Avamere at Hillsboro Assisted Living Facility

Last inspection

July 30, 2026

Inspections

10, 56 deficiencies cited

Substantiated abuse

9

Substantiated licensing violations

45

Regulatory actions

2

Fines assessed

$50,001.00 (15 violations)

License conditions and other regulatory actions

• August 19, 2025 to October 6, 2025: License Condition, Failed to provide safe environment ALFCD25-00399; incident: CALMS - 00085971
  The facility failed to carry out medication and treatment orders as prescribed. Resident 1 had a signed physicians order dated 5/16/25 for a mechanical soft diet yet was served a regularly textured meal. This put Resident 1 at risk of choking.
  Rules: 411-054-0025 (Facility Administration); 411-054-0055 (Medications and Treatments)
• February 8, 2023 to May 30, 2024: License Condition, Failed to assist with toileting ALFCD23-00093; 3 incidents: OR0003831402, OR0003831401, OR0003831400
  The facility failed to have enough staff to meet the scheduled and unscheduled needs of the resident as required by 411-054-0070(1). Per complainant the facility is always short the number of staff needed and scheduled.
  Rules: 411-054-0030 (Resident Services); 411-054-0037 (Acuity-Based Staffing Tool); 411-054-0070 (Staffing Requirements and Training)

Inspections

• July 30, 2026: Re-Licensure, 8 deficiencies cited report
  • C0252: Resident Move-in & Evaluation: Res Evaluation severity level 2, scope L2 Isolated
  • 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 Isolated
  • C0303: Systems: Treatment Orders severity level 3, scope L3 Isolated
  • C0310: Systems: Medication Administration severity level 2, scope L2 Pattern
  • C0420: Fire and Life Safety: Safety severity level 2, scope L2 Widespread
  • C0613: General Building: Doors-Walls, Cleanable severity level 2, scope L2 Pattern
• July 1, 2025: Kitchen, 1 deficiency cited report
  • C0240: Resident Services Meals, Food Sanitation Rule severity level 2, scope L2 Widespread
• September 12, 2024: Re-Licensure, 14 deficiencies cited report
  • C0154: Facility Administration: Policy & Procedure severity level 2, scope L2 Widespread
  • C0231: Reporting & Investigating Abuse-Other Action severity level 2, scope L2 Isolated
  • 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
  • C0302: Systems: Tracking Control Substances severity level 2, scope L2 Isolated
  • C0303: Systems: Treatment Orders severity level 2, scope L2 Isolated
  • C0325: Systems: Self-Administration of Meds severity level 2, scope L2 Pattern
  • C0360: Staffing Requirements and Training: Staffing severity level 2, scope L2 Widespread
  • C0361: Acuity Based Staffing Tool - Elements severity level 2, scope L2 Widespread
  • C0372: Training Within 30 Days of Hire ? Direct Care 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 Widespread
  • C0613: General Building: Doors-Walls, Cleanable severity level 2, scope L2 Widespread
• June 20, 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 20, 2024
• May 9, 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 4, 2023
  • C0455: Inspections and Investigation: Insp Interval severity level 2, scope L2 Widespread, corrected August 4, 2023

Substantiated abuse or neglect

• March 23, 2026: Failed to provide a safe medication administration system 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); 411-054-0055 (Medications and Treatments)
  State’s findings

  From approximately, February 6, 2026, through March 21, 2026, the facility repeatedly failed to administer the Alleged Victim’s (AV) medication as ordered. As a resident of the facility, AV relies on the facility to correctly administer all prescribed medications. However, facility documentation and staff interviews show that staff did not follow AV’s prescribed medication regimen or Service Plan. The facility’s failure to provide appropriate oversight of its medication administration system to ensure AV’s medication orders were followed caused AV unnecessary discomfort, placing AV at risk of harm due to the prolonged 44-day failure. This failure constitutes abuse by neglect, as outlined in OAR as defined in OAR 411-020-0002(1)(b)(A)(ii).

• June 4, 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)
  State’s findings

  On or about June 4, 2025, the Alleged Victim (AV) reported that Alleged Perpetrator 2 (AP2) and Alleged Perpetrator 3 (AP3) were rough while assisting AV with his/her toileting needs, including pushing and pulling, which caused pain and discomfort. According to facility documentation and interviews, AV reported experiencing left shoulder pain as a result of the manner in which AP2 and AP3 provided care. It was further reported that the facility failed to act on prior reported concerns that AP2 and AP3 were rushing through care tasks and had been rough with other residents. As a result of facility's lack of timely response to reported concerns on AP2 and AP3's caregiving practices, AV experienced unreasonable discomfort. The facility's failure to provide a safe environment for AV is a violation of resident rights, is considered neglect of care and constitutes abuse. AP2 and AP3 allegedly physically abused AV. An investigation determined no abuse occurred by AP2 and AP3.

• May 7, 2025: Failed to provide safe environment Abuse: Neglect; Level 3 - Moderate harm or potential for serious harm; fine $375.00; 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

  The facility failed to provide adequate supervision in accordance with the Alleged Victim’s (AV) documented history of falls, as outlined in the service plan. As a result of this failure, on or about May 7, 2025, AV was found on the floor with a head injury that required hospital treatment and staples. The facility failed to ensure AV received the necessary care and monitoring, which led to the fall causing AV unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

• July 8, 2023: 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 to ensure The Alleged Victim’s (AV) medications were administered as ordered. On or about July 8, 2023, the facility failed to administer AV's narcotic medication as ordered. Two of AV's narcotic medication went missing on the day in question and could not be accounted for in the facility's narcotic count process. The facility's failure resulted in unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse. Alleged Perpetrator 2 (AP2) allegedly financially exploited AV by wrongfully taking medication from AV. An investigation determined inconclusive findings for abuse by AP2.

• January 16, 2023: Failed to properly plan care 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 provide appropriate services according to the Alleged Victim’s (AV) wound care. Based on interviews and facility documentation, it was determined the facility gave improper and insufficient wound care to AV when facility failed to follow AV's medical orders causing AV unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Substantiated licensing violations

• February 6, 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

  On or about February 6, 2026, Alleged Perpetrator (AP2) failed to provide the stand-by assistance with showering as documented in Alleged Victim's (AV) care plan. Based on facility documentation and interviews, Witness 3 (W3) responded to calls for help coming from AV’s living quarters and found AV seated alone on a shower chair in the running shower without staff present. W3 then located AP2 lying asleep in AV’s bed. W3 awakened AP2 by shining a light on AP2’s face and physically shaking AP2. The facility subsequently terminated AP2’s employment for sleeping while on duty. Based on the statements of witness knowledge and investigator observations, the investigator determined that the following events happened: AP2 did not provide the required stand-by assistance to AV on February 6, 2026, which resulted in a risk of potential harm as AV required stand-by assistance for safety. AP2's actions is considered neglect of care which constitutes abuse. The facility failed to provide a safe environment for AV which is violation of Oregon Administrative Rules.

• November 13, 2025: 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 review, conducted during a site visit on 12/17/25, the facility's failure to carry out medication and treatment orders as prescribed was substantiated for 1 of 1 sampled resident. (#1). Findings include but are not limited to: Staff 1 stated that Resident 1 was out of the facility between 08/27/25 through 11/05/25. ?In an interview, Staff 2 stated Resident 1 was getting his/her CBGs checked daily by RN, however the facility didn't have an order to administer insulin post hospitalization due to be the insulin being sliding scale insulin. A record review indicated that the Interim Service Pan for Resident 1, dated 11/05/25, indicated Resident 1 returned to the facility 11/05/25 at 9:05 pm. Resident 1's Medication Administration Record indicated CBGs were recorded daily, 11/06/25 through 11/30/25, however the medication was not available, due to not having an order for the sliding scale insulin. A Licensing Complaint Unit (LCU) Investigation determined the facility failed to provide a safe medication administration system which is a violation of Oregon Administrative Rules.

• August 18, 2025: Failed to provide a safe medication administration system Licensing Violation; Level 4 - Serious harm, death, imminent danger or chronic regulatory noncompliance; report
  Rules: 411-054-0025 (Facility Administration); 411-054-0055 (Medications and Treatments)
  State’s findings

  Based on observation, interview, and record review, conducted during a site visit on August 18, 2025, the facility’s failure to exercise reasonable precautions against any condition that could threaten the health, safety, or welfare of residents was substantiated for 1 of 1 sampled resident (# 1). Resident 1, who had a signed physician’s order for a mechanical soft diet, was served a regularly textured meal. This put Resident 1 at risk of choking and constituted an immediate jeopardy situation. Findings include but are not limited to: Resident 1’s physician orders, dated May 16, 2025, indicated Resident 1 was to receive a mechanical soft diet. Resident 1 was admitted to the facility in July 2021 with a diagnosis of Parkinsons. On August 18, 2025, at approximately 11:45 am, Resident 1 was observed to have been served a firm sausage cut into approximately two to three-inch slices. This meal was inconsistent with a mechanical soft diet. On August 18, 2025, at approximately 12:00 pm, Resident 1 stated s/he could not eat the food, and staff were supposed to have cut up his/her food, but they had not. On August 18, 2025, at approximately 12:30 pm, Resident 1 was served a hamburger cut into quarters. Resident 1 stated s/he was unable to pick up and eat the hamburger. This meal was inconsistent with a mechanical soft diet. On August 18, 2025, at approximately 12:30 pm, Staff 4 stated s/he did not think Resident 1 required a special diet. On August 18, 2025, at approximately 12:45 pm, Staff 3 stated s/he did not know if Resident 1 required a special diet. Resident 1’s service plan, dated June 17, 2025, indicated s/he was to receive a “regular easy chew diet,” and did not indicate s/he required assistance with eating. On 08/18/25, at approximately 12:55 pm Staff 5 stated: - The sausage and hamburger that had been served would not be considered “mechanical soft;” - An indication of “regular easy to chew” on the facility’s meal chart meant the resident was to receive a mechanical soft diet; and - The incorrect meal chart had been available to kitchen staff. The facility’s “Nutritional and Culinary Services Food Size and Testing” reference guide (undated) indicated “regular easy chew” as: - Food piece size is not restricted; - Normal everyday foods of soft and tender texture; and - Foods must break apart easily test & pass Fork Pressure. This definition was not consistent with the requirements for a mechanical soft diet. The facility’s resident meal chart dated May 21, 2025, and posted in the kitchen at approximately 1:00pm on August 18, 2025, indicated Resident 1 was to receive a regular easy chew diet, and there were five additional unsampled residents who were to receive a regular easy chew diet. On August 18, 2025, at approximately 4:30 pm, Staff 1 stated an audit of the facility’s meal chart available to kitchen staff had failed to include diet orders for an additional three residents. The facility’s failure to exercise reasonable precautions against any condition that could threaten the health, safety, or welfare of residents was substantiated. On August 18, 2025, at 2:45pm, the LCU team requested an immediate plan of correction. An acceptable plan of correction was received from the facility on August 18, 2025, at 5:03 pm. The immediate risk was addressed; however, the facility will need to evaluate the overall system failures associated with the licensing violation to ensure adequate oversight of the operation of the facility and the quality of services rendered in the facility. The facility's failure is a serious violation of resident rights, which is a violation of Oregon Administrative Rules. Additional corrective action was taken concerning this case. ODHS issued condition, ALFCD25-00399, effective August 19, 2025.

• August 18, 2025: Failed to provide safe environment Licensing Violation; Level 4 - Serious harm, death, imminent danger or chronic regulatory noncompliance; report
  Rules: 411-054-0025 (Facility Administration)
  State’s findings

  Based on observation, interview, and record review, conducted during a site visit on 08/18/25, the facility’s failure to carry out medication and treatment orders as prescribed was substantiated for 1 of 1 sampled resident (# 1). Resident 1, who had a signed physician’s order for a mechanical soft diet, was served a regularly textured meal. This put Resident 1 at risk of choking and constituted an immediate jeopardy situation. Findings include but are not limited to: Resident 1’s physician orders, dated 05/16/25, indicated Resident 1 was to receive a mechanical soft diet. On 08/18/25, at approximately 11:45 am, Resident 1 was observed to have been served a firm sausage cut in approximately two to three-inch slices. This meal was inconsistent with a mechanical soft diet. On 08/18/25, at approximately 12:00 pm, Resident 1 stated s/he could not eat the food, and staff were supposed to have cut up his/her food, but they had not. On 08/18/25, at approximately 12:30 pm, Resident 1 was served a hamburger cut into quarters. Resident 1 stated s/he was unable to pick up and eat the hamburger. This meal was inconsistent with a mechanical soft diet. The facility’s failure to carry out medication and treatment orders as prescribed was substantiated. On 08/18/25 at 2:45pm, the LCU team requested an immediate plan of correction. An acceptable plan of correction was received from the facility on 08/18/25 at 5:03 pm. The immediate risk was addressed; however, the facility will need to evaluate the overall system failures associated with the licensing violation. The facility's failure is a serious violation of resident rights, which is a violation of Oregon Administrative Rules. Additional corrective action was taken concerning this case. ODHS issued condition, ALFCD25-00399, effective August 19, 2025.

• August 18, 2025: Failed to properly plan care Licensing Violation; Level 4 - Serious harm, death, imminent danger or chronic regulatory noncompliance; report
  Rules: 411-054-0025 (Facility Administration); 411-054-0036 (Service Plan – General)
  State’s findings

  Based on observation, interview, and record review, conducted during a site visit on 08/18/25 and 08/20/25, the facility’s failure to have service plan that reflected the resident's needs was substantiated for 1 of 1 sampled resident (# 1). Resident 1, who had a signed physician’s order for a mechanical soft diet and required assistance with eating, did not have a service plan reflective of these needs. This put Resident 1 at risk of choking and constituted an immediate jeopardy situation. Findings include but are not limited to: Resident 1’s physician orders, dated 05/16/25, indicated Resident 1 was to receive a mechanical soft diet. Resident 1’s service plan, dated 06/17/25, indicated s/he was to receive a “regular easy chew” diet, and did not indicate s/he required assistance with eating. Resident 1 was admitted to the facility on 07/2021 with a diagnosis of Parkinsons. On 08/18/25, at approximately 11:45 am, Resident 1 was observed to have been served a firm sausage cut in approximately two to three-inch slices. This meal was inconsistent with a mechanical soft diet. On 08/18/25, at approximately 12:00 pm, Resident 1 stated s/he could not eat the food, and staff were supposed to have cut up his/her food, but they had not. On 08/18/25, at approximately 12:30 pm, Resident 1 was served a hamburger cut into quarters. Resident 1 stated s/he was unable to pick up and eat the hamburger. This meal was inconsistent with a mechanical soft diet. On 08/20/25, Witness 1 stated Resident 1 had been having trouble feeding his/herself. The facility’s failure to have service plan that reflected the resident's needs was substantiated. On 08/18/25 at 2:45 pm, the LCU team requested an immediate plan of correction. An acceptable plan of correction was received from the facility on 08/18/25 at 5:03 pm. The immediate risk was addressed; however, the facility will need to evaluate the overall system failures associated with the licensing violation. The facility's failure is a serious violation of resident rights, which is a violation of Oregon Administrative Rules. Additional corrective action was taken concerning this case. ODHS issued condition, ALFCD25-00399, effective August 19, 2025.

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 75 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.