Avamere Rehabilitation of Oregon City
1400 Division Street · Oregon City, OR · 97045 · 5036560367
111 certified beds For profit - Limited Liability company Chain: Avamere
Why this verdict
- 3 citations involved actual harm to residents.
- Staffing hours comfortably above national benchmarks.
- Inspection results have improved across recent cycles.
The complete Safety Report — $19
Everything on this page plus the full citation-by-citation history with inspector findings, the complete penalty record, staffing vs benchmarks, side-by-side nearby comparisons, and the printable tour checklist. One PDF, emailed in minutes, yours to keep and share with family.
Red flags
No red flags in the current CMS record. Genuinely good news — pair it with an in-person tour before deciding.
Score breakdown
Quality-measure stars are deliberately excluded — they're largely self-reported by facilities. Full method.
CMS ratings & staffing
Overall: 2 of 5 Inspections: 2 of 5 Staffing: 4 of 5 Quality measures: 4 of 5
| Total nurse hours / resident-day | 5.19 | 3.48 min · 4.1 strong |
|---|---|---|
| RN hours / resident-day | 0.46 | 0.55–0.75 |
| Weekend hours / resident-day | 4.66 | ≈ weekday level |
| Nursing turnover / year | 44% | median 45% |
| Fines (3-yr window) | 1 · $85,768 |
Inspection citations (61 in the current record)
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Actual harm · G August 29, 2025 · found via complaint
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected June 26, 2025 · Quality of Life and Care
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Potential for harm · D June 6, 2025
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected July 2, 2025 · Resident Rights
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Potential for harm · D June 6, 2025
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 July 2, 2025 · Resident Rights
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Potential for harm · D June 6, 2025
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected July 2, 2025 · Resident Assessment and Care Planning
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Potential for harm · D June 6, 2025
Assist a resident in gaining access to vision and hearing services.
Corrected July 2, 2025 · Quality of Life and Care
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Potential for harm · D June 6, 2025
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 July 2, 2025 · Quality of Life and Care
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Potential for harm · E June 6, 2025
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 July 2, 2025 · Pharmacy Service
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Potential for harm · D June 6, 2025
Provide and implement an infection prevention and control program.
Corrected July 2, 2025 · Infection Control
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Potential for harm · D June 6, 2025 · found via complaint
Respond appropriately to all alleged violations.
Corrected July 2, 2025 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D January 17, 2025 · found via complaint
Prepare residents for a safe transfer or discharge from the nursing home.
Corrected February 28, 2025 · Resident Rights
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Potential for harm · D January 17, 2025 · found via complaint
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected February 28, 2025 · Quality of Life and Care
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Potential for harm · D January 17, 2025 · found via complaint
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected February 28, 2025 · Nutrition and Dietary
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Actual harm · G February 13, 2024 · found via complaint
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected April 2, 2024 · Quality of Life and Care
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Potential for harm · D February 13, 2024
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected April 2, 2024 · Resident Assessment and Care Planning
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Potential for harm · D February 13, 2024 · found via complaint
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected April 2, 2024 · Resident Rights
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Potential for harm · D February 13, 2024 · found via complaint
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 April 2, 2024 · Resident Rights
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Potential for harm · D February 13, 2024 · found via complaint
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 April 2, 2024 · Resident Rights
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Potential for harm · D February 13, 2024 · found via complaint
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected April 2, 2024 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D February 13, 2024 · found via complaint
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected April 2, 2024 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D February 13, 2024 · found via complaint
Respond appropriately to all alleged violations.
Corrected April 2, 2024 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D February 13, 2024 · found via complaint
Assess the resident when there is a significant change in condition
Corrected April 2, 2024 · Resident Assessment and Care Planning
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Potential for harm · D February 13, 2024 · found via complaint
Ensure each resident receives an accurate assessment.
Corrected April 2, 2024 · Resident Assessment and Care Planning
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Potential for harm · D February 13, 2024 · found via complaint
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected April 2, 2024 · Resident Assessment and Care Planning
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Potential for harm · D February 13, 2024 · found via complaint
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected April 2, 2024 · Resident Assessment and Care Planning
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Potential for harm · D February 13, 2024 · found via complaint
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected April 2, 2024 · Resident Assessment and Care Planning
Showing the 25 most recent. The Safety Report includes every citation with full findings.
Federal penalties
| Date | Type | Amount / length |
|---|---|---|
| February 13, 2024 | Fine | $85,768 |
Family & resident reviews — a separate signal, never mixed into the score
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Source: CMS Care Compare (public domain), data as of June 1, 2026 · CCN 385125 · certified since March 28, 1975. The score is a screen, not a verdict on any one resident's experience — read how it's computed, then visit in person.