Avamere at Sandy Assisted Living Facility

Last inspection

August 20, 2024

Inspections

3, 2 deficiencies cited

Substantiated abuse

3

Substantiated licensing violations

4

Regulatory actions

0

Fines assessed

$1,250.00 (3 violations)

Current owner since

March 31, 2000

• No deficiencies cited at the last inspection (August 2024)

Inspections

• August 20, 2024: State Licensure, 0 deficiencies cited report
  • C0000: Comment severity level 0
• July 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 September 18, 2023
• October 13, 2022: Complaint Investig., 1 deficiency cited report
  • C0160: Reasonable Precautions severity level 1, scope L1 Widespread

Substantiated abuse or neglect

• May 23, 2025: Failed to provide safe environment 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); 411-054-0030 (Resident Services); 411-054-0036 (Service Plan – General)
  State’s findings

  On or about May 23, 2025, Alleged Victim (AV) and Witness (1), both residents of the facility and under the care of the facility, engaged in a physical altercation resulting in AV being scratched and receiving a bruise on left side of his/her face. Based on facility documentation and interventions, the facility failed to service plan for W1's known behaviors, failed to implement appropriate behavior interventions, and failed to appropriately monitor W1 according to his/her known behavior and prior altercations. The facility's failure resulted in a physical altercation and causing unreasonable discomfort to the AV, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

• April 8, 2025: Failed to provide safe environment 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)
  State’s findings

  On or about April 8, 2025, the Alleged Victim (AV) sustained a head injury when his/her personal sitting scale chair collapsed while AV was being assisted into the chair by Alleged Perpetrator 2 (AP2) and Alleged Perpetrator 3 (AP3) resulting in AV hitting the back of their head during the fall. Based on facility documentation and staff interviews, it was determined that AV’s sitting scale chair was not properly maintained by the facility which contributed to the incident. As a result of the facility failure AV experienced unreasonable discomfort and sustained a physical injury which is a violation of resident rights, is considered neglect of care, which constitutes abuse. AP2 and AP3 allegedly neglected AV. An investigation determined no abuse occurred by AP2 and AP3.

• June 23, 2023: Failed to provide safe environment 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

  The facility failed to provide appropriate supervision to the Alleged Victim (AV) according to his/her care needs. The failure resulted in AV unsafely leaving the facility without assistance and without staff knowledge, placing him/her at risk of harm. Based on facility documentation and interviews, AV was admitted to the facility on or about April 16, 2023, and began exhibiting wandering behaviors and AV left the facility regularly unsupervised, shortly after admission. From April 19, 2023, to June 13, 2023, AV exhibited increased confusion, agitation, and risky behavior. During this time period, AV had multiple criminal charges filed against them due to poor decision making and a lack of capacity to understand consequences. On or about June 14, 2023, AV's PCP approved AV to be placed in Memory Care. The facility failed to supervise AV when AV left the facility and failed to implement appropriate safety planning when AV began to show signs of exit seeking behaviors. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

Substantiated licensing violations

• February 4, 2026: Failed to provide a safe medication administration system Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0025 (Facility Administration); 411-054-0055 (Medications and Treatments)
  State’s findings

  On February 4, 2026, Alleged Perpetrator 2 (AP2) administered Alleged Victim's (AV) ear medication into AV’s right eye instead of AV's prescribed eye medication. According to AV’s service plan, facility staff are responsible for administering all medications and treatments. AP2 reported that they were rushing while completing AV’s morning care and mistakenly selected the wrong medication bottle, despite checking the label against the MAR once. The facility’s medication administration training requires staff to triple check medications to ensure the correct medication, dose, and route. AP2 did not complete the required triple-check process prior to administration. As a result, AV received the ear medication in the right eye, causing immediate pain and discomfort. AP2's actions caused AV unnecessary pain and discomfort which is considered neglect of care and constitutes abuse. The facility failed to provide a safe medication administration for AV which is a violation of Oregon Administrative Rules.

• August 18, 2023: 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 18, 2023, 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.

• October 1, 2022: Failed to submit timely or adequate staffing documentation Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-061-0010
  State’s findings

  On or about October 1, 2022, the Oregon Health Authority reported to the Department that Respondent failed to comply with weekly reporting requirements of vaccinated individuals, residents and staff, to the proper authority as required by law. This failure has been ongoing from September 1, 2022 to September 30, 2022, for a total of 30 days.

• May 2, 2022: 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

  The facility failed to exercise reasonable precautions against any condition that may threaten the health, safety, or welfare of the residents. An investigation determined the facility violated 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 65 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.