9 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Oregon City, OR
3-star overall rating with 2-star inspections with $85,768 in total fines with 9 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
1400 Division Street, Oregon City, OR
(503) 656-0367
Overall
3 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Beds
111
Certified beds
Average residents
62
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Avamere
Operator or chain grouping
Approved since
1975-03-28
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
33 facilities
Chain averages 3 overall / 3 health / 4 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
RN hours / resident day
0.49
Registered nurse staffing · state 0.68 · national 0.68
LPN hours / resident day
0.86
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
3.94
Nurse aide staffing · state 3.37 · national 2.35
Total nurse hours
5.29
All reported nurse hours · state 4.95 · national 3.89
Licensed hours
1.35
RN + LPN hours · state 1.58 · national 1.54
Weekend hours
4.88
Weekend nurse staffing · state 4.39 · national 3.43
Weekend RN hours
0.39
Weekend registered nurse coverage · state 0.44 · national 0.47
Physical therapist
0.05
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.50
CMS adjusted RN staffing hours
Adjusted total hours
5.45
CMS adjusted total nurse staffing hours
Case-mix index
1.33
Higher values indicate more complex resident acuity
RN turnover
29%
Annual RN turnover · state 53% · national 45%
Total nurse turnover
37%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Program rank
962
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
61.64
Composite VBP score used to determine payment impact.
Payment multiplier
1.0167
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
5.79
Baseline 61.91% · Performance 40.00% · Measure score 5.79 · Achievement 5.79 · Improvement 5.41
Adjusted total nurse staffing
6.53
Baseline 4.78 hours · Performance 4.94 hours · Measure score 6.53 · Achievement 6.53 · Improvement 1.1
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.85% |
10.72%
0.1 pts worse
|
No Different than the National Rate · Eligible stays 55 · Observed rate 12.73% · Lower 95% interval 7.2% |
| Discharge to community | 64.06% |
50.57%
13.5 pts better
|
Better than the National Rate · Eligible stays 58 · Observed rate 58.62% · Lower 95% interval 51.25% |
| Medicare spending per beneficiary | 0.67 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 15 · Adjusted rate Not Available · Too few residents or stays to report publicly. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 23 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 37.89% |
8.2%
29.7 pts better
|
Numerator 36 · Denominator 95 |
| Staff flu vaccination coverage | 20.59% |
42%
21.4 pts worse
|
Numerator 21 · Denominator 102 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator Not Available · Newly certified or not enough cases to report. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.2% |
95.5%
1.7 pts better
|
93.4%
3.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 97.7% · Q2 95.5% · Q3 95.7% · Q4 100.0% · 4Q avg 97.2% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
95.2%
4.8 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.7% |
2.4%
0.7 pts better
|
3.3%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 6.4% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.3% |
4.7%
3.4 pts better
|
11.4%
10.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 4.7% · Q4 0.0% · 4Q avg 1.3% |
| Percentage of long-stay residents who lose too much weight | 0.6% |
5.0%
4.4 pts better
|
5.4%
4.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 2.3% · 4Q avg 0.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 18.5% |
12.5%
6 pts worse
|
19.6%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 19.0% · Q2 21.4% · Q3 18.2% · Q4 15.6% · 4Q avg 18.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 15.2% |
14.7%
0.5 pts worse
|
16.7%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.9% · Q2 12.9% · Q3 11.8% · Q4 18.8% · 4Q avg 15.2% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 23.6% |
24.1%
0.5 pts better
|
16.3%
7.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 23.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 7.1% |
15.8%
8.7 pts better
|
14.9%
7.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.5% · Q2 2.4% · Q3 6.8% · Q4 11.4% · 4Q avg 7.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.4% |
1.7%
1.3 pts better
|
1.0%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.5% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
2.0%
2 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 10.8% |
22.2%
11.4 pts better
|
19.8%
9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.7% · Q2 7.8% · Q3 15.6% · Q4 2.2% · 4Q avg 10.8% |
| Percentage of long-stay residents with pressure ulcers | 8.4% |
6.5%
1.9 pts worse
|
5.1%
3.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.0% · Q2 9.2% · Q3 5.7% · Q4 11.8% · 4Q avg 8.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 96.1% |
85.4%
10.7 pts better
|
81.7%
14.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 95.2% · Q2 95.6% · Q3 97.9% · Q4 95.8% · 4Q avg 96.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 16.1% |
15.1%
1 pts worse
|
12.0%
4.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 16.1% · Observed 17.4% · Expected 12.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.6% |
1.7%
1.1 pts better
|
1.6%
1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.3% · Q4 1.1% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 91.9% |
81.2%
10.7 pts better
|
79.7%
12.2 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 91.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 19.5% |
21.6%
2.1 pts better
|
23.9%
4.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 19.5% · Observed 17.4% · Expected 21.2% · Used in QM five-star |
Survey summary
Top issue: Quality of Life and Care (3 deficiencies)
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Top issue: Quality of Life and Care (13 deficiencies)
9 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Top issue: Nutrition and Dietary (5 deficiencies)
4 fire-safety deficiencies
Top issue: Miscellaneous (2 deficiencies)
Fire safety
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-07-08
Fire Safety
Develop Emergency Preparedness policies and procedures.
Corrected 2024-04-03
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2024-04-03
Fire Safety
Have an alternate power supply for its alarm system.
Corrected 2024-04-03
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-04-03
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-04-03
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-04-03
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-04-03
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2024-04-03
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-04-03
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-02-22
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-02-22
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-02-22
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-02-22
Inspection history
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-06-26
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2025-07-02
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2025-07-02
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2025-07-02
Health
Respond appropriately to all alleged violations.
Corrected 2025-07-02
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2025-07-02
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2025-07-02
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2025-07-02
Health
Provide and implement an infection prevention and control program.
Corrected 2025-07-02
Health
Prepare residents for a safe transfer or discharge from the nursing home.
Corrected 2025-02-28
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-02-28
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2025-02-28
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-04-02
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2024-04-02
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-04-02
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2024-04-02
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2024-04-02
Health
Post nurse staffing information every day.
Corrected 2024-04-02
Health
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Corrected 2024-04-02
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2024-04-02
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2024-04-02
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2024-04-02
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2024-04-02
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-04-02
Health
Respond appropriately to all alleged violations.
Corrected 2024-04-02
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2024-04-02
Health
Assess the resident when there is a significant change in condition
Corrected 2024-04-02
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-04-02
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-04-02
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2024-04-02
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-04-02
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-04-02
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2024-04-02
Health
Provide appropriate foot care.
Corrected 2024-04-02
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2024-04-02
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-04-02
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-04-02
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2024-04-02
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2024-04-02
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-04-02
Health
Provide or obtain dental services for each resident.
Corrected 2024-04-02
Health
Provide special eating equipment and utensils for residents who need them and appropriate assistance.
Corrected 2024-04-02
Health
Provide or get specialized rehabilitative services as required for a resident.
Corrected 2024-04-02
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2023-05-03
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-02-22
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2023-02-22
Health
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
Corrected 2023-02-22
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2023-02-22
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-02-22
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2023-02-22
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2023-02-22
Health
Provide activities to meet all resident's needs.
Corrected 2023-02-22
Health
Ensure the activities program is directed by a qualified professional.
Corrected 2023-02-22
Health
Post nurse staffing information every day.
Corrected 2023-02-22
Health
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Corrected 2023-02-22
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2023-02-22
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2023-02-22
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2023-02-22
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected 2023-02-22
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2023-02-22
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-02-22
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2023-02-22
Penalties and ownership
Fine · fine $85,768
Fine
5% Or Greater Direct Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
Corporate Director · Individual
W-2 Managing Employee · Individual
5% Or Greater Indirect Ownership Interest · Individual
Corporate Officer · Individual
5% Or Greater Indirect Ownership Interest · Individual
Corporate Officer · Individual
5% Or Greater Indirect Ownership Interest · Individual
Corporate Director · Individual
5% Or Greater Indirect Ownership Interest · Individual
Corporate Officer · Individual
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Gladstone, OR
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