Avamere Court at Keizer RCF

Last inspection

April 7, 2025

Inspections

5, 32 deficiencies cited

Substantiated abuse

6

Substantiated licensing violations

9

Regulatory actions

2

Fines assessed

$5,438.00 (7 violations)

Current owner since

October 1, 2026

License conditions and other regulatory actions

• April 4, 2025 to August 14, 2025: License Condition, Failed to provide safe environment RCFCD25-00370; incident: CALMS - 00075953
  During a facility tour of the kitchen and interviews with facility staff, the kitchen was found to be extremely unsanitary, in poor repair, and there was no person in charge. The kitchen prepares food for the residential care facility residents, nursing facility residents, and residents in independent living.
  Rules: 411-054-0030 (Resident Services)
• March 14, 2024 to October 7, 2025: License Condition, Failed to use an ABST RCFCD24-00150; incident: OR0004530300
  The facility failed to fully implement and update an acuity-based staffing tool in accordance with OAR 411-054-0037(1).
  Rules: 411-054-0037 (Acuity-Based Staffing Tool)

Inspections

• April 7, 2025: Kitchen, 2 deficiencies cited report
  • C0150: Facility Administration: Operation severity level 3, scope L3 Widespread
  • C0240: Resident Services Meals, Food Sanitation Rule severity level 4, scope L4 Widespread
• November 21, 2024: Re-Licensure, 25 deficiencies cited report
  • C0150: Facility Administration: Operation severity level 2, scope L2 Widespread
  • C0155: Facility Administration: Records severity level 2, scope L2 Pattern
  • C0156: Facility Administration: Quality Improvement 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
  Show all 25

  • C0260: Service Plan: General severity level 2, scope L2 Pattern
  • C0262: Service Plan: Service Planning Team 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
  • C0282: RN Delegation and Teaching severity level 2, scope L2 Pattern
  • C0295: Infection Prevention & Control severity level 2, scope L2 Widespread
  • C0300: Systems: Medications and Treatments severity level 2, scope L2 Pattern
  • C0302: Systems: Tracking Control Substances severity level 2, scope L2 Isolated
  • C0310: Systems: Medication Administration severity level 2, scope L2 Pattern
  • C0320: Systems: Medication & Treatment-General severity level 2, scope L2 Pattern
  • C0325: Systems: Self-Administration of Meds severity level 2, scope L2 Pattern
  • C0362: Acuity Based Staffing Tool - ABST Time severity level 2, scope L2 Pattern
  • C0363: Acuity Based Staffing Tool - Updates & Staffing Plan severity level 2, scope L2 Pattern
  • C0372: Training Within 30 Days of Hire ? Direct Care Staff severity level 2, scope L2 Pattern
  • C0374: Annual and Biennial Inservice for All Staff severity level 2, scope L2 Pattern
  • C0420: Fire and Life Safety: Safety severity level 2, scope L2 Widespread
  • C0422: Fire and Life Safety: Training for Residents severity level 2, scope L2 Widespread
  • C0513: Doors, Walls, Elevators, Odors severity level 2, scope L2 Widespread
  • C0555: Call Sys, Exit Dr Alarm, Phones, TV, or Cable severity level 2, scope L2 Widespread
  • H1515: Physical Setting: Individual Accessible severity level 2, scope L2 Widespread
• December 19, 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 February 5, 2024
• October 24, 2023: Licensure Complaint, 3 deficiencies cited report
  • C0010: Licensing Complaint Investigation severity level 2, scope L2 Isolated
  • C0303: Systems: Treatment Orders severity level 2, scope L2 Isolated
  • C0304: Systems: Medication and Treatment Review severity level 2, scope L2 Isolated
  • C0361: Acuity-Based Staffing Tool severity level 2, scope L2 Isolated
• December 15, 2022: 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 December 20, 2022

Substantiated abuse or neglect

• June 21, 2026: Failed to properly plan care 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

  On or about June 21, 2026, Alleged Victim (AV), a resident of the Respondent’s facility, fell while attempting an independent transfer from his/her recliner chair to his/her electric scooter. Facility documentation and staff interviews confirm that AV previously fell on October 21, 2025, February 9, 2026, March 25, 2026, and June 5, 2026. Despite this documented fall history, AV’s service plan dated May 14, 2026, failed to contain appropriate fall-prevention interventions to mitigate AV's fall risk. The facility also failed to complete or update an Individual Service Plan (ISP) with fall-prevention measures following AV’s June 5, 2026, fall. The facility’s failure to identify, assess, and implement appropriate care-planning for AV’s ongoing fall risk resulted in AV sustaining a serious fall on June 21, 2026, causing a fractured vertebra and facial injuries. This failure to provide adequate care and supervision caused AV unreasonable harm which constitutes abuse by neglect, as defined in OAR 411-020-0002(1)(b)(A)(i).

• March 5, 2024: Failed to provide a safe medication administration system Abuse: Neglect; Level 4 - Serious harm, death, imminent danger or chronic regulatory noncompliance; fine $1,500.00; 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); 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 by failing to have an accurate medication management system in place to correctly administer AV's medication and train staff. Based on facility documentation and interviews, AV did not get his/her diuretic prescription for several days. The medication error resulted in AV suffering shortness of breath, weight gain, edema in legs and abdomen, neck vein distention, and difficulty walking. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse. Alleged Perpetrator 2 (AP2) allegedly neglected AV. An investigation determined no abuse occurred by AP2.

• December 2, 2023: Failed to properly plan care Abuse: Neglect; Level 2 - Minor harm or potential for moderate harm; fine $338.00; 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 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 or about December 2, 2023, in which AV suffered a skin tear to his/her head causing AV unreasonable discomfort which is a violation of resident rights, is considered neglect of care and constitutes abuse.

• October 24, 2023: Failed to assure timely medical treatment Abuse: Neglect; Level 2 - Minor harm or potential for moderate harm; fine $225.00; 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

  The facility failed to supervise and train Alleged Perpetrator 2 (AP2) on protocol for calling 911. On or about October 24, 2023, AV reported that she/he was in pain and wanted AP2 to call 911. AP2 did not call 911, so AV did. Based on facility documentation and interviews, AV complained of back pain and was sent to the hospital for treatment after calling 911 on his/her own and was diagnosed with a urinary tract infection. The facility's failure to ensure AV received timely medical treatment when AV initially complained of pain, caused AV unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse. AP2 allegedly neglected AV. An investigation determined no abuse occurred by AP2.

• October 16, 2023: Failed to provide a safe medication administration system Abuse: Neglect; Level 4 - Serious harm, death, imminent danger or chronic regulatory noncompliance; fine $2,500.00; 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); 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. Based on facility documentation and interviews, between October 16, 2023, and November 27, 2023, the facility failed to administer eleven different medications to Alleged Victim (AV) on approximately forty-five separate days, resulting in seventy missed administrations of AV's prescribed medications. AV's missed medications were prescribed to treat gastrointestinal discomfort, nausea, constipation, shortness of breath, moderate to severe pain, and anxiety. Four more of AV's missed medications were prescribed to treat AV's chronic mental health disorders. As a result, AV suffered unnecessary anxiety, shortness of breath, paranoia, and nausea. Based on facility documentation and interviews, the facility failed to provide adequate training and orientation to Alleged Perpetrator 2 (AP2) and Alleged Perpetrator 3 (AP3). AP2 and AP3 were inexperienced in the type of facility they were charged with managing. The facility's failure to provide a safe medication system caused AV pain and discomfort that lasted more than 24 hours, is a violation of resident rights, is considered neglect of care and constitutes abuse. Alleged Perpetrator 2 (AP2) and Alleged Perpetrator 3 (AP3) allegedly neglected AV. An investigation determined no abuse occurred by AP2 and AP3.

• September 11, 2023: 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

  The facility failed to implement timely interventions and failed to appropriately care plan related to the Alleged Victim's (AV) fall history. The failure resulted in AV experiencing unreasonable discomfort and bruising on his/her elbow when AV fell out of his/her bed on September 18, 2023. Based on facility documentation and interviews, AV had prior falls from his/her bed on August 31, 2023 and on September 12, 2023. The documented interventions for fall prevention was entered into AV's facility records on September 21, 2023, which is after all three of AV's recent falls had already taken place. The facility's failure to properly care plan is a violation of resident rights, is considered neglect of care and constitutes abuse.

Substantiated licensing violations

• June 29, 2026: 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 investigation on 08/14/26, the facility’s failure to update and review the Acuity-Based Staffing Tool (ABST) evaluation for each resident quarterly as required was substantiated. Findings include but are not limited to: The facility’s census was 42 residents. A review of the facility’s last ABST evaluation update per resident indicated 4 of 42 residents had not been updated quarterly as required as of 06/29/26. The facility’s failure to update and review the Acuity-Based Staffing Tool (ABST) evaluation for each resident quarterly as required is a violation of Oregon Administration Rules.

• June 21, 2026: 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 investigation on 08/14/26, 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 update and review the Acuity-Based Staffing Tool (ABST) evaluation for each resident quarterly as required was substantiated. Findings include, but are not limited to: The facility’s posted staffing plan indicated: · For Day shift, 4 direct care staff; · For Swing shift, 3 direct care staff; and · For Night shift, 2 direct care staff. The facility’s staffing schedule, dated 06/21/26, indicated the facility was not staffing to its posted staffing plan for 1 of 3 shifts reviewed. The facility’s census was 45 residents. A review of the facility’s last ABST evaluation update per resident indicated 5 of 45 residents had not been updated quarterly as required as of 06/21/26. 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 update and review the Acuity-Based Staffing Tool (ABST) evaluation for each resident quarterly as required is a violation of Oregon Administrative Rules.

• May 9, 2026: Failed to provide a safe medication administration system Licensing Violation; Level 3 - Moderate harm or potential for serious harm; report
  Rules: 411-054-0025 (Facility Administration); 411-054-0030 (Resident Services); 411-054-0055 (Medications and Treatments)
  State’s findings

  On or about May 9, 2026, Alleged Perpetrator 2 (AP2), a facility employee, administered another resident’s pre-poured medications to Alleged Victim (AV). These medications included a muscle relaxant that AV is known to be allergic to. According to facility records and interviews, AP2 completed general orientation on or about January 13, 2026, and had completed all required Oregon Care Partners trainings before the incident. AP2 had previously made medication errors and had been retrained. At the time of the incident, AP2 was carrying multiple medication cups intended for different residents and gave AV the incorrect cup. As a result of receiving the wrong medications, AV required hospitalization and emergency inpatient dialysis to remove the muscle relaxant from their system. AP2 failed to administer AV's medication as ordered which caused AV unreasonable discomfort requiring hospitalization. AP2's actions is considered neglect of care which constitutes abuse. The facility failed to provide a safe medication administration system to ensure AV's medications were administered as ordered which is a violation of Oregon Administrative Rules.

• January 24, 2024: Failed to properly plan care Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0036 (Service Plan – General)
  State’s findings

  The facility allegedly failed to implement a service plan that reflects the resident's needs. An investigation determined this is a violation of Oregon Administrative Rules.

• January 24, 2024: 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

  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.

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 63 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.