Avamere Rehabilitation of Oregon City
1400 Division Street, Oregon City, OR 97045
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Follow this homeAvamere Rehabilitation of Oregon City is a nursing home in Oregon City, Oregon. This page lists the citations, fines and star ratings that CMS publishes for it. Each one has a date and a link to CMS.
At a glance
- CMS overall star rating2 of 5
- Last standard health inspectionJune 6, 2025 (1 year ago)
- Health citations since January 13, 202361 (Oregon average 34)
- Fines in the past three years1, $85,768 in total
- CMS flagsNone listed by CMS
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CMS flags
CMS does not list this home as a Special Focus Facility or a candidate. CMS does not show an abuse icon for it. CMS lists no change of ownership in the past 12 months.
Inspections, fines and changes
This list shows every citation and fine in CMS's current data, which covers about the last three years. It also shows changes CMS made to this home's ratings and records.
CMS update of October 28, 2026
Star rating
The CMS quality measures star rating changed from 3 of 5 to 4 of 5.
Name
CMS lists a new legal business name for this home.
CMS update of July 29, 2026
Star rating
The CMS quality measures star rating changed from 4 of 5 to 3 of 5.
CMS update of April 29, 2026
Star rating
The CMS overall star rating changed from 3 of 5 to 2 of 5.
Star rating
The CMS quality measures star rating changed from 5 of 5 to 4 of 5.
Ownership
CMS ownership records list new owners for this home.
CMS update of November 20, 2025
Star rating
The CMS overall star rating changed from 2 of 5 to 3 of 5. CMS changed how it scores this rating for many homes at once.
Star rating
The CMS quality measures star rating changed from 4 of 5 to 5 of 5.
Health inspection on August 29, 2025
1 citationCMS lists this as a complaint inspection.
Severity G is the second-highest of CMS's four levels. It means a resident was harmed.
23 of 128 Oregon homes (18%) got a citation at the actual harm level in 2025.
Show the 1 citation
Citation F0689. Severity G: actual harm, isolated.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on June 26, 2025.
CMS has cited this home for F0689 2 times since 2024.
CMS update of July 30, 2025
Star rating
The CMS overall star rating changed from 1 of 5 to 2 of 5. CMS changed how it scores this rating for many homes at once.
Star rating
The CMS health inspection star rating changed from 1 of 5 to 2 of 5. CMS changed how it scores this rating for many homes at once.
Health citation
CMS removed citation F0624 from the health inspection on January 17, 2025.
Health inspection on June 6, 2025
8 citationsCMS lists this as a standard inspection and a complaint inspection.
Show the 8 citations
Citation F0761. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
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.
CMS lists it as corrected on July 2, 2025.
Citation F0552. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that residents are fully informed and understand their health status, care and treatments.
CMS lists it as corrected on July 2, 2025.
Citation F0584. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on July 2, 2025.
CMS has cited this home for F0584 2 times since 2024.
Citation F0610. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Respond appropriately to all alleged violations.
CMS lists it as corrected on July 2, 2025.
CMS has cited this home for F0610 2 times since 2024.
Citation F0644. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
CMS lists it as corrected on July 2, 2025.
Citation F0685. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Assist a resident in gaining access to vision and hearing services.
CMS lists it as corrected on July 2, 2025.
CMS has cited this home for F0685 2 times since 2024.
Citation F0688. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on July 2, 2025.
CMS has cited this home for F0688 2 times since 2024.
Citation F0880. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on July 2, 2025.
Fire safety inspection on June 6, 2025
1 citationCMS lists this as a standard inspection.
Show the 1 citation
Citation K0918. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have generator or other power source capable of supplying service within 10 seconds.
CMS lists it as corrected on July 8, 2025.
CMS update of April 30, 2025
Star rating
The CMS quality measures star rating changed from 3 of 5 to 4 of 5.
CMS update of February 26, 2025
CMS abuse icon
CMS removed its abuse icon from this home.
Health inspection on January 17, 2025
3 citationsCMS lists this as a complaint inspection.
Show the 3 citations
Citation F0624. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Prepare residents for a safe transfer or discharge from the nursing home.
CMS lists it as corrected on February 28, 2025.
Citation F0684. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS lists it as corrected on February 28, 2025.
CMS has cited this home for F0684 3 times since 2023.
Citation F0804. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
CMS lists it as corrected on February 28, 2025.
CMS has cited this home for F0804 2 times since 2023.
CMS update of October 30, 2024
Star rating
The CMS quality measures star rating changed from 2 of 5 to 3 of 5.
CMS update of April 25, 2024
Star rating
The CMS overall star rating changed from 2 of 5 to 1 of 5.
Star rating
The CMS health inspection star rating changed from 2 of 5 to 1 of 5.
Star rating
The CMS staffing star rating changed from 3 of 5 to 4 of 5.
Star rating
The CMS quality measures star rating changed from 3 of 5 to 2 of 5.
CMS abuse icon
CMS added its abuse icon to this home.
CMS update of March 28, 2024
Star rating
The CMS overall star rating changed from 1 of 5 to 2 of 5.
Star rating
The CMS health inspection star rating changed from 1 of 5 to 2 of 5.
CMS update of February 29, 2024
CMS abuse icon
CMS removed its abuse icon from this home.
Health inspection on February 13, 2024
31 citationsCMS lists this as a standard inspection and a complaint inspection.
Severity G is the second-highest of CMS's four levels. It means a resident was harmed.
30 of 128 Oregon homes (23%) got a citation at the actual harm level in 2024.
CMS fine of $85,768 on February 13, 2024.
Show the 31 citations
Citation F0686. Severity G: actual harm, isolated.
The rule CMS cited:
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
CMS lists it as corrected on April 2, 2024.
Citation F0867. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
CMS lists it as corrected on April 2, 2024.
CMS has cited this home for F0867 2 times since 2023.
Citation F0684. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS lists it as corrected on April 2, 2024.
Citation F0725. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
CMS lists it as corrected on April 2, 2024.
CMS has cited this home for F0725 2 times since 2023.
Citation F0730. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Observe each nurse aide's job performance and give regular training.
CMS lists it as corrected on April 2, 2024.
Citation F0732. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Post nurse staffing information every day.
CMS lists it as corrected on April 2, 2024.
CMS has cited this home for F0732 2 times since 2023.
Citation F0947. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
CMS lists it as corrected on April 2, 2024.
Citation F0554. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Allow residents to self-administer drugs if determined clinically appropriate.
CMS lists it as corrected on April 2, 2024.
Citation F0578. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on April 2, 2024.
Citation F0584. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on April 2, 2024.
Citation F0602. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Protect each resident from the wrongful use of the resident's belongings or money.
CMS lists it as corrected on April 2, 2024.
Citation F0609. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
CMS lists it as corrected on April 2, 2024.
Citation F0610. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Respond appropriately to all alleged violations.
CMS lists it as corrected on April 2, 2024.
Citation F0636. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
CMS lists it as corrected on April 2, 2024.
Citation F0637. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Assess the resident when there is a significant change in condition
CMS lists it as corrected on April 2, 2024.
Citation F0641. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure each resident receives an accurate assessment.
CMS lists it as corrected on April 2, 2024.
Citation F0656. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
CMS lists it as corrected on April 2, 2024.
Citation F0657. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
CMS lists it as corrected on April 2, 2024.
CMS has cited this home for F0657 2 times since 2023.
Citation F0658. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure services provided by the nursing facility meet professional standards of quality.
CMS lists it as corrected on April 2, 2024.
Citation F0677. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide care and assistance to perform activities of daily living for any resident who is unable.
CMS lists it as corrected on April 2, 2024.
Citation F0685. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Assist a resident in gaining access to vision and hearing services.
CMS lists it as corrected on April 2, 2024.
Citation F0687. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate foot care.
CMS lists it as corrected on April 2, 2024.
Citation F0688. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on April 2, 2024.
Citation F0689. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on April 2, 2024.
Citation F0695. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide safe and appropriate respiratory care for a resident when needed.
CMS lists it as corrected on April 2, 2024.
Citation F0697. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide safe, appropriate pain management for a resident who requires such services.
CMS lists it as corrected on April 2, 2024.
Citation F0698. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide safe, appropriate dialysis care/services for a resident who requires such services.
CMS lists it as corrected on April 2, 2024.
Citation F0759. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure medication error rates are not 5 percent or greater.
CMS lists it as corrected on April 2, 2024.
CMS has cited this home for F0759 2 times since 2023.
Citation F0791. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide or obtain dental services for each resident.
CMS lists it as corrected on April 2, 2024.
Citation F0810. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide special eating equipment and utensils for residents who need them and appropriate assistance.
CMS lists it as corrected on April 2, 2024.
Citation F0825. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide or get specialized rehabilitative services as required for a resident.
CMS lists it as corrected on April 2, 2024.
Fire safety inspection on February 13, 2024
9 citationsCMS lists this as a standard inspection.
Show the 9 citations
Citation E0013. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Develop Emergency Preparedness policies and procedures.
CMS lists it as corrected on April 3, 2024.
Citation K0341. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Install a fire alarm system that can be heard throughout the facility.
CMS lists it as corrected on April 3, 2024.
Citation K0344. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have an alternate power supply for its alarm system.
CMS lists it as corrected on April 3, 2024.
Citation K0353. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Inspect, test, and maintain automatic sprinkler systems.
CMS lists it as corrected on April 3, 2024.
Citation K0511. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have properly installed electrical wiring and gas equipment.
CMS lists it as corrected on April 3, 2024.
Citation K0712. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have simulated fire drills held at unexpected times.
CMS lists it as corrected on April 3, 2024.
CMS has cited this home for K0712 2 times since 2023.
Citation K0761. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
CMS lists it as corrected on April 3, 2024.
CMS has cited this home for K0761 2 times since 2023.
Citation K0911. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Meet requirements for the installation and maintenance of electrical systems.
CMS lists it as corrected on April 3, 2024.
Citation K0920. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure proper usage of power strips and extension cords.
CMS lists it as corrected on April 3, 2024.
CMS update of January 31, 2024
Star rating
The CMS staffing star rating changed from 4 of 5 to 3 of 5.
Health inspection on January 13, 2023
18 citationsCMS lists this as a standard inspection.
Severity G is the second-highest of CMS's four levels. It means a resident was harmed.
29 of 128 Oregon homes (23%) got a citation at the actual harm level in 2023.
Show the 18 citations
Citation F0684. Severity G: actual harm, isolated.
The rule CMS cited:
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS lists it as corrected on February 22, 2023.
Citation F0725. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
CMS lists it as corrected on February 22, 2023.
Citation F0802. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
CMS lists it as corrected on February 22, 2023.
Citation F0804. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
CMS lists it as corrected on February 22, 2023.
Citation F0812. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS lists it as corrected on February 22, 2023.
Citation F0867. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
CMS lists it as corrected on February 22, 2023.
Citation F0565. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Honor the resident's right to organize and participate in resident/family groups in the facility.
CMS lists it as corrected on February 22, 2023.
Citation F0679. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide activities to meet all resident's needs.
CMS lists it as corrected on February 22, 2023.
Citation F0680. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure the activities program is directed by a qualified professional.
CMS lists it as corrected on February 22, 2023.
Citation F0732. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Post nurse staffing information every day.
CMS lists it as corrected on February 22, 2023.
Citation F0813. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
CMS lists it as corrected on February 22, 2023.
Citation F0558. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Reasonably accommodate the needs and preferences of each resident.
CMS lists it as corrected on February 22, 2023.
Citation F0561. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
CMS lists it as corrected on February 22, 2023.
Citation F0657. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
CMS lists it as corrected on February 22, 2023.
Citation F0744. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
CMS lists it as corrected on February 22, 2023.
Citation F0757. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure each resident’s drug regimen must be free from unnecessary drugs.
CMS lists it as corrected on February 22, 2023.
Citation F0759. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure medication error rates are not 5 percent or greater.
CMS lists it as corrected on February 22, 2023.
Citation F0806. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
CMS lists it as corrected on February 22, 2023.
Fire safety inspection on January 13, 2023
4 citationsCMS lists this as a standard inspection.
Show the 4 citations
Citation K0712. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have simulated fire drills held at unexpected times.
CMS lists it as corrected on February 22, 2023.
Citation K0211. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Keep aisles, corridors, and exits free of obstruction in case of emergency.
CMS lists it as corrected on February 22, 2023.
Citation K0324. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide properly protected cooking facilities.
CMS lists it as corrected on February 22, 2023.
Citation K0761. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
CMS lists it as corrected on February 22, 2023.
CMS star ratings
- 2 of 5CMS overall star rating
- 2 of 5CMS health inspection star rating
- 4 of 5CMS staffing star rating
- 4 of 5CMS quality measures star rating
Facts from CMS
- Phone
- (503) 656-0367
- Last standard health inspection
- June 6, 2025 (1 year ago)
- Certified beds
- 111
- Residents per day, on average
- 60
- Ownership type
- For profit - Limited Liability company
- Legal business name
- Legal Business Name Not Available
- Chain
- Avamere
- Takes part in
- Medicare and Medicaid
More health citations than the Oregon average (61 vs 34).
Questions
When was Avamere Rehabilitation of Oregon City last inspected?
CMS lists June 6, 2025 as the date of its most recent standard health inspection.
How many citations (violations) does Avamere Rehabilitation of Oregon City have?
CMS lists 61 health citations since January 13, 2023. CMS also calls these deficiencies.
Has Avamere Rehabilitation of Oregon City been fined?
CMS lists 1 fine in the past three years, $85,768 in total.
What is the CMS star rating of Avamere Rehabilitation of Oregon City?
Its CMS overall star rating is 2 of 5.
Is Avamere Rehabilitation of Oregon City a Special Focus Facility?
No. CMS does not list it as a Special Focus Facility or a candidate.