Federal inspection record · CMS data as of October 1, 2026
Avamere Rehabilitation Of Oregon City
1400 Division Street, Oregon City, OR · (503) 656-0367
- Certified beds
- 111
- Residents per day
- 60
- Ownership
- For-Profit
- Chain
- Avamere
- Medicare / Medicaid
- Medicare + Medicaid
- Certified since
- March 28, 1975
1
How this home got 2 stars
The overall rating isn't an average. CMS starts from the inspection rating and nudges it at most two steps. Here is the arithmetic for this home, using CMS's own rules.
-
Health inspections
★★★★★starting point
Everything starts from what state inspectors found on site. This is a ranking against other homes in Oregon.
-
Staffing
★★★★★no change
Only a 5-star staffing rating adds a star, and only a 1-star rating removes one. Ratings of 2 to 4 change nothing.
-
Quality measures
★★★★★no change
Same rule: 5 stars adds one, 1 star takes one away. These measures are mostly reported by the home itself.
-
Overall
★★★★★2 of 5
Matches the rating CMS publishes on Care Compare.
2
Where it sits among Oregon homes
Avamere Rehabilitation Of Oregon City carries 78 inspection points. That is fewer than 33% of Oregon's 126 rated homes.
Inspectors' citations earn points by how serious and how widespread they were (the grid below). CMS then ranks every home in Oregon: the 10% with the fewest points get 5 stars, the 20% with the most get 1 star, and the middle 70% split evenly into 2, 3 and 4.
- 5★ 0–14 pts
- 4★ 14–41 pts
- 3★ 41–65 pts
- 2★ 65–95.25 pts
- 1★ over 95.25 pts
Bars show every rated home in Oregon by its weighted inspection score. CMS recalibrates the cut points monthly but holds a home's rating until its own score changes, so a home can sit just outside today's band.
3
What inspectors found
61 health citations on record since 2023. Each one gets a letter: the row says how badly residents were affected, the column how many.
Immediate jeopardyResidents at risk of serious injury or death
Actual harmA resident was hurt
Potential for harmNo one was hurt, but could have been
Minimal harmPaperwork-level problems
Read the rows, not the total. Most citations nationwide are a D: one problem, nobody hurt. Rows G–I mean a resident was harmed; J–L mean inspectors found residents in immediate danger of serious injury or death.
Small numbers in each cell are the inspection points CMS assigns per citation. Those points are what the state curve above ranks.
Harm and immediate-jeopardy citations (3)
-
G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
-
G
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
-
G
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Everything else, by area of care
Quality of Life and Care17E
- D
Assist a resident in gaining access to vision and hearing services.
- D
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.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- E
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
- D
Assist a resident in gaining access to vision and hearing services.
- D
Provide appropriate foot care.
- D
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.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- D
Provide safe and appropriate respiratory care for a resident when needed.
- D
Provide safe, appropriate pain management for a resident who requires such services.
- D
Provide safe, appropriate dialysis care/services for a resident who requires such services.
- D
Provide or obtain dental services for each resident.
- D
Provide or get specialized rehabilitative services as required for a resident.
- E
Provide activities to meet all resident's needs.
- E
Ensure the activities program is directed by a qualified professional.
- D
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Resident Rights9E
- D
Ensure that residents are fully informed and understand their health status, care and treatments.
- D
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.
- D
Prepare residents for a safe transfer or discharge from the nursing home.
- D
Allow residents to self-administer drugs if determined clinically appropriate.
- D
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.
- D
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.
- E
Honor the resident's right to organize and participate in resident/family groups in the facility.
- D
Reasonably accommodate the needs and preferences of each resident.
- D
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Resident Assessment and Care Planning8D
- D
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
- D
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
- D
Assess the resident when there is a significant change in condition
- D
Ensure each resident receives an accurate assessment.
- D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- D
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
- D
Ensure services provided by the nursing facility meet professional standards of quality.
- D
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Nutrition and Dietary7F
- D
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
- D
Provide special eating equipment and utensils for residents who need them and appropriate assistance.
- F
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
- F
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
- F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- E
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
- D
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Nursing and Physician Services6F
- E
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
- E
Observe each nurse aide's job performance and give regular training.
- E
Post nurse staffing information every day.
- E
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
- F
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
- E
Post nurse staffing information every day.
Pharmacy Service4E
- E
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.
- D
Ensure medication error rates are not 5 percent or greater.
- D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
- D
Ensure medication error rates are not 5 percent or greater.
Freedom from Abuse, Neglect, and Exploitation4D
- D
Respond appropriately to all alleged violations.
- D
Protect each resident from the wrongful use of the resident's belongings or money.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
- D
Respond appropriately to all alleged violations.
Administration2F
- F
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
- F
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Infection Control1D
- D
Provide and implement an infection prevention and control program.
Inspection history
2025-06-06
8 health deficiencies · 1 fire-safety deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
2024-02-13
35 health deficiencies · 9 fire-safety deficiencies
Top issue: Quality of Life and Care (14 deficiencies)
2023-01-13
18 health deficiencies · 4 fire-safety deficiencies
Top issue: Nutrition and Dietary (5 deficiencies)
4
Nursing time per resident, per day
Each resident here gets about 5 h 20 min of nursing staff time a day, 34 min of it from a registered nurse.
This home
5 h 20 min
Oregon average
5 h 8 min
U.S. average
3 h 54 min
- Registered nurse
- Licensed practical nurse
- Nurse aide
Turnover: 55% of nursing staff and 86% of registered nurses left in the past year.
Reported hours from payroll data the home submits to CMS, divided by its daily resident count. Not adjusted for how sick residents are.
5
Fines and payment denials
$85,768 in federal fines on record over the past three years.
| Date | Penalty | Amount |
|---|---|---|
| 2024-02-13 | Fine | $85,768 |
6
Resident outcomes
Quality measures compared with state and national averages. Most come from assessments the home itself reports.
| Measure | This home | State | U.S. |
|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine0.3 pts worse | 95.0% | 95.3% | 93.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine6 pts better | 100.0% | 94.0% | 95.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury1.9 pts worse | 4.3% | 2.4% | 3.2% |
| Percentage of long-stay residents who have depressive symptoms0.1 pts worse | 5.0% | 4.9% | 13.5% |
| Percentage of long-stay residents who lose too much weight3.9 pts better | 0.7% | 4.6% | 5.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication0.7 pts worse | 12.9% | 12.2% | 19.5% |
| Percentage of long-stay residents who received an antipsychotic medication0.5 pts worse | 14.8% | 14.3% | 15.4% |
| Percentage of long-stay residents who were physically restrained0.1 pts better | 0.0% | 0.1% | 0.1% |
| Percentage of long-stay residents whose ability to walk independently worsened0.6 pts worse | 19.2% | 18.6% | 12.7% |
| Percentage of long-stay residents whose need for help with daily activities has increased0.3 pts better | 13.9% | 14.2% | 13.5% |
| Percentage of long-stay residents with a catheter inserted and left in their bladder1.3 pts better | 0.0% | 1.3% | 0.7% |
| Percentage of long-stay residents with a urinary tract infection0.1 pts better | 1.9% | 2.0% | 1.5% |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence6.9 pts better | 13.9% | 20.8% | 18.3% |
| Percentage of long-stay residents with pressure ulcers0.9 pts worse | 6.5% | 5.6% | 4.5% |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine8.5 pts better | 94.3% | 85.8% | 82.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit16 pts better | 0.0% | 16.0% | 11.8% |
| Percentage of short-stay residents who newly received an antipsychotic medication0.3 pts worse | 1.7% | 1.4% | 1.5% |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine15.3 pts better | 96.2% | 80.9% | 80.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission5.5 pts worse | 27.4% | 21.9% | 23.4% |
·
Fire safety
14 life-safety citations (sprinklers, exits, alarms). These don't count toward the star rating.
Smoke4F
- F
Install a fire alarm system that can be heard throughout the facility.
- F
Have an alternate power supply for its alarm system.
- F
Inspect, test, and maintain automatic sprinkler systems.
- D
Provide properly protected cooking facilities.
Miscellaneous4F
- F
Have simulated fire drills held at unexpected times.
- F
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
- F
Have simulated fire drills held at unexpected times.
- D
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Gas, Vacuum, and Electrical Systems3F
- F
Have generator or other power source capable of supplying service within 10 seconds.
- D
Meet requirements for the installation and maintenance of electrical systems.
- D
Ensure proper usage of power strips and extension cords.
Emergency Preparedness1F
- F
Develop Emergency Preparedness policies and procedures.
Services1F
- F
Have properly installed electrical wiring and gas equipment.
Egress1D
- D
Keep aisles, corridors, and exits free of obstruction in case of emergency.
·
Other homes nearby
-
Rivercrest Post Acute
Oregon City, OR · Pacs Group
★★★★★- Worst citation, 3 yrs
- F
- Nursing / resident / day
- 4 h 50 min
- Fines
- $18,075
-
Marquis Oregon City Post Acute Rehab
Oregon City, OR · Marquis Companies
★★★★★- Worst citation, 3 yrs
- F
- Nursing / resident / day
- 4 h 54 min
- Fines
- $0
-
Avamere Rehabilitation Of Clackamas
Gladstone, OR · Avamere
★★★★★- Worst citation, 3 yrs
- K
- Nursing / resident / day
- 5 h 14 min
- Fines
- $175,773