Avamere Living at St Helens

Last inspection

July 8, 2024

Inspections

5, 11 deficiencies cited

Substantiated abuse

4

Substantiated licensing violations

5

Regulatory actions

0

Fines assessed

$1,126.00 (4 violations)

• Every deficiency from the July 8, 2024 inspection was corrected by September 9, 2024

Inspections

• July 8, 2024: Re-Licensure, 7 deficiencies cited report
  • C0000: Comment severity level 0
  • C0160: Reasonable Precautions severity level 3, scope L3 Isolated, corrected September 9, 2024
  • C0231: Reporting & Investigating Abuse-Other Action severity level 2, scope L2 Isolated, corrected September 9, 2024
  • C0374: Annual and Biennial Inservice For All Staff severity level 2, scope L2 Pattern, corrected September 9, 2024
  • C0420: Fire and Life Safety: Safety severity level 2, scope L2 Widespread, corrected September 9, 2024
  Show all 8

  • C0610: General Building Exterior severity level 2, scope L2 Widespread, corrected September 9, 2024
  • C0613: General Building: Doors-Walls, Cleanable severity level 2, scope L2 Widespread, corrected September 9, 2024
  • C0640: Heating and Ventilation severity level 2, scope L2 Widespread, corrected September 9, 2024
• April 30, 2024: State Licensure, 0 deficiencies cited report
  • C0000: Comment severity level 0
• February 28, 2024: Complaint Investig., 1 deficiency cited report
  • C0231: Reporting & Investigating Abuse-Other Action severity level 2, scope L2 Isolated
• May 31, 2023: State Licensure, 0 deficiencies cited report
  • C0000: Comment severity level 0
• February 9, 2022: Validation, 3 deficiencies cited report
  • C0000: Comment severity level 0
  • C0374: Annual and Biennial Inservice For All Staff severity level 2, scope L2 Pattern, corrected April 10, 2022
  • C0420: Fire and Life Safety: Safety severity level 2, scope L2 Widespread, corrected April 10, 2022
  • C0422: Fire and Life Safety: Training For Residents severity level 2, scope L2 Widespread, corrected April 10, 2022

Substantiated abuse or neglect

• August 22, 2025: 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

  On August 22, 2025, the Alleged Victim (AV) and Witness 1 (W1) were involved in a resident-to-resident altercation in which W1 slapped AV, and AV responded by spraying W1 with a hose. During the incident, AV fell and sustained injuries requiring hospitalization and medical treatment overnight. Based on facility documentation and staff interviews, the facility failed to appropriately monitor W1 during the facility's activity of watering plants, according to W1’s known behavioral history and prior altercations. The facility's failure caused unreasonable discomfort and physical harm to AV which is a violation of resident rights, is considered neglect of care and constitutes abuse.

• March 29, 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

  On or about March 29, 2025, Alleged Victim (AV) suffered an unwitnessed fall in his/her room, and it was unknown when the fall happened. Based on facility documentation and interviews, it was determined that day shift had not completed a timely safety check on AV when day shift started, and the last safety check was completed at 4am by NOC shift. It is not known if AV had fallen earlier in the night and then went back to bed or if the fall happened between the times of 4am and 8:40am, when AV was found by day shift staff. Facility documentation shows that AV's call pendant was not working at time of incident. The investigation determined that the facility failed to complete a safety check on AV, leaving AV almost 5 hours without a safety check and AV's call pendant was not working correctly at time of incident. The facility's failure to provide a safe environment caused AV unreasonable discomfort, which is a moderate violation of resident rights, is considered neglect of care and constitutes abuse.

• March 24, 2024: Failed to provide safe environment Abuse: Neglect; Level 2 - Minor harm or potential for moderate harm; fine $188.00; 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 appropriately monitor Alleged Victim (AV) according to his/her known behavior. AV is known by the facility, to become easily agitated when other residents enter his/her room. Based on this behavior, AV is scheduled to have regular safety checks. On March 24, 2024, AV was involved in a physical altercation with Witness 1 (W1), causing unreasonable discomfort to the AV. Based on facility documentation and interviews, safety checks on AV were not performed on day of incident. The facility failed to provide adequate supervision to prevent AV from being hit by another resident, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

• March 23, 2024: 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 March 23, 2024, Alleged Victim (AV) was outside in the facility courtyard. As AV was coming towards the door to come into the dining room, Witness 1 (W1) held the door closed so AV could not enter. AV then tried to enter the facility going through the facility's sunroom door. W1 went outside as AV was trying to enter the sunroom door and pushed AV causing AV to fall to the ground. Based on facility documentation and interviews, AV and W1 had been separated earlier the day of incident due to AV' behaviors. The facility failed to appropriately monitor W1 and AV according to his/her known behavior and prior altercations. The failure resulted in a physical altercation, causing unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Substantiated licensing violations

• January 7, 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

  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.

• December 18, 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

  On or about December 18, 2025, 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 5, 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

  On or about March 5, 2025, 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.

• May 21, 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); 411-054-0055 (Medications and Treatments)
  State’s findings

  On or about May 20, 2024, Alleged Perpetrator 2 (AP2), was preparing resident medications for morning rounds. AP2 noticed that Alleged Victim (AV) had two bottles of the same medication for blood pressure. AP2 observed one bottle was full and the other bottle was almost empty. AP2 then combined the two bottles to save space. AP2 discarded the empty bottle. AP2 then continued with medication distribution. Based on facility documentation and interviews, AP2 made an error when he/she combined AV's medication. AP2 combined AV's medication that deals with gout into the bottle of the medication that deals with blood pressure, mistaking it for the same medication. Facility staff administered what they thought was AV's medication that deals with blood pressure on May 21, 2024, but due to AP2's actions, it was unclear what the medication administered was actually for. AP2's actions placed AV at risk of harm which 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.

• December 20, 2023: Failed to investigate injury of unknown origin to rule out abuse Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0028 (Reporting and Investigating Abuse and Other Actions Affecting Resident Welfare)
  State’s findings

  The facility failed to document all required elements of an investigation of reports of abuse and suspected abuse. 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 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.