Avamere at Sandy

Last inspection

December 12, 2024

Inspections

3, 10 deficiencies cited

Substantiated abuse

8

Substantiated licensing violations

7

Regulatory actions

0

Fines assessed

$6,251.00 (9 violations)

Inspections

• December 12, 2024: Re-Licensure, 8 deficiencies cited report
  • C0260: Service Plan: General severity level 2, scope L2 Isolated
  • C0270: Change of Condition and Monitoring severity level 2, scope L2 Isolated
  • C0295: Infection Prevention & Control severity level 2, scope L2 Pattern
  • C0513: Doors, Walls, Elevators, Odors severity level 2, scope L2 Widespread
  • Z0142: Administration Compliance severity level 2, scope L2 Widespread
  Show all 8

  • Z0162: Compliance with Rules Health Care severity level 2, scope L2 Isolated
  • Z0163: Nutrition and Hydration severity level 2, scope L2 Pattern
  • Z0164: Activities severity level 2, scope L2 Pattern
• August 20, 2024: State Licensure, 0 deficiencies cited report
  • C0000: Comment severity level 0
• July 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 September 18, 2023
  • Z0142: Administration Compliance severity level 2, scope L2 Widespread, corrected September 18, 2023

Substantiated abuse or neglect

• June 1, 2025: Failed to provide safe environment 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); 411-054-0030 (Resident Services); 411-054-0036 (Service Plan – General)
  State’s findings

  On or about June 1, 2025, Alleged Victim (AV) eloped from the facility through an outside gate that was left unlocked. Based on facility documentation and interviews, prior to incident AV was observed showing signs of being agitated, distressed, exhibiting exiting seeking behavior and saying loudly "I'm getting out of here". Staff intervened by providing approximately ten minutes of one on one time to help AV calm down. After staff provided one on one care to AV, staff went about their duties in which AV got up and walked very fast to the exit door and was able to elope through an outside gate. AV was later found by staff when staff drove their car past AV who was walking on busy street. The staff returned AV to the facility. The facility failed to provide appropriate supervision to the AV according to his/her care needs and known exit seeking behavior which resulted in AV eloping the secured building, placing him/her at risk of harm, which is a moderate violation of resident rights, is considered neglect of care and constitutes abuse.

• March 24, 2025: Failed to provide safe environment 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); 411-054-0030 (Resident Services); 411-054-0036 (Service Plan – General)
  State’s findings

  On or about March 24, 2025, the facility failed to provide appropriate supervision to the Alleged Victim (AV) according to his/her care needs. Based on facility documentation and interviews, AV was last seen by facility staff at around midnight. According to facility records, at 2:11am the facility door alarm went off and staff did not check the door. AV was later found by the LEA a quarter of a mile away from the facility. LEA brought AV back to the facility and staff did not know that AV had left the facility. Alleged Perpetrator 2 (AP2) failed to provide proper supervision and oversight result in AV exiting the facility. Prior to incident, AP2 knew AV had been riding the elevator for hours and AP2 did not redirect AV. AP2 was trained to intervene when AV is exhibiting exit seeking behaviors; however, AP2 failed to intervene when AP2 saw that AV was having behaviors. AP2 did not follow any of AV's interventions as detailed in AV's service plan. AP2's actions is considered neglect of care which constitutes abuse. The facility's failure resulted in AV leaving the facility, without staff knowledge, placing him/her at risk of harm due to AV having to cross a busy highway before AV was found by LEA, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

• November 12, 2024: 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); 411-054-0030 (Resident Services); 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 eloping the secured building on or about November 12, 2024, 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.

• July 27, 2024: Failed to properly plan care 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 July 27, 2024, Alleged Victim (AV), fell causing AV pain and unreasonable discomfort due to AV falling on his/her knees on impact of the fall. Based on facility documentation and interviews, the facility failed to provide consistent information to the staff regarding AV's care needs which resulted in AV falling. The facility failed to ensure AV's service plan was reflective of AV's care needs and preferences and the facility failed to provide clear direction to staff which resulted in AV falling which caused pain and unreasonable discomfort, which is a violation of resident rights, considered neglect of care and constitutes abuse. Alleged Perpetrator 2 (AP2) allegedly neglected AV. An investigation determined no abuse occurred by AP2.

• August 6, 2023: Failed to provide safe environment Abuse: Neglect; Level 3 - Moderate harm or potential for serious harm; fine $1,125.00; report
  Rules: 411-054-0027 (Resident Rights and Protections); 411-054-0028 (Reporting and Investigating Abuse and Other Actions Affecting Resident Welfare); 411-054-0030 (Resident Services); 411-054-0036 (Service Plan – General)
  State’s findings

  The facility failed to implement appropriate interventions and failed to appropriately monitor Witness 1 (W1) according to his/her known sexualized behavior and prior altercations. On or about August 23, 2023, W1 walked past Alleged Victim (AV) in the hallway of the facility and reached out and touched AV's breast with both hands and slid his/her hand to AV's bottom. Based on facility documentation and interviews, there were prior altercations between W1 and AV on August 7, 2023, August 12, 2023, August 18, 2023, August 19, 2023, and August 20, 2023. The failure resulted caused unreasonable discomfort to the AV, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Substantiated licensing violations

• November 17, 2025: 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 November 17, 2025, Alleged Perpetrator 2 (AP2) attempted to independently transfer Alleged Victim (AV) from a wheelchair to a recliner. Based on facility documentation and interviews, AV is service-planned to be transferred with a second caregiver present and with the use of a gait belt or a sit-to-stand assistive device. At time of incident, AP2 did not follow these requirements and attempted the transfer AV alone and without any required equipment. During the transfer, AP2 lost their grip, resulting in an assisted fall in which AP2 lowered AV to the floor. AP2 had been trained to read and follow AV’s Service Plan and has a history of not following Service Plans, including completing transfers without required assistance. AP2's actions placed AV a risk of harm which is considered neglect of care which constitutes abuse. The facility failed to provide a safe environment for AV which is a violation of Oregon Administrative Rules.

• March 1, 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

  Based on interview and record review, conducted during an offsite review on 10/03/25, the facility’s failure to develop, maintain, and implement an Acuity Based Staffing Tool (ABST) was substantiated. Findings include, but are not limited to: A review of facility records provided via email on 03/10/25, indicated the following: The ABST evaluations for 3 of 22 residents had not been updated in the last quarter. The facility failed to use the results of an ABST to develop and update the facility's posted staffing plan; the facility failed to update resident profiles at least quarterly. An investigation determined the licensing violation occurred. 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.

• March 1, 2025: 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 an offsite review on 10/03/25, the facility’s failure to provide direct care staff sufficient in numbers to meet the scheduled and unscheduled needs of each resident was substantiated. Findings include, but are not limited to: A review of facility records provided via email on 03/10/25, indicated the following: The facility's posted staffing plan indicated the following: • Day: 4 Direct Care Staff; • Swing: 4 Direct Care Staff; and • NOC: 2 Direct Care Staff. The facility's ABST indicated the following required staffing hours: • Day: 3.5 Direct Care Staff; • Swing: 3.1 Direct Care Staff; and • NOC: 1.5 Direct Care Staff. The facility's staff schedule, dated 03/01/25, revealed the facility was not staffed to their posted staffing plan: • Day: 3.75 Direct Care Staff; • Swing: 3.6 Direct Care Staff; and • NOC: 2 Direct Care Staff. The facility failed to consistently staff to the levels, intensity and qualifications indicated by the Acuity-Based Staffing Tool (ABST). Inconsistencies were identified between the staffing schedule and the data produced by the ABST. The facility failed to provide direct care staff to meet the facility's posted staffing plan. An investigation determined this is a violation of Oregon Administrative Rules.

• February 2, 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

  Based on interview and record review, conducted during an offsite review on 10/03/25, the facility’s failure to update and review the Acuity Based Staffing Tool (ABST) evaluation for each resident was substantiated. Findings include, but are not limited to: A review of facility records provided via email on 02/27/25, indicated the following: - The ABST evaluations for 2 of 22 residents had not been updated in the last quarter. 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 31, 2024: Failed to follow care plan Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0036 (Service Plan – General)
  State’s findings

  The facility failed to appropriately monitor Witness 1's (W1) known behaviors. The facility's failure to follow W1's care plan enabled W1 to enter Alleged Victim's (AV) room unattended for five to seven minutes before being escorted out of AV's room by staff. AV did not suffer a negative outcome as a result of W1's actions. The facility's failure to follow W1's care plan is a violation of Oregon Administrative Rules.

• December 25, 2023: 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 December 25, 2023, Alleged Perpetrator 2 (AP2) slapped Alleged Victim (AV) in the face while trying to administer AV's medication a second time after the first attempt was refused by AV. During the second attempt, AV spat at AP2 and AP2 responded with a slap to AV's face. AP2's hands made physical contact with AV's face and as a result, AV cried out in pain. AP2's action is considered physical abuse. The facility failed to provide a safe environment for AV which is a violation of Oregon Administrative Rules.

• August 6, 2023: Failed to provide safe environment Licensing Violation; Level 2 - Minor harm or potential for moderate harm; fine $1,125.00; report
  Rules: 411-054-0030 (Resident Services)
  State’s findings

  On or about August 6, 2023, Alleged Victim (AV) was walking through the dining room of the facility when Witness 1 (W1) suddenly touched AV inappropriately. W1 was admitted to the facility on July 18, 2023, with known sexualized behaviors. The facility failed to provide appropriate supervision of W1 which 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 24 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.