Nursing home report card · Oregon City, OR
Avamere Rehabilitation of Oregon City
1400 Division Street, Oregon City, OR 97045
Call this home: (503) 656-0367
View this home on Medicare.gov ↗
Quick summary
Below-average Medicare rating
Overall rating is 2 of 5 stars. Its health-inspection rating is 2 of 5. Read the dated inspection findings and separate staffing and care ratings below.
Our summary of public Medicare records. It does not establish that this home harmed a particular resident. About this summary.
How recent is this information?
- Medicare file prepared
- Aug 1, 2026
- Our record last updated
- Oct 15, 2026
- Last routine health inspection
- Jun 6, 2025
These dates mean different things. A new file can include older inspections and staffing figures. Read about the dates.
Medicare ratings
One star is the lowest rating. Five stars is the highest. Ratings are a starting point—read the inspection findings too.
Combines inspection, staffing, and care measures.
Below-average Medicare rating
Based on problems found during health inspections.
Below-average Medicare rating
Based on staffing levels and related measures.
Above average
Based on reported health and care results.
About average for U.S. nursing homes
What do the ratings and warnings mean?
- Medicare ratings
- One star is the lowest rating. Five stars is the highest. These are government ratings, not family reviews.
- Inspection problems
- Inspectors found that a home did not meet a care or safety rule. The official term is “deficiency.”
- Abuse warning
- Medicare has flagged the home because of abuse-related inspection findings. Read the findings and dates.
- Nursing staff time
- Average staff hours for each resident per day. This does not mean each resident gets that much one-to-one care.
At a glance
These numbers come from the records we have. Inspection problems are rules the home did not meet. The dates covered can differ.
Care, safety, and resident-rights issues on recent inspections
Building, alarms, exits, and related safety citations
Total fine amounts in the imported penalty records
Medicare home ID: 385125
Inspection findings to read first
Start with these past findings. We show the most serious first, then the most recent. They do not describe the home’s condition today.
Caused actual harm · isolated case
Aug 29, 2025 · Inspection rule 0689
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Caused actual harm · isolated case
Feb 13, 2024 · Inspection rule 0686
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Caused actual harm · isolated case
Jan 13, 2023 · Inspection rule 0684
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Nursing staff time
These are average staff hours for each resident per day. They are not one-to-one bedside care. The file does not give the reporting period for each figure.
about 28 minutes per resident per day
about 5 hr 16 min per resident per day
about 22 minutes per resident per day
Latest inspection summary
A summary of the most recent routine inspections. You can open the dated findings below.
We do not have a routine inspection summary for this home. Check the dated findings below and the Medicare.gov record.
How this home compares
Compared with state and national averages. The numbers may cover different periods.
- Overall CMS rating: 2 stars
- Health inspection rating: 2 stars
- Staffing rating: 4 stars
- Registered nurse time per resident: 0.47 hours/day
- Total nurse time per resident: 5.26 hours/day
See the dates used for these averages
Medicare file dates: this home Aug 1, 2026; Oregon averages Unavailable; U.S. averages Oct 1, 2026.
Other concerns in the records
These points may be worth asking about. They do not establish what happened to a particular resident. See our Terms of Use.
- Overall star rating is 2 or lower
- Health inspection rating is 2 stars or lower
- Recent citations include infection-control problems
- Inspectors have listed an unusually high number of problems
- CMS has fined this home in the recent reporting period
How serious were the problems?
Inspectors rate each problem by how much harm it caused or could cause. We group the CMS letter codes into plain language.
- Caused actual harm3 citations
- Could have caused harm58 citations
Why inspectors showed up
Routine checks happen on a schedule. Complaint visits happen when someone reports a concern.
- Complaints
- 0
- Routine
- 61
- Fire safety
- 0
- Other
- 0
Who owns it
Names CMS lists as owners or managers · reported as For profit - Limited Liability company.
- We do not have individual owner names for this home.
Other homes in this group: All Avamere nursing homes
Inspection history
Open a date to read what inspectors found. The harm labels explain how serious the problem was at the time.
August 29, 20251 finding
- Quality of Life and Care problemsCaused actual harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0689 · code G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
June 6, 20258 findings
- Quality of Life and Care problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0688 · code 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.
- Pharmacy Service problemsCould have caused harm · pattern case
Inspection type and official rule codes
Routine health inspection · CMS tag 0761 · code 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.
- Resident Rights problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0552 · code D
Ensure that residents are fully informed and understand their health status, care and treatments.
- Resident Rights problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0584 · code 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.
- Freedom from Abuse, Neglect, and Exploitation problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0610 · code D
Respond appropriately to all alleged violations.
- Resident Assessment and Care Planning problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0644 · code D
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
- Infection Control problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0880 · code D
Provide and implement an infection prevention and control program.
- Quality of Life and Care problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0685 · code D
Assist a resident in gaining access to vision and hearing services.
January 17, 20253 findings
- Quality of Life and Care problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0684 · code D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- Resident Rights problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0624 · code D
Prepare residents for a safe transfer or discharge from the nursing home.
- Nutrition and Dietary problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0804 · code D
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
February 13, 202431 findings
- Freedom from Abuse, Neglect, and Exploitation problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0610 · code D
Respond appropriately to all alleged violations.
- Resident Assessment and Care Planning problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0636 · code D
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
- Resident Assessment and Care Planning problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0637 · code D
Assess the resident when there is a significant change in condition
- Resident Assessment and Care Planning problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0656 · code D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- Resident Assessment and Care Planning problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0658 · code D
Ensure services provided by the nursing facility meet professional standards of quality.
- Quality of Life and Care problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0677 · code D
Provide care and assistance to perform activities of daily living for any resident who is unable.
- Quality of Life and Care problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0685 · code D
Assist a resident in gaining access to vision and hearing services.
- Quality of Life and Care problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0687 · code D
Provide appropriate foot care.
- Nutrition and Dietary problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0810 · code D
Provide special eating equipment and utensils for residents who need them and appropriate assistance.
- Quality of Life and Care problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0688 · code 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.
- Quality of Life and Care problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0689 · code D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- Quality of Life and Care problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0695 · code D
Provide safe and appropriate respiratory care for a resident when needed.
- Quality of Life and Care problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0697 · code D
Provide safe, appropriate pain management for a resident who requires such services.
- Quality of Life and Care problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0698 · code D
Provide safe, appropriate dialysis care/services for a resident who requires such services.
- Quality of Life and Care problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0791 · code D
Provide or obtain dental services for each resident.
- Quality of Life and Care problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0825 · code D
Provide or get specialized rehabilitative services as required for a resident.
- Resident Assessment and Care Planning problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0657 · code D
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
- Quality of Life and Care problemsCould have caused harm · pattern case
Inspection type and official rule codes
Routine health inspection · CMS tag 0684 · code E
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- Nursing and Physician Services problemsCould have caused harm · pattern case
Inspection type and official rule codes
Routine health inspection · CMS tag 0725 · code E
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
- Nursing and Physician Services problemsCould have caused harm · pattern case
Inspection type and official rule codes
Routine health inspection · CMS tag 0730 · code E
Observe each nurse aide's job performance and give regular training.
- Nursing and Physician Services problemsCould have caused harm · pattern case
Inspection type and official rule codes
Routine health inspection · CMS tag 0732 · code E
Post nurse staffing information every day.
- Nursing and Physician Services problemsCould have caused harm · pattern case
Inspection type and official rule codes
Routine health inspection · CMS tag 0947 · code E
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
- Resident Rights problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0554 · code D
Allow residents to self-administer drugs if determined clinically appropriate.
- Resident Rights problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0578 · code 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.
- Resident Assessment and Care Planning problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0641 · code D
Ensure each resident receives an accurate assessment.
- Resident Rights problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0584 · code 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.
- Freedom from Abuse, Neglect, and Exploitation problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0602 · code D
Protect each resident from the wrongful use of the resident's belongings or money.
- Freedom from Abuse, Neglect, and Exploitation problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0609 · code D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
- Quality of Life and Care problemsCaused actual harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0686 · code G
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
- Administration problemsCould have caused harm · widespread case
Inspection type and official rule codes
Routine health inspection · CMS tag 0867 · code F
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
- Pharmacy Service problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0759 · code D
Ensure medication error rates are not 5 percent or greater.
January 13, 202318 findings
- Quality of Life and Care problemsCould have caused harm · pattern case
Inspection type and official rule codes
Routine health inspection · CMS tag 0679 · code E
Provide activities to meet all resident's needs.
- Quality of Life and Care problemsCould have caused harm · pattern case
Inspection type and official rule codes
Routine health inspection · CMS tag 0680 · code E
Ensure the activities program is directed by a qualified professional.
- Nursing and Physician Services problemsCould have caused harm · pattern case
Inspection type and official rule codes
Routine health inspection · CMS tag 0732 · code E
Post nurse staffing information every day.
- Nutrition and Dietary problemsCould have caused harm · pattern case
Inspection type and official rule codes
Routine health inspection · CMS tag 0813 · code E
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
- Resident Rights problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0558 · code D
Reasonably accommodate the needs and preferences of each resident.
- Resident Rights problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0561 · code 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 Planning problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0657 · code D
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
- Quality of Life and Care problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0744 · code D
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
- Pharmacy Service problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0757 · code D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
- Pharmacy Service problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0759 · code D
Ensure medication error rates are not 5 percent or greater.
- Nutrition and Dietary problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0806 · code D
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
- Nutrition and Dietary problemsCould have caused harm · widespread case
Inspection type and official rule codes
Routine health inspection · CMS tag 0804 · code F
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
- Nutrition and Dietary problemsCould have caused harm · widespread case
Inspection type and official rule codes
Routine health inspection · CMS tag 0802 · code F
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
- Nursing and Physician Services problemsCould have caused harm · widespread case
Inspection type and official rule codes
Routine health inspection · CMS tag 0725 · code F
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
- Quality of Life and Care problemsCaused actual harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0684 · code G
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- Nutrition and Dietary problemsCould have caused harm · widespread case
Inspection type and official rule codes
Routine health inspection · CMS tag 0812 · code F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- Administration problemsCould have caused harm · widespread case
Inspection type and official rule codes
Routine health inspection · CMS tag 0867 · code F
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
- Resident Rights problemsCould have caused harm · pattern case
Inspection type and official rule codes
Routine health inspection · CMS tag 0565 · code E
Honor the resident's right to organize and participate in resident/family groups in the facility.
Fines & penalties
These fines appear in Medicare’s records. A listed amount does not tell us whether it has been paid.
- Fine · Feb 13, 2024$85,768
Other homes in this chain
Avamere · other locations in Oregon
- Avamere Rehabilitation Of Eugene · Eugene1 of 5 · 54 problems
- Avamere Rehabilitation Of Lebanon · Lebanon1 of 5 · 60 problems
- Avamere Rehabilitation of Coos Bay · Coos Bay2 of 5 · 45 problems
- Avamere Riverpark of Eugene · Eugene2 of 5 · 47 problems
- Avamere Health Services of Rogue Valley · Medford2 of 5 · 51 problems
- Avamere Transitional Care at Sunnyside · Salem2 of 5 · 52 problems
- Avamere Rehabilitation Of Hillsboro · Hillsboro3 of 5 · 40 problems
- Avamere Crestview of Portland · Portland4 of 5 · 57 problems
Related topics
Questions about Avamere Rehabilitation of Oregon City
What is Avamere Rehabilitation of Oregon City's Medicare star rating?
Has Avamere Rehabilitation of Oregon City been fined?
Does Avamere Rehabilitation of Oregon City have a Medicare abuse warning?
How does Avamere Rehabilitation of Oregon City compare with other nursing homes in Oregon?
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