Print Violation: 00440182-AP-392027

Provider Information

Avamere at Sandy

17727 SE LANGENSAND RD
Sandy, OR 97055

Date: 11/17/2025
Report number: 00440182-AP-392027
Type: Licensing Violation
Level: 2 - Minor harm or potential for moderate harm
Allegation: Failed to provide safe environment
Result: Substantiated
Rule(s) Violated: External site: 411-054-0025(1)(a) and (b)
Findings: On November 17, 2025, Alleged Perpetrator 2 (AP2) attempted to independently transfer Alleged Victim (AV) from a wheelchair to a recliner. Based on facility documentation and interviews, AV is service-planned to be transferred with a second caregiver present and with the use of a gait belt or a sit-to-stand assistive device. At time of incident, AP2 did not follow these requirements and attempted the transfer AV alone and without any required equipment. During the transfer, AP2 lost their grip, resulting in an assisted fall in which AP2 lowered AV to the floor. AP2 had been trained to read and follow AV’s Service Plan and has a history of not following Service Plans, including completing transfers without required assistance. AP2's actions placed AV a risk of harm which 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.