Avamere Rehabilitation of Oregon City
1400 Division Street, Oregon City, OR 97045 · Clackamas County · (503) 656-0367
111 certified beds, about 62 residents a day · For profit - Limited Liability company · Medicare and Medicaid since 1975
Certified for Medicaid Certified for Medicare
Overall
2 of 5
Health inspections
2 of 5
Staffing
4 of 5
Quality measures
3 of 5
CMS Care Compare ratings, data as of September 1, 2026 · CCN 385125 · See it on Medicare.gov · Compare with other homes
The record in brief
At its most recent standard inspection, on June 6, 2025, inspectors cited 8 health deficiencies (the Oregon average is 9.2, the national average 9.2).
Of 61 health citations since January 2023, 3 were rated as actual harm or immediate jeopardy to residents.
CMS lists 1 fine totaling $85,768 in the last three years; the largest was $85,768, and the latest is dated February 13, 2024.
Nurses and nurse aides worked 5.26 hours per resident per day, against 5.03 across Oregon and 3.86 nationally. Registered nurses accounted for 0.47 of those hours.
52.6% of nursing staff left within the year CMS measured (Oregon average 47.4%).
CMS links it to Avamere, an affiliated group of 27 nursing homes.
Health inspections
Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.
Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.
1801/23
3102/24
301/25
806/25
108/25
Potential for minimal harm Potential for more than minimal harm Actual harm Immediate jeopardy Found on a complaint visit
Where its citations fall on CMS's grid
CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 61 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
3G
0H
0I
Potential for more than minimal harm
41D
11E
6F
Potential for minimal harm
0A
0B
0C
August 29, 2025Complaint inspection · 1 citation
- G Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on interview and record review it was determined the facility failed to provide adequate supervision and assistance to prevent a fall with injury for 1 of 2 sampled residents (#8) reviewed for falls. As a result, Resident 8 sustained a fractured arm.
June 6, 2025Standard inspection, Complaint inspection · 8 citations
- 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.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure biologicals were stored securely for 1 of 3 sampled medication carts reviewed for medication storage. This placed residents at risk for unauthorized access to drugs and biologicals.
- D Ensure that residents are fully informed and understand their health status, care and treatments.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure residents were informed of the risks and benefits of psychotropic medications for 1 of 5 sampled residents (#14) reviewed for unnecessary medications. This placed residents at risk for being uninformed about their medications.
- 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.
Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to provide a homelike environment for 1 of 4 sampled residents (#15) reviewed for environment. This placed residents at risk for lessened quality of life.
- D Respond appropriately to all alleged violations.
Inspectors wroteBased on interview and record review it was determined the facility failed to thoroughly investigate allegations of mental abuse for 1 of 2 sampled residents (#2) reviewed for abuse. This placed residents at risk for abuse.
- D Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure a PASARR Level II (Preadmission Screening and Resident Review for individuals with a mental disorder and individuals with intellectual disability/developmental disability) was completed for 1 of 1 sampled resident (#30) reviewed for PASARR Level II. This placed residents at risk for not receiving specialized services.
- D Assist a resident in gaining access to vision and hearing services.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure hearing aids fit properly and worked for 1 of 1 sampled resident (#45) reviewed for communication. This placed residents at risk for decreased quality of life.
- 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.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to offer restorative services to increase range of motion for 1 of 1 sampled resident (#4) reviewed for rehabilitation and restorative. This placed resident at risk for decrease in range of motion.
- D Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure staff followed transmission-based precautions for 1 of 5 sampled residents (#260) reviewed for infection control. This placed residents at risk for exposure and contraction of infectious diseases.
January 17, 2025Complaint inspection · 3 citations
- D Prepare residents for a safe transfer or discharge from the nursing home.
Inspectors wroteBased on interview and record review it was determined the facility failed properly orientate and sufficiently prepare a resident for a facility-initiated discharged for 1 of 3 sampled residents (#11) reviewed for safe discharge. This placed residents at risk for unsafe, facility-initiated discharges.
- D Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on interview and record review it was determined the facility failed to follow physician's orders for 1 of 3 sampled residents (#2) reviewed for diabetic medication management. This placed residents at risk for complications from diabetes.
- D Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to provide palatable food for 4 of 5 sampled residents (#s 3, 9, 12 and 13) reviewed for dietary services. This placed residents at risk for unmet nutritional needs.
February 13, 2024Standard inspection, Complaint inspection · 31 citations
- G Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on interview, and record review it was determined the facility failed to provide the necessary care to prevent pressure ulcers, and accurately assess and provide timely treatment and repositioning to promote healing of pressure ulcers for 2 of 2 sampled residents (#s 2 and 46) reviewed for pressure ulcers. Resident 2 developed a preventable Stage 3 pressure ulcer.
- F Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Inspectors wroteBased on interview and record review it was determined the facility's quality assessment and assurance committee (QAA) failed to implement and oversee appropriate plans of action to correct identified deficiencies related to: investigation of abuse, sufficient staffing, inaccurate daily staff postings, medication error rate and reference checks. This placed residents at risk for lack of quality of life and quality of care.
- E Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on interview and record review it was determined the facility failed to follow physician orders for 4 of 5 sampled resident (#s 26, 34, 52 and 259) reviewed medications. This placed residents at risk for side effects and of lack medication efficacy.
- E Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Inspectors wroteBased on observation, interview, and record review the facility failed to provide sufficient nursing staff to ensure residents attained or maintained their highest practicable mental, physical, and psychosocial well-being for 12 of 14 sampled residents (#s 2, 8, 15, 19, 23, 26, 28, 33, 34, 42, 46, and 157) and 3 of 3 halls reviewed for call light wait times and staffing. This placed residents at risk for delayed care.
- E Observe each nurse aide's job performance and give regular training.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure CNAs received annual performance reviews for 4 of 5 randomly selected CNA staff (#s 19, 21, 22 and 23) reviewed for staffing. This placed residents at risk for lessened quality of care.
- E Post nurse staffing information every day.
Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to ensure the Direct Care Daily Staff Reports (DCSDR) were accurate for 79 of 188 days reviewed for staffing. This placed residents and the public at risk for lack of knowledge of accurate staffing.
- E Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Inspectors wroteBased on interview and record review it was determined the facility failed to have a system in place to ensure CNA staff received 12 hours of in-service training annually for 3 of 5 randomly selected staff members (#s 21, 22, and 23) reviewed for in-service training. This placed residents at risk for lack of competent staff.
- D Allow residents to self-administer drugs if determined clinically appropriate.
Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to assess a resident's ability to self-administer medications for 1 of 1 sampled resident (#33) reviewed for self-administration of medications. This placed residents at risk for adverse side effects.
- 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.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure residents received written information in a manner they understand for 1 of 1 sampled residents (#24) and failed to follow-up regarding advance directives for 2 of 5 sampled residents (#s 15 and 42) reviewed for advance directives. This placed residents at risk for not having their health wishes honored.
- 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.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to maintain adequate room temperatures for 1 of 1 resident (#156) reviewed comfortable environments. This placed residents at risk for uncomfortable environments.
- D Protect each resident from the wrongful use of the resident's belongings or money.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure resident drug records including narcotics were accurate for 1 of 1 sampled resident (#259) reviewed for medications. This placed residents at risk for inaccurate clinical records related to narcotics and drug diversion.
- D Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on interview and record review it was determined the facility failed to timely report an allegation of abuse and injury of unknown origin to the State Survey Agency for 2 of 4 sampled residents (#s 42 and 46) reviewed for abuse and accidents. This placed residents at risk for abuse and neglect.
- D Respond appropriately to all alleged violations.
Inspectors wroteBased on interview and record review it was determined the facility failed to investigate an allegation of abuse and injury of unknown origin for 2 of 4 sampled residents (#s 42 and 46) reviewed for abuse and accidents. This placed residents at risk for abuse and injuries.
- D Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Inspectors wroteBased on interview and record review it was determined the facility failed to provide ongoing assessments of a skin condition for 1 of 1 sampled resident (#33) reviewed for skin conditions. This placed residents at risk for worsening skin conditions.
- D Assess the resident when there is a significant change in condition
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure a significant change of condition assessment was completed for 1 of 3 sampled residents (#46) reviewed for accidents. This placed residents at risk for unmet care needs.
- D Ensure each resident receives an accurate assessment.
Inspectors wroteBased on interview and record review it was determined the facility failed to accurately code MDS assessments for 2 of 3 sampled residents (#s 2 and 33) reviewed for dental and pressure ulcers. This placed residents at risk for inaccurate assessments.
- D Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Inspectors wroteBased on interview, and record review it was determined the facility failed to develop comprehensive care plans for 2 of 3 sampled residents (#s 17, and 33) reviewed for dialysis and dental. This placed residents at risk for lack of ADL care needs.
- D Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to revise care plans and conduct person-centered care conferences for 2 of 5 sampled residents (#s 15 and 42) reviewed for care planning and care conferences. This placed residents at risk for unmet needs.
- D Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on observation, interview and record review it was determined facility staff failed to meet professional standards for medication administration for 2 of 2 unsampled residents (#s 13 and 37) and 1 of 1 sampled resident (#17) observed during medication administration. This placed residents at risk for adverse medication reactions.
- D Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to provide showers to maintain appropriate hygiene for 2 of 7 sampled residents (#s 8 and 34) reviewed for ADLs. This placed residents at risk for lack of showers and grooming.
- D Assist a resident in gaining access to vision and hearing services.
Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to ensure treatment and services to maintain vision abilities were provided for 1 of 1 sampled resident (#1) reviewed for vision. This placed residents at risk for impaired vision.
- D Provide appropriate foot care.
Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to provide appropriate foot care for 2 of 2 sampled residents (#19 and 34) reviewed for foot care. This placed residents at risk for lack of nail care, pain, and increased infections.
- 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.
Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to provide a restorative program to prevent further decline in range of motion as ordered for 1 of 1 sampled resident (#3) reviewed for ROM. This placed residents at risk for decline in their range of motion abilities.
- D Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure staff followed the care plan related to fall safety for 1 of 2 sampled residents (#46) reviewed for accidents. This placed residents at risk for injury.
- D Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to follow physician orders related to oxygen and BiPAP (breathing support through a face mask) administration for 1 of 1 sampled resident (#33) reviewed for respiratory care. This placed residents at risk for difficulty breathing.
- D Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to provide appropriate and timely pain management for 1 of 4 sampled residents (#156) reviewed for pain. This placed residents at risk for experiencing pain.
- D Provide safe, appropriate dialysis care/services for a resident who requires such services.
Inspectors wroteBased on observation, interview, and record review the facility failed to ensure ongoing communication with the dialysis center for 1 of 1 sampled resident (#17) reviewed for dialysis. This placed residents at risk for dialysis complications.
- D Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to maintain a medication error rate of less than 5%. There were 3 errors in 26 opportunities resulting in an 11.54% error rate. This placed residents at risk for adverse medication side effects.
- D Provide or obtain dental services for each resident.
Inspectors wroteBased on interview and record review it was determined the facility failed to provide timely dental services to meet resident needs for 1 of 1 sampled resident (#33) reviewed for dental. This placed residents at increased risk for decline in oral health.
- D Provide special eating equipment and utensils for residents who need them and appropriate assistance.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure residents received adaptive utensils for 1 of 7 sampled resident (#16) reviewed for ADLs. This placed residents at risk for unmet care needs and weight loss.
- D Provide or get specialized rehabilitative services as required for a resident.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to provide physical and occupational therapy services as ordered for 2 of 2 sampled residents (#s 8 and 49) reviewed for rehabilitation services. This placed residents at risk for a decline in functional abilities and diminished quality of life.
January 13, 2023Standard inspection · 18 citations
- G Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wrote1. Based on interview and record review it was determined the facility failed to follow physician's orders for a timely post-operative follow-up appointment for 1 of 1 sampled residents (#98) reviewed for quality of care. This delay resulted in Resident 98 being sent from the physician's clinic, directly to the hospital for surgery.
- F Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to provide sufficient nursing staff to attain and maintain the highest practicable wellbeing for 3 of 3 halls (100, 200 and 300 halls) reviewed for staffing. This placed residents at risk for lack of timely assistance for ADL care needs.
- F Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
Inspectors wroteBased on observation and interview it was determined the facility failed to provide sufficient support personnel to effectively carry out the functions of the food and nutrition service for 1 of 1 kitchen reviewed. This placed residents at risk for delayed meals and cold food.
- F Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure proper flavor, food textures and food temperatures were maintained for food trays served from 1 of 1 facility kitchens reviewed for food service. This placed residents at risk for food that was not palatable, safe or appetizing.
- F Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure kitchen equipment was clean, food was stored and labeled according to appropriate food handling guidelines, and all kitchen staff wore hairnets while working in for 1 of 1 kitchen reviewed. This placed residents at risk for cross-contamination and foodborne illness.
- F Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Inspectors wroteBased on interview and record review it was determined the facility's quality assessment and assurance committee (QAA) failed to implement and oversee appropriate plans of action to correct identified deficiencies related to: To bowel care, sufficient staffing, food procurement, sufficient staffing and CNA staffing ratios. This placed residents at risk for unmet needs.
- E Honor the resident's right to organize and participate in resident/family groups in the facility.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure resident council requests or grievances were followed up on for 1 of 1 Resident Council reviewed for grievances. This placed residents at risk for unaddressed needs.
- E Provide activities to meet all resident's needs.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to provide an ongoing activities program designed to meet the individual interests and needs of residents for 4 of 5 sampled residents (#s 4, 13, 16, and 25) reviewed for activities. This placed residents at risk for diminished physical, emotional and psychosocial well-being.
- E Ensure the activities program is directed by a qualified professional.
Inspectors wroteBased on interview and record review it was determined the facility failed to provide a qualified professional to direct the activities program for the facility. This placed residents at risk for unmet physical, mental and psychosocial needs.
- E Post nurse staffing information every day.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure the daily staff posting was accurate for 18 out of 31 days reviewed for staffing. This placed residents, public and staff at risk for lack of accurate staffing information.
- E Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to develop a policy that identified staff responsible for monitoring the use and storage of food in resident personal refrigerators for 4 of 4 sampled residents (#s 1, 3, 4 and 12). This placed residents at risk for cross-contamination and foodborne illness.
- D Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure a resident received a recliner chair for 1 of 2 sampled residents (#26) reviewed for accommodation of needs.
- D Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Inspectors wroteBased on observation and interview the facility failed to assist a resident with transportation to a medical appointment for 1 of 1 sampled residents (#98) reviewed for medical transportation. This placed residents at risk of not attending scheduled medical appointments.
- D Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to update the care plan for feeding assistance for 1 of 5 sampled residents (#25) reviewed for food. This placed residents at risk for unmet needs and aspiration.
- D Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to consistently document behaviors and update and implement care plan interventions to ensure residents with dementia maintained their highest practicable level of well-being for 2 of 4 sampled residents (#s 16 and 25) reviewed for dementia. This placed residents at risk for a lack of psychosocial well-being and increased behaviors.
- D Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on observation and interview it was determined the facility failed to not administer a blood pressure medication according to physician ordered parameters for 1 of 5 sampled residents (#15) reviewed for unnecessary medications. This placed residents at risk for low blood pressure.
- D Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure a medication error rate of less than five percent for 1 of 4 sampled residents (#15) reviewed for medication administration. The facility had 12 errors out of 25 opportunities for an error rate of 48 percent. This placed residents at risk for adverse medication consequences.
- D Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to accommodate resident food preferences for 1 of 5 sampled residents (#25) reviewed for food. This placed residents at risk for weight loss.
Fire safety inspections
14 fire safety citations on file: 1 on June 6, 2025, 9 on February 13, 2024, 4 on January 13, 2023.
Every fire safety citation14 citations
- F Have generator or other power source capable of supplying service within 10 seconds.
- F Develop Emergency Preparedness policies and procedures.
- 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.
- F Have properly installed electrical wiring and gas equipment.
- F Have simulated fire drills held at unexpected times.
- F To conduct inspection, testing and maintenance of fire doors by qualified individuals.
- D Meet requirements for the installation and maintenance of electrical systems.
- D Ensure proper usage of power strips and extension cords.
- F Have simulated fire drills held at unexpected times.
- D Keep aisles, corridors, and exits free of obstruction in case of emergency.
- D Provide properly protected cooking facilities.
- D To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Fines and payment denials
| Date | Penalty | Amount or length |
|---|---|---|
| February 13, 2024 | Fine | $85,768 |
A payment denial means Medicare and Medicaid stopped paying for new admissions for that period.
Staffing
Hours of care per resident per day, from the payroll records every home sends CMS. Higher means more staff time with each resident.
| Measure | This home | Oregon | United States |
|---|---|---|---|
| All nursing staff (RN, LPN and aides) | 5.26 | 5.03 | 3.86 |
| Registered nurses | 0.47 | 0.72 | 0.69 |
| All nursing staff on weekends | 4.72 | 4.51 | 3.42 |
| Nurse aides | 3.85 | ||
| Licensed practical nurses | 0.95 | ||
| Nursing staff turnover (share who left in a year) | 52.6% | 47.4% | 45.8% |
| Registered nurse turnover | 70.0% | 51.6% | 42.9% |
| Administrators who left | 0 |
CMS expects 3.54 hours a day for residents as sick as this home's (its case-mix figure). The staffing star compares the two.
Staffing by quarter, from daily payroll records
Every nursing home sends CMS its staff hours for each day (the Payroll Based Journal). Here they are added up by quarter. The latest quarter is the one behind the figures above. In January to March 2026, nursing staff hours per resident were 5.48 on weekdays and 4.72 on weekends, 14% lower on weekends (nationally, weekends ran 15% lower). Contract or agency staff worked 3.2% of nursing hours, against 5.3% nationally. Total nursing hours per resident went from 5.27 in April to June 2025 to 5.26 in January to March 2026.
| Quarter | All nursing staff | Registered nurses | Weekdays | Weekends | Contract staff share | Days with no RN hours | Residents a day |
|---|---|---|---|---|---|---|---|
| Jan to Mar 2026 | 5.26 | 0.47 | 5.48 | 4.72 | 3.2% | 0 of 90 | 62 |
| Oct to Dec 2025 | 5.19 | 0.46 | 5.41 | 4.66 | 3.0% | 0 of 92 | 63 |
| Jul to Sep 2025 | 5.29 | 0.49 | 5.45 | 4.88 | 7.6% | 0 of 92 | 62 |
| Apr to Jun 2025 | 5.27 | 0.57 | 5.52 | 4.66 | 7.1% | 0 of 91 | 62 |
| United States, Jan to Mar 2026 | 3.75 | 0.62 | 3.92 | 3.33 | 5.3% | 0.5% of days | |
| Oregon, Jan to Mar 2026 | 4.91 | 0.64 | 5.12 | 4.40 | 6.2% | 0.4% of days |
Hours per resident per day: staff hours in the quarter divided by resident days (the daily census CMS derives from resident assessments). Registered nurses include the director of nursing and RNs with administrative duties; aides include nurse aides in training and medication aides, as in CMS's own staffing measure. How these are calculated.
Quality measures
The measures CMS uses for the quality star. Lower is better for every one of them.
| Measure | This home | Oregon | US |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased Long Stay residents, 2025Q2-2026Q1 | 12.2 | 14.9 | 13.9 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder Long Stay residents, 2025Q2-2026Q1 | 0.4 | 1.4 | 0.8 |
| Percentage of long-stay residents with a urinary tract infection Long Stay residents, 2025Q2-2026Q1 | 1.2 | 2.0 | 1.6 |
| Percentage of long-stay residents experiencing one or more falls with major injury Long Stay residents, 2025Q2-2026Q1 | 4.1 | 2.4 | 3.2 |
| Percentage of short-stay residents who newly received an antipsychotic medication Short Stay residents, 2025Q2-2026Q1 | 0.9 | 1.4 | 1.6 |
| Percentage of long-stay residents whose ability to walk independently worsened Long Stay residents, 2025Q2-2026Q1 | 18.0 | 20.6 | 14.1 |
| Percentage of long-stay residents with pressure ulcers Long Stay residents, 2025Q2-2026Q1 | 6.7 | 5.8 | 4.6 |
| Percentage of long-stay residents who received an antipsychotic medication Long Stay residents, 2025Q2-2026Q1 | 13.7 | 13.9 | 15.4 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission Short Stay residents, 20250101-20251231 | 24.6 | 21.4 | 23.8 |
| Percentage of short-stay residents who had an outpatient emergency department visit Short Stay residents, 20250101-20251231 | 11.8 | 16.1 | 12.0 |
Owners and operators
Legal business name: MOUNTAIN VIEW REHAB, LLC. CMS links this home to Avamere, a group of 27 nursing homes averaging 3 stars overall.
| Name | Role | Type | Share | Since |
|---|---|---|---|---|
| Ariso LLC | Direct ownership interest | Organization | 01/06/2006 | |
| Ari Operations, LLC | Indirect ownership interest | Organization | 01/06/2006 | |
| Avamere Group LLC | Indirect ownership interest | Organization | 01/06/2006 | |
| Karl Rickard Miller Jr Revocable Trust | Indirect ownership interest | Organization | 07/11/2011 | |
| Miller, Karl | Indirect ownership interest | Individual | 07/20/2001 | |
| Midcap Finco LLC | 5% or greater security interest | Organization | 06/25/2013 | |
| Cavallo, Glen | Managing control - governing body | Individual | 06/01/2025 | |
| Feakin, Cody | Managing control - governing body | Individual | 06/01/2025 | |
| Funderberg, Michelle | Managing control - governing body | Individual | 06/01/2025 | |
| Haskins, Damien | Managing control - governing body | Individual | 09/01/2025 | |
| Hill, Kevin | Managing control - governing body | Individual | 06/01/2025 | |
| Hoskins, Tonia | Managing control - governing body | Individual | 06/01/2025 | |
| Inskeep, Todd | Managing control - governing body | Individual | 06/01/2025 | |
| Kofstad, Mary | Managing control - governing body | Individual | 06/01/2025 | |
| Munro, Jolynn | Managing control - governing body | Individual | 06/01/2025 | |
| Okoli, Ike | Managing control - governing body | Individual | 06/01/2025 | |
| Polson, Justin | Managing control - governing body | Individual | 06/01/2025 | |
| Powelson, Michele | Managing control - governing body | Individual | 06/01/2025 | |
| Reid, Misty | Managing control - governing body | Individual | 06/01/2025 | |
| Sanders, Amanda | Managing control - governing body | Individual | 06/01/2025 | |
| Simpson, Andrew | Managing control - governing body | Individual | 06/01/2025 | |
| Strunk, Colby | Managing control - governing body | Individual | 06/01/2025 | |
| Vanderzanden, Carrie | Managing control - governing body | Individual | 06/01/2025 | |
| Avamere Health Services LLC | Operational/managerial control | Organization | 01/01/2005 | |
| Avamere Skilled Advisors LLC | Operational/managerial control | Organization | 01/01/2005 | |
| Midcap Finco LLC | Operational/managerial control | Organization | 06/25/2013 | |
| Angerhofer, Nicole | Operational/managerial control | Individual | 12/01/2023 | |
| Dana, Jennifer | Operational/managerial control | Individual | 05/01/2022 | |
| Doepker, Andrea | Operational/managerial control | Individual | 09/28/2023 | |
| Feakin, Cody | Operational/managerial control | Individual | 07/15/2025 | |
| Hoskins, Tonia | Operational/managerial control | Individual | 07/19/2024 | |
| James, Allen | Operational/managerial control | Individual | 07/08/2022 | |
| Kofstad, Mary | Operational/managerial control | Individual | 02/13/2024 | |
| Lee, Carie | Operational/managerial control | Individual | 05/01/2024 | |
| Munro, Jolynn | Operational/managerial control | Individual | 09/01/2023 | |
| Powelson, Michele | Operational/managerial control | Individual | 03/25/2015 | |
| Presley, Yolanda | Operational/managerial control | Individual | 01/06/2025 | |
| Reid, Misty | Operational/managerial control | Individual | 01/02/2025 | |
| Simpson, Andrew | Operational/managerial control | Individual | 06/01/2024 | |
| Vellody, Nita | Operational/managerial control | Individual | 08/01/2020 | |
| Kofstad, Mary | Individual is an owner, partner or trustee of any ADP of the SNF | Individual | 03/11/2026 | |
| Avamere Health Services LLC | Adp of the SNF | Organization | 07/10/2025 | |
| Avamere Skilled Advisors LLC | Adp of the SNF | Organization | 07/14/2025 | |
| Moss Adams LLP | Adp of the SNF | Organization | 01/01/2009 | |
| Angerhofer, Nicole | Adp of the SNF | Individual | 12/01/2023 | |
| Dana, Jennifer | Adp of the SNF | Individual | 05/01/2022 | |
| Davis, Julie | Adp of the SNF | Individual | 08/01/2024 | |
| Doepker, Andrea | Adp of the SNF | Individual | 09/08/2023 | |
| Feakin, Cody | Adp of the SNF | Individual | 01/01/2025 | |
| Funderberg, Michelle | Adp of the SNF | Individual | 12/31/2024 | |
| Games, Kim | Adp of the SNF | Individual | 08/15/2024 | |
| Hill, Kevin | Adp of the SNF | Individual | 03/12/2022 | |
| Inskeep, Todd | Adp of the SNF | Individual | 01/21/2022 | |
| James, Allen | Adp of the SNF | Individual | 07/10/2025 | |
| Kofstad, Mary | Adp of the SNF | Individual | 02/13/2024 | |
| Lee, Carie | Adp of the SNF | Individual | 05/01/2024 | |
| Munro, Jolynn | Adp of the SNF | Individual | 09/01/2023 | |
| Polson, Justin | Adp of the SNF | Individual | 02/10/2025 | |
| Powelson, Michele | Adp of the SNF | Individual | 03/25/2015 | |
| Presley, Yolanda | Adp of the SNF | Individual | 01/06/2025 | |
| Reid, Misty | Adp of the SNF | Individual | 01/02/2025 | |
| Simpson, Andrew | Adp of the SNF | Individual | 06/01/2024 | |
| Staples, Carolyn | Adp of the SNF | Individual | 10/05/2023 | |
| Strunk, Colby | Adp of the SNF | Individual | 09/06/2022 | |
| Vanderzanden, Carrie | Adp of the SNF | Individual | 01/01/2025 | |
| Vellody, Nita | Adp of the SNF | Individual | 08/01/2020 | |
| Yount, Mark | Adp of the SNF | Individual | 10/01/2019 |
As listed in the CMS ownership file, which names owners with a 5% or greater stake and the people and companies with operational or managerial control.
Questions to ask on a visit
Chosen from this home's own inspection record.
- How do you prevent falls and pressure injuries, and how are families told when one happens?Inspectors cited 20 problems in this area, most recently on August 29, 2025: "Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents."
- How do residents and families raise a complaint or grievance, and how fast is it answered?Inspectors cited 9 problems in this area, most recently on June 6, 2025: "Ensure that residents are fully informed and understand their health status, care and treatments."
- When is the care plan meeting, and can family attend it?Inspectors cited 8 problems in this area, most recently on June 6, 2025: "Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed."
- Can we see a week of menus and the kitchen, and how are special diets handled?Inspectors cited 7 problems in this area, most recently on January 17, 2025: "Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature."
Other nursing homes nearby
- Rivercrest Post Acute Oregon City, 1.2 mi · 2 of 5 stars · 35 citations
- Marquis Oregon City Post Acute Rehab Oregon City, 1.5 mi · 5 of 5 stars · 13 citations
- Avamere Rehabilitation of Clackamas Gladstone, 2 mi · 4 of 5 stars · 16 citations
- Rose Linn Care Center West Linn, 3.4 mi · 3 of 5 stars · 14 citations
- Stanley Post Acute Milwaukie, 5.7 mi · 3 of 5 stars · 32 citations
- Fernwood Supportive Living at Madrona Grove Portland, 5.7 mi · 4 of 5 stars · 19 citations
- Willamette View Health Center Milwaukie, 5.8 mi · 5 of 5 stars · 5 citations
- The Pearl at Kruse Way Lake Oswego, 7.7 mi · 4 of 5 stars · 22 citations
Oregon contacts for a concern about a nursing home
These are the official offices in Oregon. NursingHomeClear cannot take or act on complaints.
- Inspections and complaints: Oregon Department of Human Services, Nursing Facility Licensing, the state agency that inspects nursing homes for CMS and takes complaints about care.
- Resident advocate: Oregon Office of the Long-Term Care Ombudsman, (800) 522-2602. The long-term care ombudsman is a free, confidential advocate for residents and families, set up under the federal Older Americans Act.
- State inspection reports: Oregon Licensed Long-Term Care Settings Search, where Oregon publishes its own records on licensed homes.
Common questions
- What is Avamere Rehabilitation of Oregon City's Medicare star rating?
- CMS rates Avamere Rehabilitation of Oregon City 2 out of 5 stars overall, with 2 for health inspections, 4 for staffing and 3 for quality measures (CMS data as of September 1, 2026).
- How many deficiencies did Avamere Rehabilitation of Oregon City get at its last inspection?
- 8 health deficiencies at the standard inspection on June 6, 2025. The Oregon average is 9.2.
- Has Avamere Rehabilitation of Oregon City been fined?
- Yes. CMS lists 1 fine totaling $85,768 in the last three years.
- Does Avamere Rehabilitation of Oregon City accept Medicaid?
- It is certified to take Medicaid (CMS lists it as "Medicare and Medicaid"). Certification does not mean a Medicaid bed is open: ask the admissions office.
- Who owns Avamere Rehabilitation of Oregon City?
- CMS lists 67 owners and managers, and links the home to Avamere. Legal business name: MOUNTAIN VIEW REHAB, LLC.
Sources
- Ratings, staffing and fines: CMS Provider Information, released September 30, 2026, data as of September 1, 2026.
- Citations: CMS Health Deficiencies and Fire Safety Deficiencies.
- Owners: CMS Ownership. Penalties: CMS Penalties.
- Staffing by quarter: CMS Payroll Based Journal Daily Nurse Staffing, April 2025 to March 2026, summed by NursingHomeClear.
- Inspector summaries: CMS Full Statement of Deficiencies (CMS-2567 text), data as of September 1, 2026. Each quote is the part of the statement before the detailed findings.
- Inspection reports with the inspectors' full notes are on this home's Medicare.gov page.
- Something wrong on this page? Ask for a correction. We fix errors in our copy of the data; findings themselves can only be changed by CMS and the state.
- NursingHomeClear is independent and not affiliated with CMS, Medicare or any state agency. This page reports federal records; it does not rate, recommend or endorse any home, and it is not medical or legal advice.