Avamere at Seaside Residential Care Facility

On or about December 1, 2024, the facility failed to appropriately care plan related to the Alleged Victim's (AV) fall history. The facility's failure resulted in AV experiencing an unwitnessed fall with head injury and was transferred to the hospital for treatment. AV experienced unreasonable discomfort as a result of the fall, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to implement appropriate interventions and failed to appropriately care plan related to the Alleged Victim's (AV) fall history. On or about September 26, 2024, AV had an unwitnessed fall in AV's room and was found lying on the floor with one skid sock off and with AV's walker over him/her. At time of incident, the locks on AV's walker were sticking and needing to be fixed. Based on facility documentation and interviews, AV suffered an unwitnessed fall two days prior to the incident that resulted in injury to AV knuckles. The facility's failure to properly care plan resulted in AV experiencing repeated falls in a short period of time, causing AV unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to implement interventions and appropriately care plan related to the Alleged Victim's (AV) fall history. On or about September 29, 2024, AV had an unwitnessed fall in his/her room. AV was found lying on the floor on his/her back in front of AV's dresser. AV was transported to the hospital for treatment, and was diagnosed with a hematoma with bleeding in the brain. Based on facility documentation and interviews, AV moved into the facility on August 22, 2024, and had six falls between August 22, 2024, and September 26, 2024; two of the six falls during this time period resulted in injury. The facility's failure to properly care plan for AV's known fall risk, caused AV unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to provide appropriate services according to the Alleged Victim’s (AV) care needs and wound care. Based on facility documentation and interviews, the facility failed to change AV's wound dressing after AV was released from the hospital. Based on facility documentation and interviews, AV wore the same wound dressing from August 22, 2024, through September 4, 2024. The facility failed to clean or dress AV's forearm wound which caused AV’s wound to become infected, causing AV repeated unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to appropriately care plan related to the Alleged Victim's (AV) fall history. On or about August 14, 2024, AV suffered an unwitnessed fall that resulted in a laceration to AV's right forearm that exposed AV's muscle, which required sutures. Based on facility documentation and interviews, AV has suffered multiple falls prior to this incident. The facility's failure resulted in AV experiencing unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Based on witness statements, investigator observations, and documentary evidence collected during Adult Protective Services (APS) Investigation #00339624, the APS Investigator determined that on or about June 28, 2024, the facility failed to provide adequate supervision to ensure the safety of the Alleged Victim (AV). At time of incident, Witness 2 (W2) was providing care to other residents when W2 heard AV calling out, “help, help, help.” Upon responding, W2 observed Witness 1 (W1) holding onto AV’s hair and AV trying to fight W1 off. It was reported that W1 frequently targets AV, by grabbing and pulling AV’s hair. The facility's failure to properly monitor and supervise W1 resulted in a physical altercation, causing unreasonable discomfort to the AV, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to provide appropriate services according to the Alleged Victim's (AV) care needs. On April 5, 2024, AV was discovered not wearing an adult brief, soaked in urine with feces smeared on both his/her person and bedding. Based on facility documentation and interviews, the facility failed to provide appropriate services for AV's toileting and incontinence care need between March 14, 2024, and April 3, 2024. AV was reported to have increased incontinence and increased confusion during this time. The facility's failure resulted in AV experiencing unreasonable discomfort and a loss of personal dignity by being dirty and unkept, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

On March 27, 2024, ODHS Adult Protective Services (APS) initiated investigation #00321323 and issued a written investigation report, which is incorporated here by reference. Alleged Victim (AV) lived at Respondent’s facility. The AV was identified as being at risk for falls per their service plan. On or about March 4, 2024, the AV fell from their bed, sustaining a laceration to the eyebrow and nose. At the time of the incident, AV's fall mat, an intervention outlined in the AV’s fall risk plan, was missing from the AV’s room. Based on documentation and interviews, the facility failed to follow AV's required fall risk interventions, contributing to the incident. The facility's failure to follow AV's care plan is a violation of resident rights, is considered neglect of care, and constitutes abuse.

The facility failed to implement interventions and appropriately monitor Witness 1 (W1) according to his/her known behavior and prior altercations. The failure resulted in a physical altercation between W1 and Alleged Victim (AV) on or about August 8, 2023. Based on facility documentation and interviews, W1 walked up to AV and hit AV in the forehead, causing unreasonable discomfort to the AV, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

On or about August 8, 2023, the facility failed to implement interventions and failed to appropriately monitor Witness 1 (W1) according to his/her known behavior and prior altercations. The failure resulted in a physical altercation between in W1 and Alleged Victim (AV) in which W1 grabbed AV's wrist, causing unreasonable discomfort to the AV, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to implement interventions and appropriately monitor Witness 1 (W1) according to his/her known behavior and prior altercations. On or about May 5, 2023, W1 hit Alleged Victim (AV) in the face causing unreasonable discomfort which is a violation of resident rights, is considered neglect of care and constitutes abuse.

On or about May 2, 2023, Witness 1 (W1) hit Alleged Victim (AV) in the back of the head causing AV unreasonable discomfort. Based on facility documentation and interviews, W1 had other resident-to-resident altercations on April 18, 2023, April 22, 2023, April 27, 2023, April 28, 2023, April 29, 2023, and April 30, 2023. The facility was aware the pharmacologic and non-pharmacological interventions in place were not successful for preventing W1's aggression. The facility failure to implement appropriate interventions and appropriately monitor W1 according to his/her known behavior and prior altercations caused an unsafe environment for AV which is a violation of resident rights, is considered neglect of care and constitutes abuse.

On or about May 2, 2023, Witness 1 (W1) hit Alleged Victim (AV) in the head resulting in AV yelling out at W1. Based on facility documentation and interviews, the pharmacologic and non-pharmacological interventions in place were not successful for preventing W1's aggression. During the month of April 2023, W1 engaged in six other resident-to-resident altercations. The facility failed to implement appropriate interventions and appropriately monitor W1 according to his/her known behavior and prior altercations, causing unreasonable discomfort to the AV, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to maintain a safe medication administration system by administering a medication containing a known allergen to the Alleged Victim (AV). As a result, AV experienced adverse symptoms, became unwell, and required hospitalization. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to provide appropriate supervision to the Alleged Victim (AV) according to his/her needs. The failure resulted in AV eloping the secured building on or about March 5, 2023, without staff knowledge, resulting in unreasonable comfort. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to implement interventions and appropriately monitor Witness 1 (W1) according to his/her known behavior and prior altercations. The failure resulted in a physical altercation between W1 and Alleged Victim (AV) in which W1 struck AV on the side of AV's body as W1 passed by AV in the facility hallway, causing unreasonable discomfort to the AV, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to provide appropriate services for Alleged Victim (AV) according to his/her needs for assistance with nail care which resulted in AV getting a scratch on his/her abdomen. Based on interviews and facility documentation, AV did not receive proper nail care for over a year prior to incident which left AV’s nails long and sharp. The facility's failure to follow AV's care plan caused unreasonable discomfort which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to provide services as ordered by Home Health according to the Alleged Victim’s (AV) care needs. The failure resulted in AV’s sustaining a bruise on the right side of AV's forehead causing unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

On or about October 28, 2022, Alleged Victim (AV) was found to have a quarter-sized bruise on his/her forehead. Based on interviews and facility documentation, AV had four (4) bruises within the two (2) months prior to the incident without documented interventions to prevent the bruising. The facility failed to protect Alleged Victim (AV) from continued bruising, causing AV unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to provide appropriate services according to the Alleged Victim's (AV) needs. The facility's failure caused AV to get a bruise the size of a silver dollar on his/her left hand, causing AV unreasonable discomfort. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to implement interventions and provide appropriate supervision related to the Alleged Victim’s (AV) known history of falls. The failure resulted in AV experiencing eight falls between June 29, 2022 and August 14, 2022, and an injury fall on August 16, 2022, causing AV unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to implement interventions and appropriately care plan related to the Alleged Victim's (AV) fall history. The failure resulted in AV experiencing an unwitnessed fall in the common area of the facility on August 20, 2022. AV sustained an injury to the right side of his/her head causing unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to implement interventions and appropriately care plan related to the Alleged Victim's (AV) fall history. The failure resulted in AV experiencing an unwitnessed fall on September 3, 2022. AV sustained a bump to the right side of his/her head causing unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to provide supervision and training of staff which resulted in Alleged Victim (AV) being wrongfully restrained in his/her wheelchair. The facility's failure is a violation of resident rights is considered neglect of care and constitutes abuse.

The facility failed to provide supervision and training of staff in bandaging Alleged Victim's (AV) hand which resulted in AV's wound not healing. The facility's failure caused AV unreasonable discomfort which is a violation of resident rights, is considered neglect of care and constitutes abuse.

On or about March 14, 2022, the facility failed to provide basic care and supervision resulting in a resident-to-resident altercation that caused harm to Alleged Victim (AV) when Witness 1 (W1) inappropriately touched AV in a sexual manner. W1 has a history of inappropriate behaviors. The facility failed to properly care plan for W1's in appropriate behaviors which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to implement interventions and appropriately care plan related to the Alleged Victim's (AV) fall history. The failure resulted in AV experiencing a fall from his/her bed, was transferred to the hospital and required staples in his/her head, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to implement interventions and appropriately care plan related to the Alleged Victim's (AV) fall history. The failure resulted in AV experiencing an unwitnessed fall, was transferred to the hospital and diagnosed with a fractured right hip, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

On or about July 3, 2026, 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. Facility was not staffed to the levels as indicated by the ABST to meet the scheduled and unscheduled needs of residents. An investigation determined this is a violation of Oregon Administrative Rules.

On or about June 25, 2025, 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. Facility was not staffed to the levels as indicated by the ABST to meet the scheduled and unscheduled needs of residents. An investigation determined this is a violation of Oregon Administrative Rules.

Based on interview and record review, conducted during an investigation on 8/18/2026, 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 was substantiated. Findings include, but are not limited to: The facility’s posted staffing plan indicated: - For Day shift, 4 to 4.5 direct care staff; - For Swing shift, 4 to 4.5 direct care staff; and - For Night shift, 2 direct care staff. The facility’s staffing schedule dated 01/08/2026 indicated the facility was not staffing to its posted staffing plan for 1 of 3 shifts reviewed. 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.

Based on interview and record review, conducted during an investigation on 08/18/2026, the facility’s failure to use the results of an ABST to have qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident was substantiated. Findings include, but are not limited to: A review of the facility’s ABST care times as of 10/15/2025 indicated: For Day shift, 4.04, or a minimum of 4.5 direct care staff; For Swing shift, 3.40, or a minimum of 3.5 direct care staff; and For Night shift, 0.99 hours, or a minimum of 1 direct care staff. The facility’s posted staffing plan indicated: For Day shift, 4-4.5 direct care staff; For Swing shift, 4-4.5 direct care staff; and For Night shift, 2 direct care staff. The facility’s direct care staffing schedule, dated 10/11/2025, indicated: For Day shift, 4 direct care staff; For Swing shift, 4 direct care staff; and For Night shift, 2 direct care staff. According to the facility’s direct care staffing schedule, the facility was not staffing to the ABST care times to account for the scheduled and unscheduled needs of the residents for 1 of 3 shifts reviewed. 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 was substantiated. The findings were reviewed with and acknowledged by Staff 1 on 08/20/2026. An investigation determined this is a violation of Oregon Administrative Rules.

Based on interview and record review, conducted during an investigation on 08/21/2026, the facility’s failure to use the results of an Acuity-Based Staffing Tool (ABST) to develop and routinely update the facility’s posted staffing plan was substantiated. Findings include, but are not limited to: A review of the facility’s ABST care times as of 10/10/2025 indicated: - For Day shift, 4.04, or a minimum of 4.5 direct care staff; - For Swing shift, 3.43, or a minimum of 3.5 direct care staff; and - For Night shift, 0.99 hours, or a minimum of 1 direct care staff. The facility’s posted staffing plan indicated: - For Day shift, 4 direct care staff; - For Swing shift, 4 direct care staff; and - For Night shift, 2 direct care staff. The posted staffing plan did not exceed the ABST hours required. The facility’s failure to use the results of an ABST to develop and routinely update the facility’s posted staffing plan is a violation of Oregon Administrative Rules.

Based on interview and record review, conducted during an investigation on 08/21/2026, the facility’s failure to use the results of an Acuity-Based Staffing Tool (ABST) to develop and routinely update the facility’s posted staffing plan was substantiated. Findings include, but are not limited to: A review of the facility’s ABST care times as of 10/10/2025 indicated: - For Day shift, 4.04, or a minimum of 4.5 direct care staff; - For Swing shift, 3.43, or a minimum of 3.5 direct care staff; and - For Night shift, 0.99 hours, or a minimum of 1 direct care staff. The facility’s posted staffing plan indicated: - For Day shift, 4 direct care staff; - For Swing shift, 4 direct care staff; and - For Night shift, 2 direct care staff. - The posted staffing plan did not exceed the ABST hours required. The facility’s failure to use the results of an ABST to develop and routinely update the facility’s posted staffing plan is a violation Oregon Administrative Rules.

Based on interview and record review, conducted during an investigation on 08/21/2026, the facility’s failure to use the results of an Acuity-Based Staffing Tool (ABST) to develop and routinely update the facility’s posted staffing plan and to have qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident was substantiated. Findings include, but are not limited to: A review of the facility’s ABST care times as of 09/25/2025 indicated: - For Day shift, 4.02, or a minimum of 4.5 direct care staff; - For Swing shift, 3.41, or a minimum of 3.5 direct care staff; and - For Night shift, 0.97 hours, or a minimum of 1 direct care staff. The facility’s posted staffing plan indicated: - For Day shift, 4 direct care staff; - For Swing shift, 4 direct care staff; and - For Night shift, 2 direct care staff. The posted staffing plan did not exceed the ABST hours required. The facility’s staffing schedule, dated 09/22/2025, indicated the facility was not staffing above the ABST care times to account for unscheduled needs of the residents for 1 of 3 shifts reviewed. 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 and to use the results of an Acuity-Based Staffing Tool (ABST) to develop and routinely update the facility’s posted staffing plan is a violation of Oregon Administrative Rules.

Based on interview and record review, conducted during an investigation on 08/26/2026, 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 was substantiated. was substantiated. Findings include, but are not limited to: The facility’s posted staffing plan indicated: - For Day shift, 4 to 4.5 direct care staff; - For Swing shift, 4 to 4.5 direct care staff; and - For Night shift, 2 direct care staff. The facility’s staffing schedule dated 07/08/2025 indicated the facility was not staffing to its posted staffing plan for 1 of 3 shifts reviewed. 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.

On or about April 4, 2025, Alleged Victim (AV) was not given AV's evening dose of one his/her seizure medications. Av did not have any adverse reactions to the medication error; however, the facility did fail to provide a safe medication administration system which is a violation of Oregon Administrative Rules.

On or about November 3, 2024, Alleged Perpetrator #2 (AP2) was working at the facility as a med tech, administering medication to residents. On this day, the Alleged Victim (AV) was ordered to receive insulin during the shift AP2 was working. AP2 did not administer insulin to AV as ordered, placing AV at risk for harm. AP2's actions are a violation of resident rights, are considered neglect of care and constitute abuse. The facility's failure to provide a safe medication administration system is a violation of Oregon Administrative Rules.

On or about August 5, 2022, Alleged Perpetrator 2 (AP2) neglected Alleged Victim (AV) by giving AV another resident's pain medication which was double the amount prescribed to AV, resulting in potential risk of harm. AP2's actions is considered neglect of care which constitutes abuse. The facility failed to provide a safe medication administration system which is a violation of Oregon Administrative Rules.

Alleged Perpetrator 2 (AP2) failed to follow Alleged Victim's (AV) care plan when he/she failed to ensure AV's fall protocols were in place when AP2 was working as AV's caregiver. AP2 failed to place AV's fall mat on the floor next to AV's bed which put AV at risk of harm. AP2's actions 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.

The allegation that the facility failed to ensure all stairways, halls, doorways, passageways, and exits from rooms and the building must be unobstructed was investigated and findings were verified.

The allegation that facility failed to ensure residents are treated with dignity and respect was investigated and verified.

The allegation that the facility failed to provide enough staff to meet the scheduled and unscheduled needs of the resident was investigated and findings were verified.

The facility failed to ensure that the Department was notified of an administrator absence of more than 30 days obtain approval for arrangements, and submit information for an interim administrator was investigated and verified.