Avamere at Waterford Assisted Living Facility

Last inspection

August 7, 2024

Inspections

3, 7 deficiencies cited

Substantiated abuse

5

Substantiated licensing violations

5

Regulatory actions

0

Fines assessed

$3,875.00 (5 violations)

Current owner since

October 1, 2026

• Every deficiency from the August 7, 2024 inspection was corrected by April 24, 2025

Inspections

• August 7, 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 April 24, 2025
  • C0455: Inspections and Investigation: Insp Interval severity level 2, scope L2 Widespread, corrected April 24, 2025
• September 12, 2023: State Licensure, 0 deficiencies cited report
  • C0000: Comment severity level 0
• July 11, 2022: Validation, 6 deficiencies cited report
  • C0000: Comment severity level 0
  • C0270: Change of Condition and Monitoring severity level 2, scope L2 Isolated, corrected September 11, 2022
  • C0372: Training Within 30 Days: Direct Care Staff severity level 2, scope L2 Pattern, corrected September 11, 2022
  • C0374: Annual and Biennial Inservice For All Staff severity level 2, scope L2 Pattern, corrected September 11, 2022
  • C0420: Fire and Life Safety: Safety severity level 2, scope L2 Widespread, corrected September 11, 2022
  Show all 8

  • C0422: Fire and Life Safety: Training For Residents severity level 2, scope L2 Widespread, corrected September 11, 2022
  • C0455: Inspections and Investigation: Insp Interval severity level 2, scope L2 Widespread, corrected July 30, 2023
  • C0613: General Building: Doors-Walls, Cleanable severity level 2, scope L2 Widespread, corrected July 30, 2023

Substantiated abuse or neglect

• February 4, 2024: Failed to provide safe environment Abuse: Neglect; Level 4 - Serious harm, death, imminent danger or chronic regulatory noncompliance; fine $1,500.00; 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); 411-054-0070 (Staffing Requirements and Training)
  State’s findings

  On or about February 4, 2024, Alleged Victim (AV) pressed his/her call light seeking assistance with his/her Activities of Daily Living. Based on facility documentation and interviews, AV waited 40 minutes after using AV's call light before AV attempted to self-transfer to use the restroom, resulting in AV falling, being transported to the hospital for treatment, and was diagnosed with a fractured hip. Due to AV's age, he/she was not a candidate for surgery due to risk, was placed on hospice, and passed away on February 10, 2024. At time of incident, the facility was operating short-staffed and received many requests for assistance from other residents that required two caregivers. The facility's call system was not set up to let caregivers know who was waiting, or who called for assistance first. Due to facility being short staffed, the facility failed to meet AV's scheduled and unscheduled care needs. The failure resulted in AV’s condition worsening causing further unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

• August 31, 2023: Failed to provide safe environment 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); 411-054-0030 (Resident Services); 411-054-0036 (Service Plan – General)
  State’s findings

  On or about August 31, 2023, the Alleged Victim (AV) and Witness 1 (W1) got into a fight on the smoking patio of the facility. Both AV and W1 are residents of the facility. Based on facility documentation and interviews, the fight escalated into a physical altercation in which hair pulling, slapping, punching, and biting occurred. The facility failed to implement appropriate interventions and monitor W1's known behaviors and history of altercations. The failure caused AV unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

• August 31, 2023: Failed to provide safe environment Abuse: Neglect; Level 3 - Moderate harm or potential for serious harm; fine $1,500.00; report
  Rules: 411-054-0027 (Resident Rights and Protections); 411-054-0028 (Reporting and Investigating Abuse and Other Actions Affecting Resident Welfare); 411-054-0030 (Resident Services); 411-054-0036 (Service Plan – General)
  State’s findings

  On or about August 31, 2023, the Alleged Victim (AV) and Witness 1 (W1) got into a fight on the smoking patio of the facility. Both AV and W1 are residents of the facility. Based on facility documentation and interviews, the fight escalated into a physical altercation in which W1 bit the tip of AV's finger off. The facility failed to implement appropriate interventions and monitor W1's known behaviors and history of altercations. The failure caused AV unreasonable discomfort and emotional harm, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

• December 21, 2022: Failed to properly plan care Abuse: Neglect; Level 2 - Minor harm or potential for moderate harm; fine $250.00; 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

  On or about December 21, 2022, facility staff found Alleged Victim (AV) on the floor of another resident's apartment. AV was observed to be lethargic, slurring words, and not making sense which resulted in AV being sent to the hospital for a medical evaluation. The hospital physician stated that AV's medical evaluation determined AV tested positive for recreational drug use and AV's symptoms were due to recreational drugs not mixing well with AV's multiple prescriptions. Based on facility documentation and interviews, the facility failed to implement interventions and appropriately care plan related to AV's alcohol consumption and narcotic use while taking numerous medications, and the facility failed to provide timely safety checks as noted in AV's care plan. The facility's failure caused AV unreasonable discomfort which is a violation of resident rights, is considered neglect of care and constitutes abuse.

• March 28, 2022: Failed to provide safe environment Abuse: Neglect; Level 2 - Minor harm or potential for moderate harm; fine $250.00; report
  Rules: 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 March 28, 2022, Alleged Victim (AV) suffered an unwitnessed fall in the middle of the night and was later found on the floor by facility staff. Based on interviews and facility documentation, it was determined that AV's call pendant was not working and the facility's phone system was down at time of incident which resulted in AV not being able to notify facility staff that he/she fell. 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.

Substantiated licensing violations

• September 20, 2024: 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 September 20, 2024, Alleged Victim (AV) had money go missing from his/her room. The money was taken by an unknown Alleged Perpetrator 2 (AP2), and this person is responsible for theft of property, which is considered financial exploitation and constitutes abuse. The facility failed to protect AV's property from theft. The facility's failure to provide a safe environment for AV is a violation of Oregon Administrative Rules.

• May 3, 2024: 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); 411-054-0027 (Resident Rights and Protections); 411-054-0055 (Medications and Treatments)
  State’s findings

  On May 2, 2024, facility discovered that one of Alleged Victim's (AV) card of 28 narcotics was missing from the medication cart. Based on facility documentation and interviews, several narcotic medications counting errors were found on the facility's NARC log between staff hand-offs including no double signatures, missing signatures, and missing times. It was reported that medications are to be counted and logged together during the shift change and hand-off the medication cart. It was determined to be unclear if there was an initial counting error or if a full sheet of AV's narcotics went missing. AV did not experience any negative outcome from this incident and AV did not experience any discomfort or pain due to the missing medications. Although, there was no negative outcome to AV, the facility failed to provide a safe medication administration system which is a violation of Oregon Administrative Rules. An unknown Alleged Perpetrator 2 (AP2) financially exploited AV. An investigation determined no abuse occurred.

• January 23, 2024: Failed to provide safe environment Licensing Violation; Level 3 - Moderate harm or potential for serious harm; report
  Rules: 411-054-0025 (Facility Administration)
  State’s findings

  Alleged Victim (AV) disclosed to facility staff that Alleged Perpetrator 2 (AP2) slapped Alleged Victim (AV) on his/her leg causing AV unreasonable discomfort. AV stated that he/she did not initially report this incident to facility staff because AV had not seen AP2 after incident. However, when AP2 returned to the facility about five weeks after the incident AV became anxious and nervous with AP2's presence and made a disclosure that AP2 refused to change his/her brief, was mean to AV, and AP2 slapped AV which caused AV emotional and physical harm. AP2 neglected AV by failing to provide basic care and services when AV needed assistance with changing his/her brief. AP2's actions is considered neglect of care which constitutes abuse. AP2 physically abused AV. The facility failed to provide a safe environment for AV which is a violation of Oregon Administrative Rules.

• July 16, 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 or about July 16, 2023, Alleged Perpetrator 2 (AP2) raised his/her voice at Alleged Victim (AV) in frustration while assisting AV with his/her Activities of Daily Living which caused AV emotional harm. AP2's actions is considered verbal abuse. On or about July 14, 2023, AP2 refused to let AV get up out of his/her bed when AV requested. Not being able to get up when AV wanted to upset and angered AV. AP2's actions is considered neglect of care which constitutes abuse. The facility's failure to provide a safe environment is a violation of Oregon Administrative Rules.

• March 1, 2022: 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

  The facility failed to carry out medication orders as prescribed. An investigation determined the facility violated an Oregon Administrative Rule.

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 85 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.