws to stabilize the bone. Based on facility documentation and interviews, AV had two prior falls dated July 26, 2024, and August 1, 2024. An investigation determined the facility failed to identify AV as a fall risk on AV's care plan and failed to implement sufficient fall interventions to mitigate AV's fall risk. The facility's failure to properly care plan for AV's fall risk caused unreasonable discomfort and severe pain which is a violation of resident rights, is considered neglect of care and constitutes abuse.

• December 3, 2021: Failed to provide a safe medication administration system Abuse: Neglect; Level 2 - Minor harm or potential for moderate harm; fine $375.00; 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 for Alleged Victim (AV) by failing to administer essential medications as ordered. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

• December 3, 2021: Failed to provide a safe medication administration system Abuse: Neglect; Level 2 - Minor harm or potential for moderate harm; fine $375.00; 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 for Alleged Victim (AV) by failing to administer essential medications as ordered. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

• November 30, 2021: Failed to provide a safe medication administration system Abuse: Neglect; Level 2 - Minor harm or potential for moderate harm; fine $375.00; 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 for Alleged Victim (AV) by failing to administer essential medications as ordered. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

• November 5, 2021: 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 administered as ordered which resulted in AV being transported to hospital for observation on November 7, 2021. Based on facility documentation and interviews, facility missed medication dosages for AV on November 1, 2021, November 3, 2021, November 5, 2021, and November 6, 2021. The failure resulted in unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Substantiated licensing violations

• July 28, 2026: Failed to provide safe environment Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0025 (Facility Administration)
  State’s findings

  Based on observations, interviews, and record review conducted during a site visit on 07/28/26, the facility failed to maintain reasonable precautions against conditions that could threaten the health, safety, or welfare of residents. This issue was substantiated for 1 of 1 sampled residents (#1). Findings include, but are not limited to the following: A review of Incident Report #3653 dated 07/04/26 regarding the elopement of Resident 1 (R1) indicated that she/he exited the secured unit by following a visitor out of the main door unnoticed by Staff. Staff became aware of the elopement after a visitor outside the building notified staff inside the building, Additinal information indicated in the report, R1 is continuously and actively trying to leave the community and she/he wanders, roams and looks for people/things that are not there. Observations: The door alarm for the main entrance to the Memory Care unit was observed plugged into a hallway outlet. Staff 2 (Med Tech) reported that when residents unplugged the alarm and staff reconnected it, the alarm volume would reset to the lowest level unless manually adjusted. At the lowest level the alarm could not be heard if not in the immediate area where the alarm was placed. The south door was observed to have an 8-second delay before locking after closing and did not have a functioning audible alarm. This door led to a hallway connecting to an elevator on the east side and a hallway on the west side that exited outside near the dumpster and parking lot. R1 was known as an active exit seeker, and she/he would often try to open doors. Maintenance staff adjusted the timing of the south door to lock within 3 seconds after the code was entered. This adjustment appeared reasonable to ensure the door locked promptly after staff or visitors exited and could not be opened again without the code. Staff Interviews: Staff 1 (Regional Director) stated she/he was unaware that the south Memory Care door had an extended delay before locking after code entry. Staff 1 indicated she/he would work with maintenance to put covers over the alarms in the hallway and have batteries checked frequently to prevent alarm failure. Staff 2 (Med Tech) stated that the door R1 exited to where she/he was found in the parking lot was typically locked without delay but acknowledged that there had been occasions when it did not. Staff 2 reported that residents sometimes unpluged the door alarms and that, when reconnected, the alarms reset to a low volume unless staff adjusted them. Staff 3 (Life Enrichment Coordinator) stated that the main door had a delay before locking after someone entered or exited. Staff 3 believed that the south door alarm battery needed replacement. Staff 5 (Caregiver) stated that the door where R1 exited when she/he had eloped did not lock immediately upon closing on the day of the elopement. Staff 5 reported that door the alarms sometimes failed due to battery issues. Staff 5 notified management, and maintenance subsequently adjusted the door lock timing and replaced the alarm battery. The facility failed to ensure reasonable precautions were taken to protect the resident from conditions when a resident eloped from the facility by providing secure doors that locked timely to prevent resident from following visitors out of the facility and having functioning door alarms is a violation of Oregon Administrative Rules.

• July 7, 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

  Based on interview, and record reviews conducted during a site visit on 07/28/26, the facility failed to ensure medications were carried out as prescribed and physician’s orders were followed was substantiated for 1 of 1 sampled residents (#1). Findings include but are not limited to the following: On 07/28/26 following documents were reviewed for Resident 1 (R1): Incident report #3660 dated 07/07/26 indicated Lorazepam 1mg on 07/07/26 @19:18 instead of Lorazepam 0.5mg. Note on 07/10/26 stated bubble cards for both dosages were in the narcotics drawer. Note indicated on 07/10/26 that staff would be re-educated on medication administration. Progress notes effective date 07/07/26 9:48, for Medication error. Resident was given Lorazepam 1mg instead of 0.5mg as per order. Resident was found sleeping in another resident's bed. MAR indicated a D/C date of 07/02/26 for Lorazepman 1mg. Physician’s Orders dated 07/02/26 with a received date of 07/03/26 indicated an order to start Lorazepam oral tablet 0.5mg 2 times daily. Interview with Staff 2 (Med Tech) stated she/he caught an error when doing the medication count on 07/08/26 for day shift and the bubble pack for 1mg Lorazepam should have had a sticker with bold red letters “Directions change refer to chart”. Staff 2 stated R1 changed from 0.5mg am and 1mg in pm to 0.5mg twice per day on 07/03/26. Staff 2 showed Compliance Specialist an example of the red sticker that would indicate a change of medication. The facility’s failure to ensure R1’s medication and physician’s orders were carried out as prescribed is a violation of Oregon Administrative Rules.

• July 4, 2026: Failed to provide safe environment Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0036 (Service Plan – General)
  State’s findings

  Based on observations, interviews, and record reviews conducted during a site visit on 07/28/26, the facility failed to ensure implementation of services for 1 of 1 resident (#1) sampled. Findings include, but are not limited to: Observations: Resident 1 (R1) she/he was observed by compliance specialist exiting another resident’s room unsupervised, carrying a pair of shoes that were not her/his. R1 had put the shoes in a basket outside her/his room. R1 went into her/his room and closed the door. A staff member returned the shoes to the other resident’s room. Record review: - ALF/RCF Facility Safety Plan dated 07/13/26 indicated the facility would increase supervision and safety checks. - R1's service plan last completed 06/04/26 and 07/13/26 under safety indicated she/he would have safety checks of 2-3 hours. Safety checks were not increased on 07/13/26 R1's her/his service plan but was indicated the facility would increase per safety plan. - Incident report #3653 Elopement dated 07/04/26 indicated R1 eloped from the secured memory care facility, and she/he was an active exit seeker. Interview(s): - Staff 6 (Caregiver) stated R1 she/he was on two-hour checks but should have increased frequency as she/he was a very active exit seeker who frequently entered other residents’ rooms and removed their personal belongings and this could have caused conflict with other residents. Staff 6 believed that R1's care plan should be updated to help she/he with tasks for redirection. Staff 6 stated she/he think R1’s service plan should be updated for her/his anxiety. - Staff 5 (Caregiver) stated R1 was on 2–3-hour safety checks and that was not enough for she/he as R1 was an active exit seeker. Staff 5 indicated R1 was often up most nights and she/he slept a lot of the day. Staff 5 indicated R1 was looking for snacks in the kitchen area, and she/he pulled very hard on locked cupboards causing damage. Staff 5 stated R1 had put things in the microwave that are not appropriate when she/he was unsupervised. - R1 was not available for interview. The facility’s failure to ensure implementation of services to meet resident’s needs is a violation of Oregon Administrative Rules.

• July 4, 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

  Based on interview and record review conducted during a site visit on 07/28/26 the facility failed to complete or update and review the Acuity-Based Staffing Tool (ABST) evaluation for each resident quarterly as required. Findings include but are not limited to: The facility’s census was 21. A review of the facility’s last ABST evaluation update per resident indicated 5 of 21 residents had not been updated quarterly as required as of 07/04/26. The facility’s failure to complete or update and review the Acuity-Based Staffing Tool (ABST) evaluation for each resident quarterly as required is a violation of Oregon Administrative Rules.

• July 4, 2026: Failed to staff as indicated by ABST Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0037 (Acuity-Based Staffing Tool)
  State’s findings

  Based on interview and record review, conducted during a site visit on 07/28/26, the facility failed to have qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and/or unscheduled needs of each resident. Findings include, but are not limited to: The facility’s posted staffing plan indicated: For Day shift, 5 direct care staff; For Swing shift, 4 direct care staff; and For Night shift, 3 direct care staff. The facility’s staffing schedule dated 06/28/26-07/04/26, indicated the facility was not staffing to its posted staffing plan for 3 of 21 shifts reviewed. Interview with Staff 5 (Caregiver) stated Resident 1 (R1) was often up all night and had damaged cupboards as she/he is looking for snacks. R1 had been able to plug the microwave back in and she/he had put things in that are not appropriate for the appliance. Staff 5 believed this was due to R1 being up all night and she/he was unsupervised. ?The facility's failure to have qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident 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 26 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.