Print Violation: 00455761-AP-407910

Provider Information

Avamere at Sandy Assisted Living Facility

17727 SE LANGENSAND RD
Sandy, OR 97055

Date: 2/4/2026
Report number: 00455761-AP-407910
Type: Licensing Violation
Level: 2 - Minor harm or potential for moderate harm
Allegation: Failed to provide a safe medication administration system
Result: Substantiated
Rule(s) Violated: External site: 411-054-0025(1)(a) and (b)
External site: 411-054-0055(1)(a) and (f)
Findings: On February 4, 2026, Alleged Perpetrator 2 (AP2) administered Alleged Victim's (AV) ear medication into AV’s right eye instead of AV's prescribed eye medication. According to AV’s service plan, facility staff are responsible for administering all medications and treatments. AP2 reported that they were rushing while completing AV’s morning care and mistakenly selected the wrong medication bottle, despite checking the label against the MAR once. The facility’s medication administration training requires staff to triple check medications to ensure the correct medication, dose, and route. AP2 did not complete the required triple-check process prior to administration. As a result, AV received the ear medication in the right eye, causing immediate pain and discomfort. AP2's actions caused AV unnecessary pain and discomfort which is considered neglect of care and constitutes abuse. The facility failed to provide a safe medication administration for AV which is a violation of Oregon Administrative Rules.