Avamere Living at Newberg

Last inspection

April 28, 2026

Inspections

8, 19 deficiencies cited

Substantiated abuse

6

Substantiated licensing violations

18

Regulatory actions

1

Fines assessed

$5,500.00 (6 violations)

License conditions and other regulatory actions

• August 19, 2025 to November 25, 2025: License Condition, Failed to provide safe environment ALFCD25-00400; incident: CALMS - 00085981
  The facility failed to have operable windows designed to prevent accidental falls when sill heights are lower than 36 inches and above the first floor in accordance with OAR 411-054-0300(5)(c)(D).
  Rules: 411-054-0025 (Facility Administration); 411-054-0300 (Assisted Living Facility Building Requirements)

Inspections

• April 28, 2026: Kitchen, 1 deficiency cited report
  • C0240: Resident Services Meals, Food Sanitation Rule severity level 2, scope L2 Widespread
  • C0455: Inspections and Investigation: Insp Interval severity level 2, scope L2 Widespread
• September 3, 2025: Kitchen, 1 deficiency cited report
  • C0240: Resident Services Meals, Food Sanitation Rule severity level 2, scope L2 Widespread
• April 10, 2025: Re-Licensure, 4 deficiencies cited report
  • C0200: Resident Rights and Protection - General severity level 2, scope L2 Pattern
  • C0260: Service Plan: General severity level 2, scope L2 Pattern
  • C0420: Fire and Life Safety: Safety severity level 2, scope L2 Widespread
  • C0640: Heating and Ventilation severity level 2, scope L2 Pattern
• March 18, 2025: Complaint Investig., 2 deficiencies cited report
  • C0010: Licensing Complaint Investigation severity level 2, scope L2 Isolated
  • C0360: Staffing Requirements and Training: Staffing severity level 2, scope L2 Isolated
  • C0363: Acuity Based Staffing Tool - Updates & Plan severity level 2, scope L2 Isolated
• September 25, 2024: Kitchen, 1 deficiency cited report
  • C0240: Resident Services Meals, Food Sanitation Rule severity level 2, scope L2 Widespread

Substantiated abuse or neglect

• May 24, 2025: Failed to properly plan care Abuse: Neglect; Level 3 - Moderate harm or potential for serious harm; 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); 411-054-0036 (Service Plan – General)
  State’s findings

  The facility failed to implement new and progressive fall interventions and failed to provide appropriate supervision related to the Alleged Victim’s (AV) known history of falls. On May 24, 2025, AV suffered an unwitnessed fall which resulted in a fracture to his/her small toe. During the month of May 2025, AV suffered 4 falls prior to fall on May 24, 2025. The facility's failure to properly care plan for AV's fall risk resulted in AV experiencing several falls, causing AV unreasonable discomfort, which is a moderate violation of resident rights, is considered neglect of care and constitutes abuse.

• April 28, 2025: Failed to provide safe environment 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

  During a shift change on or about April 28, 2025, Alleged Victim (AV) requested assistance with his/her Activities of Daily Living (ADLs). Alleged Perpetrator 2 (AP2), an employee of the facility, responded to AV's request for assistance. Shortly after AP2 began to assist AV with toileting, AP2 stated to AV that he/she needed to check on another resident. AP2 had partially taken AV's clothes off when he/she left AV unattended during toileting. Based on facility documentation and interviews, no other resident had pressed their call pendant during the time that AP2 was with AV. AV is a fall risk and requires assistance with all care relating to toileting, bathing, and dressing. The investigation concluded that AP2 abandoned AV by leaving AV in the restroom while in the middle of providing care to AV, resulting in AV being left alone for approximately 10 to 15 minutes, placing AV in a situation in which AV was exposed to a potential for serious risk of harm due to AV's known fall risk. AP2's actions is considered abandonment of care which is considered abuse. The facility is responsible for the supervision, training, and overall conduct of AP2 when AP2 is acting within the scope of his or her employment duties. Based on facility documentation and interviews, AP2 received a performance improvement notification on February 20, 2025, due to AP2 not providing care to another resident of the facility when this resident requested assistance. AP2 did not receive any additional training or guidance after receiving his/her first Non-Compliance Notice nor did AP2 receive training after the 2 Performance Improvement Notifications. The facility failed to provide adequate oversight and training to AP2, resulting in AP2 abandoning AV in the restroom when he/she was in the middle of providing care to AV which caused AV emotional harm, unreasonable discomfort, and placed AV at risk for a serious fall with injury. The facility's failure is a moderate violation of resident rights, is considered neglect of care which constitutes abuse.

• April 19, 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); 411-054-0036 (Service Plan – General)
  State’s findings

  On or about April 18, 2025, at approximately 11:15 PM, Alleged Victim (AV) fell in his/her room and was not found until 7:45 AM the following day. AV is care planned to have one safety check each shift due to AV's risk for falls. AV was able to keep track of the time as he/she has a clock that sits near his/her television. Based on facility documentation and interviews, AV was documented to have received his/her safety check on April 19, 2025, at 2:12AM by Alleged Perpetrator 2 (AP2). Facility documentation shows AP2 did not complete AV's safety check as documented due to AP2 being on his/her meal break at time of incident and was not in the facility. AP2 failed to follow AV's care plan for scheduled safety checks, resulting in AV laying on the floor in his/her room after a fall from 11:15 PM to 7:15 AM causing AV to have pain on the right side of his/her body. AP2's actions is considered neglect of care which constitutes abuse. The facility failed to provide adequate oversight of AP2, resulting in AV laying on the floor of h/h room from 11:15 PM to 7:45 AM causing AV to have pain on the right side of h/h body. The facility's failure to provide a safe environment is a moderate violation of resident rights, is considered neglect of care which constitutes abuse.

• September 27, 2024: Failed to provide a safe medication administration system 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); 411-054-0055 (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, AV went without blood pressure medication for two months. On September 27, 2024, AV was sent to the emergency room due to elevated blood pressure and another health issue after going to a scheduled appointment. The facility's failure resulted in unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

• May 9, 2022: Failed to provide safe environment Abuse: Neglect; Level 3 - Moderate harm or potential for serious harm; fine $1,000.00; 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 provide appropriate supervision related to the Alleged Victim’s (AV) known history of falls. The failure resulted in AV experiencing several falls (3 injury falls and 13 non injury falls) between February 10, 2022 through April 21, 2022, causing unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

• May 9, 2022: Failed to provide safe environment Abuse: Neglect; Level 3 - Moderate harm or potential for serious harm; fine $1,000.00; 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 provide appropriate supervision related to the Alleged Victim’s (AV) known history of falls. The failure resulted in AV experiencing a fall on May 9, 2022 in which AV sustained an abrasion to his/her forehead. Based on facility documentation and interviews, the facility failed to implement new interventions after AV's last fall on April 21, 2022. The facility's failure caused AV unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Substantiated licensing violations

• February 25, 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 or about February 25, 2026, at approximately 8:30 PM, Alleged Perpetrator 2 (AP2) administered Alleged Victim's (AV) medication twice instead of once, resulting in AV receiving an extra dose. Based on facility documentation and interviews, AP2 had been trained and deemed competent to administer medications, including the requirement to perform a triple-check prior to each administration. As a result of AP2's medication administration of AV's medication, resulted in AV experiencing unreasonable discomfort which included confusion, drowsiness, and lethargy. AP2's actions is considered neglect of care which constitutes abuse. The facility failed to provide a safe medication administration system for AV which is a violation of Oregon Administrative Rules.

• August 19, 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

  Based on observation and record review conducted during a site visit on 08/18/25 and 08/20/25, the facility's failure to implement a written policy that prohibits the falsification of records in accordance with OAR 411-054-0025 (8) (a) for 1 of 1 sampled Resident (# 1) was substantiated. Findings include, but are not limited to, the following: On 08/18/25, the facility provided to the Department an original incident report for Resident 1. The incident report consisted of two parts: The facility's system generated Incident Report 08/15/25; and a separate multipage investigation document that was not signed or dated. On 08/18/25, Staff 2 stated there was not enough room in the chart incident report form to include all the information, so a separate document had to be generated. On 08/19/25, the Department received from the facility an identical incident report and additional investigation document via email. The investigation document was signed by Staff 2 and dated 08/15/25. The facility's failure to implement a written policy that prohibits the falsification of records is violation of Oregon Administrative Rules.

• August 13, 2025: Failed to provide safe environment Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0300 (Assisted Living Facility Building Requirements)
  State’s findings

  On or about August 14, 2025, the Oregon Department of Human Services (ODHS) Adult Protective Services (APS) initiated Investigation #00420205 following a serious safety concern at a licensed care facility. The APS investigation triggered The ODHS Licensing Complaint Unit (LCU) to conduct a follow-up investigation, which led to the issuance of Condition ALFCD25-00400. The investigation determined the facility failed to provide a safe environment for residents by not ensuring that second-floor windows were equipped with operable safety mechanisms to prevent accidental falls which is a violation of Oregon Administrative Rules.

• August 13, 2025: Failed to provide oversight and monitoring of change of condition Licensing Violation; Level 4 - Serious harm, death, imminent danger or chronic regulatory noncompliance; report
  Rules: 411-054-0025 (Facility Administration); 411-054-0040 (Change of Condition and Monitoring)
  State’s findings

  Based on interview and record review, conducted during a site visit on 08/18/25 and 08/20/25, the facility failed to evaluate the resident, refer to the facility nurse, document the change, and update the service plan as needed, and failed to provide written communication of a resident's change of condition, including any required interventions, to caregivers on each shift in accordance with OAR 411-054-0040 (1-2) was substantiated for 1 of 1 sampled resident. (# 1). Resident 1’s mental health and medication changes were not evaluated, and interventions were not communicated to caregivers on each shift. Resident 1 suffered a fall from a second story window resulting in serious injury. Findings include but are not limited to: Resident 1 moved into the facility on 03/2024 with a diagnosis of major depressive disorder. S/He was admitted to hospice on 06/13/25. Resident 1’s service plan, dated 06/17/25, indicated “Staff should be aware of actions that may indicate increased mental health struggles and/or the need for support such as self-isolation or showing a lack of interest such as: refusing to eat, refusing to take medications or see family.” And noted Resident 1 had a history of hallucinations and delusions and had demonstrated “anxious/paranoid or suspicious behavior.” Staff were instructed to “reassure [him/her] [s/he] was safe and give [him/her] time to vent and express [his/herself].” On 06/13/25, Staff 5 completed a form titled Significant Change of Condition Comprehensive Assessment. There was no documented evidence interventions were made as a result of the assessment or communicated to staff. There was no documented evidence of interventions for staff on each shift to take or monitor in the event Resident 1 was experiencing suicidal ideations or hallucinations. Progress notes for Resident 1, dated 07/17/25 through 08/13/25, indicated: - On 08/06/25, Resident 1 was suffering hallucinations, seeing children in his/her room; - On 08/10/25, Resident 1 was experiencing hallucinations, thinking s/he was a fictional character; - On 08/11/25, Resident was found on the floor of his/her apartment, confused, with unidentified pills in his/her hand, again experiencing hallucinations, that there was a man in his/her bathroom; - On 08/12/25, Resident 1 “appears agitated, restless, and [sic] hallucinations;” and - On 08/13/25, Resident 1 had hit a family member in the face with a metal water bottle, made comments about wanting “to be taken out of this world,” and staff had administered PRN Haloperidol and Olazepam. The 08/13/25 progress note also indicated on 08/11/25 Resident 1 had been combative with staff, hallucinating, and telling staff “everyone was trying to kill [him/her].” - The progress note entries on 08/06/25, 08/10/25, 08/11/25, and 08/12/25 were documented as “outside provider notes.” Resident 1’s physician orders, dated 07/17/25 through 08/12/25, indicated: - On 07/17/25, Resident one was prescribed Haloperidol 5mg scheduled once a day, one hour before bedtime, for nighttime hallucinations; - On 08/05/25, Haloperidol 2mg (hallucinations and agitation) every six hours PRN discontinued, Lorazepam 0.5mg (agitation and restlessness) every four hours as needed discontinued and Haloperidol 2mg every four hours PRN started, Lorazepam 1mg every four hours as needed started. - On 08/11/25, the following medications were discontinued: Lantus SoloStar 100 units/mL (insulin) once daily at bedtime, Risperidone 1mg (hallucinations) twice daily, Carvedilol 6.25mg (hypertension) two times daily, Duloxetine 20mg (depression) two capsules twice a day, Furosemide 40mg (edema) once daily, and Gabapentin 100mg (neuropathy) twice a day; - On 08/11/25 Resident 1 was prescribed Lorazepam 1 mg (sleep/hallucinations) once a day; - On 08/12/25, the following medications were discontinued: Lorazepam 1mg every four hrs PRN, Lorazepam 1mg once a day, Dilaudid 2mg (pain management) every 0.5 tablet every two hours as needed, Dilaudid 2mg three times a day; - On 08/12/25, the following medications were prescribed: Methadone Hydrochloride 0.25mL (pain management) every 12 hours as scheduled, Olanzapine 5mg 0.5 tablet. Notes indicated staff to use Haloperidol if Olanzapine was ineffective. - There was no documented evidence Resident 1’s ongoing hallucinations or multiple medication changes were monitored, previous interventions for hallucinations had been used and/or were effective, or new actions or interventions were developed or communicated to staff. An incident report, dated 08/15/25, indicated: - Resident 1 had been administered PRN medication for hallucinations at 02:38 pm with ineffective results; - Staff had noted the medications administered had been ineffective; - At 05:08 pm Resident 1 had fallen from a second story window; and - At the time s/he fell from the window s/he was hallucinating and stating someone was after her. On 08/13/25 at approximately 5:08 pm, Staff 1 heard someone yelling for help. S/He found Resident 1 beneath an open second story window. Resident 1 was sent to the hospital and diagnosed with “multiple fractures.” Resident 1 died at the hospital on 08/14/25. On 08/18/25 at 12:35 pm, Staff 5 stated "I did a Change of Condition on 06/13/25 when [s/he] went on Hospice. I reviewed the Change of Condition on 06/18/25 and determined monthly reviews of the Change of Condition were appropriate." There was no documented evidence the RN had reviewed the change of condition since 06/18/25. The facility’s failure to evaluate the resident, refer to the facility nurse, document the change, update the service plan as needed, and provide written communication of required actions or interventions for caregivers on each shift was substantiated. On 08/20/25 at 5:10 pm, the LCU team requested an immediate plan of correction. An acceptable plan of correction was received from the facility on 08/20/25 at 6:38 pm. The immediate risk was addressed; however, the facility will need to evaluate the overall system failures associated with the licensing violation. The facility failed to assess, monitor, and intervene when Resident 1 experienced a significant change of condition. The facility's failure is a serious violation of Oregon Administrative Rules. Corrective Action taken on related allegation.

• August 13, 2025: Failed to use an ABST Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0025 (Facility Administration); 411-054-0037 (Acuity-Based Staffing Tool)
  State’s findings

  Based on interview and record review, conducted during site visits on 08/18/25 and 08/20/25, the facility's failure to accurately capture care time and care elements that staff are providing to each resident as outlined in each individual service plan in the facility’s Acuity-Based Staffing Tool (ABST) was substantiated for 1 of 1 sampled resident (# 1). Findings include, but are not limited to: Resident 1's service plan, dated 06/17/25, indicated: Resident 1 does have off days where she is confused about where she is and what day it is; S/He required staff assistance with orientation and redirection within the community weekly, sometimes multiple times a week; Resident 1 will forget what floor she is on; and non-pharmacological behavioral interventions included spending time with family and sitting one-on-one with staff. Resident 1's ABST, last updated on 07/18/25, indicated zero minutes were allocated for ensuring non-drug interventions for behaviors and cueing or redirecting due to a cognitive impairment. Resident 1's ABST was not reflective of care needs outlined in his/her service plan. The facility's failure to accurately capture care time and care elements that staff are providing to each resident as outlined in each individual service plan in the facility’s Acuity-Based Staffing Tool was substantiated. 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. Corrective Action taken on related allegation.

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 70 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.