Avamere at Chestnut Lane

Last inspection

August 19, 2024

Inspections

4, 14 deficiencies cited

Substantiated abuse

11

Substantiated licensing violations

25

Regulatory actions

1

Fines assessed

$9,125.00 (11 violations)

License conditions and other regulatory actions

• August 29, 2023 to April 26, 2024: License Condition, Failed to use an ABST ALFCD23-00562; incident: CALMS - 00045910
  The facility failed to ensure resident ABST entries were reflective of resident care needs and were updated quarterly.
  Rules: 411-054-0037 (Acuity-Based Staffing Tool)

Inspections

• August 19, 2024: Complaint Investig., 1 deficiency cited report
  • C0010: Licensing Complaint Investigation severity level 0
  • C0303: Systems: Treatment Orders severity level 2, scope L2 Isolated
• May 28, 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 July 27, 2024
• February 12, 2024: Complaint Investig., 2 deficiencies cited report
  • C0360: Staffing Requirements and Training: Staffing severity level 2, scope L2 Pattern
  • C0372: Training Within 30 Days: Direct Care Staff severity level 2, scope L2 Pattern
• July 17, 2023: Validation, 10 deficiencies cited report
  • C0000: Comment severity level 0
  • C0252: Resident Move-In and Eval: Res Evaluation severity level 2, scope L2 Isolated, corrected September 17, 2023
  • C0260: Service Plan: General severity level 2, scope L2 Pattern, corrected September 17, 2023
  • C0270: Change of Condition and Monitoring severity level 2, scope L2 Isolated, corrected September 17, 2023
  • C0303: Systems: Treatment Orders severity level 3, scope L3 Isolated, corrected April 6, 2024
  Show all 12

  • C0310: Systems: Medication Administration severity level 2, scope L2 Pattern, corrected September 17, 2023
  • C0330: Systems: Psychotropic Medication severity level 2, scope L2 Isolated, corrected September 17, 2023
  • C0340: Restraints and Supportive Devices severity level 2, scope L2 Isolated, corrected September 17, 2023
  • C0361: Acuity-Based Staffing Tool severity level 2, scope L2 Pattern, corrected September 17, 2023
  • C0420: Fire and Life Safety: Safety severity level 2, scope L2 Widespread, corrected September 21, 2023
  • C0455: Inspections and Investigation: Insp Interval severity level 2, scope L2 Widespread, corrected April 6, 2024
  • C0613: General Building: Doors-Walls, Cleanable severity level 2, scope L2 Widespread, corrected April 6, 2024

Substantiated abuse or neglect

• September 5, 2025: Failed to properly plan care Abuse: Neglect; Level 2 - Minor harm or potential for moderate harm; fine $250.00; 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); 411-054-0040 (Change of Condition and Monitoring)
  State’s findings

  Alleged Victim (AV) returned to the facility on September 3, 2025, after a hospital stay with a diagnosis of “failure to thrive.” Due to AV’s change in condition, staff were required to deliver meals to AV’s apartment, place them within AV’s reach, and provide cuing to eat. On the afternoon of September 5, 2025, AV’s breakfast and lunch trays were found in AV’s room untouched, still covered, and positioned out of AV’s reach. Based on facility documentation and interviews, staff working with AV at time of incident were not aware of AV’s need for meal setup and cuing. When staff made AV’s food accessible and provided cuing, AV began eating. The facility's failure to provide adequate oversight and training of staff to ensure AV was receiving necessary meal support, resulted in unreasonable discomfort when AV was not able to eat meals which were left in AV's room. The facility failed to properly care plan for AV's care needs which resulted in unreasonable discomfort and physical harm to AV, which is a violation of resident rights, is considered neglect of care which constitutes abuse, as defined by OAR 411-020-0002(1)(b)(A)(i).

• July 16, 2025: Failed to properly plan care Abuse: Neglect; Level 3 - Moderate harm or potential for serious harm; fine $1,125.00; 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); 411-054-0040 (Change of Condition and Monitoring)
  State’s findings

  On or about July 16, 2025, the Alleged Victim (AV) was transported to the hospital due to unexplained bruising on the backs of the thighs and an elevated blood sugar reading. Hospital staff later reported that imaging revealed AV had a fractured pelvis. The attending physician estimated that the injury likely occurred within the previous three days. The facility’s internal investigation determined that multiple caregivers observed bruising between the night of July 14, 2025, and July 16, 2025; however, none of the staff reported or documented the bruising to facility nursing staff or management. Prior to being transported to the hospital on July 16, documentation indicated that AV’s pain level appeared to be “10/10,” as AV was reportedly screaming during assessment of the legs. Due to systemic failures in staff reporting and documentation of symptoms, the facility did not adequately monitor AV’s change in condition, resulting in a delay in the diagnosis and treatment of the pelvic fracture which is a violation of resident rights, is considered neglect of care which constitutes abuse, as defined by 411-020-0002(1)(b)(A)(i).

• July 16, 2025: Failed to follow care plan Abuse: Neglect; Level 3 - Moderate harm or potential for serious harm; fine $1,125.00; 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 July 16, 2025, the facility failed to provide appropriate services as required by the Alleged Victim’s (AV) care plan and assessed needs. As a result of this failure, AV was admitted to the hospital after reporting significant pain of unknown origin and was subsequently diagnosed with a pelvic fracture. Facility documentation and staff interviews indicate that management was not aware of any incident that may have caused the injury. At the time of incident, staff were required to use a gait belt for all transfers; however, it had become common practice for staff to assist AV without a gait belt. Management was not aware that staff were inconsistently using the required transfer equipment. The facility's failure to provide adequate oversight of staff to ensure AV's care plan was followed, resulted in physical harm when AV sustained a pelvic fracture during a transfer which is a violation of resident rights, is considered neglect of care which constitutes abuse, as defined by 411-020-0002(1)(b)(A)(i). Alleged Perpetrator 2 (AP2) allegedly neglected AV. An investigation determined no abuse occurred by AP2.

• December 12, 2023: Failed to provide oversight and monitoring of change of condition Abuse: Neglect; Level 3 - Moderate harm or potential for serious harm; fine $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); 411-054-0036 (Service Plan – General); 411-054-0040 (Change of Condition and Monitoring)
  State’s findings

  The facility failed to provide appropriate services according to Alleged Victim's (AV) care needs concerning AV's skin impairment. Based on facility documentation and interviews, staff did not place AV on alert monitoring and also failed to notify facility nurse when staff observed AV's perineal and abdominal fold with a rash on November 26, 2023. As a result of this failure, AV did not receive an appropriate treatment plan from AV's medical provider until after AV returned from visiting Witness 1 (W1) on December 7, 2023. The facility's failure resulted in AV's unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

• December 12, 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: 411-054-0025 (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 or about December 12, 2023, an investigation determined that the facility failed to provide adequate training and oversite to ensure staff packed the appropriate medications for Alleged Victim's (AV) trip away from the facility to visit Witness 1 (W1), resulting in AV's unreasonable discomfort when AV's [GABA analogue medication] was not available for administration. The facility's failure to provide a safe medication system for AV is a violation of resident rights, is considered neglect of care which constitutes abuse.

Substantiated licensing violations

• November 30, 2025: 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.

• September 12, 2025: Failed to follow care plan Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0025 (Facility Administration)
  State’s findings

  On the morning of the incident, the Alleged Victim (AV) was having breakfast under the supervision of Alleged Perpetrator 2 (AP2), who was the staff member assigned to monitor and assist AV with meals. AV’s initial meal included a sausage patty that had been cut into small, manageable pieces. According to facility documentation and staff interviews, AV was eating well and requested a second serving of the sausage patty. AP2 went to the kitchen to request an additional portion but did not inform kitchen staff that the food was for AV. The second sausage patty was provided whole and uncut. AP2 gave the uncut patty to AV, believing it was small enough to be safely consumed. Shortly after eating the second serving, AV began exhibiting signs of distress, including abnormal behavior, cessation of breathing, and facial discoloration (turning purple). AP2 responded by patting AV on the back and calling for additional staff assistance. AP2 then performed the Heimlich maneuver, successfully dislodging and ejecting pieces of the sausage patty from AV’s airway. AP2 later acknowledged not noticing that the initial portion had been cut and believed they were adequately monitoring AV’s food intake. Although AP2 is trained in resident care, meal assistance, and dietary need, including food handling and safety, at time of incident AP2 failed to ensure that AV’s second meal portion adhered to AV’s dietary restrictions. This failure resulted in AV choking on a meal item. AP2's actions is considered neglect of care which constitutes abuse. Furthermore, the facility failed to provide adequate oversight to ensure AP2 followed AV's dietary and safety protocols. This failure is a violation of Oregon Administrative Rules.

• September 12, 2025: 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.

• August 9, 2025: 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

  On or about August 9, 2025, 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.

• July 16, 2025: 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

  On July 16, 2025, 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 78 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.