Compiled from official CMS federal data
AVAMERE REHABILITATION OF OREGON CITY, OREGON CITY, OR — Violations & Inspection Reports
Does AVAMERE REHABILITATION OF OREGON CITY have a federal violation or abuse history?
According to the public federal record on file with the Centers for Medicare & Medicaid Services (CMS), AVAMERE REHABILITATION OF OREGON CITY (CCN 385125), in OREGON CITY, OR, has federal inspection findings.
In its current inspection cycle, CMS cited the facility for 9 deficiencies; the most severe is rated G, a level CMS classifies as actual harm. The latest standard health inspection on file is dated 2025-06-06. Earlier-cycle citations appear in the dated timeline below as historical, not current. CMS has $85,768 in civil money penalties on file against the facility. The record also includes 4 abuse- or neglect-related citations in CMS's "Freedom from Abuse, Neglect, and Exploitation" family (F600-series; most recent Jun 2025). This page restates the federal record and draws no conclusion of its own.
Abuse-, fall-, and care-related findings on the federal record
- 4 citations in CMS's "Freedom from Abuse, Neglect, and Exploitation" family (F600-series) — most recent Jun 2025.
- 2 citations for accident hazards or inadequate supervision (F689) — the deficiency family behind fall-related findings; most recent Aug 2025.
- 1 pressure-ulcer care citation (F686) — the consumer term is "bedsores"; most recent Feb 2024.
- 35 findings on file from complaint-triggered inspections.
Every figure above restates CMS’s own dated record; this page draws no conclusion of its own. Strict state filing deadlines can apply to nursing-home injury claims — a licensed attorney in your state can review this record.
FOR FAMILIES
What brings you to this record?
The Federal Record
Federal abuse- or neglect-related citations on record (F600-series).
Below is this facility's federal inspection record as on file with CMS.
Scope & Severity — current cycle
CMS's own A–L scope/severity grid. Plotted cells mark this facility's most recent (current-cycle) citations.
Civil money penalties on file
$85,768
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About this record: Federal nursing-home surveys are conducted on a recurring cycle by state survey agencies acting on CMS's behalf, and the figures on this page are compiled from CMS's published provider data, as on file with CMS; the federal record may understate what actually occurred, and inspection findings are point-in-time survey results, not a determination that any specific resident was harmed.
Deficiency timeline
Citations are listed by scope/severity (most severe first), not chronologically; each entry is labeled current-cycle or historical.
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
57 more citations on file — Abuse & neglect 4 · Accidents & supervision 1 · Medication & pharmacy 4 · Resident rights 7 · Other citations 40 (expand)
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.
Provide and implement an infection prevention and control program.
Respond appropriately to all alleged violations.
Ensure that residents are fully informed and understand their health status, care and treatments.
Assist a resident in gaining access to vision and hearing services.
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
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.
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.
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Prepare residents for a safe transfer or discharge from the nursing home.
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Post nurse staffing information every day.
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Observe each nurse aide's job performance and give regular training.
Provide safe, appropriate pain management for a resident who requires such services.
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Provide special eating equipment and utensils for residents who need them and appropriate assistance.
Allow residents to self-administer drugs if determined clinically appropriate.
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.
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.
Protect each resident from the wrongful use of the resident's belongings or money.
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Respond appropriately to all alleged violations.
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Assess the resident when there is a significant change in condition
Ensure each resident receives an accurate assessment.
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Ensure services provided by the nursing facility meet professional standards of quality.
Provide care and assistance to perform activities of daily living for any resident who is unable.
Assist a resident in gaining access to vision and hearing services.
Provide appropriate foot care.
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.
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Provide safe and appropriate respiratory care for a resident when needed.
Ensure medication error rates are not 5 percent or greater.
Provide or obtain dental services for each resident.
Provide or get specialized rehabilitative services as required for a resident.
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Post nurse staffing information every day.
Honor the resident's right to organize and participate in resident/family groups in the facility.
Provide activities to meet all resident's needs.
Ensure the activities program is directed by a qualified professional.
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Ensure medication error rates are not 5 percent or greater.
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Overall CMS star rating
This facility: 2 · CMS state average: 3.1
Both figures as published by CMS.
You may be reading this record for the first time.
If something happened to someone you love at this facility, this federal record may be new to you today. The company that operates a nursing home, by contrast, is rarely seeing records like this for the first time — operators like these typically retain standing legal, risk, and insurance teams whose routine work includes records exactly like the one on this page. That is not a judgment of this facility; it is how the business is structured. Because strict time limits can apply, families often find it helps to have a qualified person review the record with them sooner rather than later.
Your federal record — tap to preview
Federal record
AVAMERE REHABILITATION OF OREGON CITY — Federal Record
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SECTION 7 — CASE CONTEXT
Add what you saw at AVAMERE REHABILITATION OF OREGON CITY to this record
No call centers, no auctions. CareSentinel is an independent service that compiles the public CMS record and does not provide legal advice. The federal record is a point-in-time inspection record and may understate what actually occurred. CareSentinel is operated by Nodal Logics LLC.
Strict time limits can apply to taking legal action — consider consulting a qualified attorney promptly.
If you believe a resident is in immediate danger, call 911. Care concerns can also be reported at no cost to your state survey agency or the Long-Term Care Ombudsman program (ltcombudsman.org) — independent of any legal inquiry.
How to read this record
Making sense of a CMS inspection record
CMS scores every citation on a grid from A to L, combining how widespread a finding was with how serious it was. A–C is a deficiency CMS classifies as no harm; D–F as the potential for harm; G–I as actual harm that reached a resident; and J–L as immediate jeopardy, CMS’s most serious level. Later letters mark more serious findings.
Three questions to ask on a tour
- How is the home staffed on nights, weekends, and holidays?
- What happens when a resident’s condition changes suddenly?
- How, and how quickly, are families told about an incident?