The nursing home failed to keep the area free of hazards and provide enough supervision to prevent accidents. Cited August 2025 — isolated incident, actual harm.
View the original federal record
F-Tag 689 — 42 CFR §483.25(d) — S/S: G
Nursing home report
AVAMERE REHABILITATION OF OREGON CITY
OREGON CITY, OR · Medicare-certified · 111 beds
In good standing
For-profitChain member
2 of 5 overall
2 out of 5 stars overall. Health inspection is also 2 stars, while staffing and quality measures are 4 stars; reported nurse staffing is 5.19 hours per resident per day versus the 4.1-hour federal benchmark, and there were no fines in the last 24 months.
Facility ratings
Health inspections
Staffing
5.1946 hrs/resident/day
Quality measures
Last inspection: August 29, 2025Penalties, last 24 months: $0
Federal guidance recommends at least 4.1 nursing hours per resident each day. This facility reports 5.1946.
Staffing detail
- Registered nurses
- 0.46
- Licensed practical nurses
- 0.89
- Nurse aides
- 3.84
- Weekend nursing
- 4.66
Hours per resident per day.
Total staff turnover: 44%
Registered nurse turnover: 43%
Resident outcomes
How often residents experience these outcomes, with the direction over the past year.
Long-stay residents on antipsychotic medication
12.4%Worsening
Residents with a fall causing major injury
2.9%Worsening
Residents with pressure ulcers (bedsores)
8%Improving
Residents with a urinary tract infection
0.6%Worsening
Residents who lost too much weight
0.6%Steady
Residents who were physically restrained
0%Steady
Residents needing more help with daily activities
6.7%Worsening
Residents whose ability to walk got worse
20.5%Steady
Show all measures
Long-stay residents on antianxiety or sleep medication
17.5%Improving
Short-stay residents newly given an antipsychotic
0.5%Steady
Residents with a long-term catheter
0.4%Steady
Residents with new or worsening incontinence
9.5%Worsening
Residents with depressive symptoms
3.3%Worsening
Long-stay residents given the seasonal flu vaccine
100%Steady
Long-stay residents given the pneumonia vaccine
96.6%Worsening
Short-stay residents given the seasonal flu vaccine
91.9%Steady
Short-stay residents given the pneumonia vaccine
95.7%Worsening
What the inspectors found
The nursing home failed to provide proper pressure ulcer care and failed to prevent new pressure sores from developing. Cited February 2024 — isolated incident, actual harm.
View the original federal record
F-Tag 686 — 42 CFR §483.25(b) — S/S: G
The nursing home failed to provide appropriate treatment and care according to residents' orders, preferences, and goals. Cited January 2023 — isolated incident, actual harm.
View the original federal record
F-Tag 684 — 42 CFR §483.25 — S/S: G
The home failed to have an ongoing quality review group that finds problems and makes corrective plans. Cited February 2024 — widespread issue, potential for harm.
View the original federal record
F-Tag 867 — 42 CFR §483.75 — S/S: F
The home failed to make food and drinks appealing and served them at a safe, appetizing temperature. Cited January 2023 — widespread issue, potential for harm.
View the original federal record
F-Tag 804 — 42 CFR §483.60 — S/S: F
Recent history
- STAFFING
Reported nurse staffing met or exceeded the federal recommendation.
- INSPECTION
Health inspection found 1 health deficiency.
See what inspectors found
- INSPECTION
Health inspection found 8 health deficiencies.
See what inspectors found
- INSPECTION
Health inspection found 3 health deficiencies.
See what inspectors found
Penalties & enforcement
On record with Medicare: 1 fine · $85,768 in total fines.
- $85,768
Federal fine
Feb 13, 2024
Operator & ownership
- Ownership
- For profit - Limited Liability company
- Chain
- Part of AVAMERE · 29 homes · 3.1 stars avg
- Occupancy
- 62.5 residents on an average day (56% of 111 beds)
- Resident voice
- Resident & family councils
- Medicare history
- Certified for 51 years
Things at a nursing home change — inspections, staffing, ownership, news.
Source: Centers for Medicare & Medicaid Services — public records, updated monthly. GoodStanding presents official records with plain-language summaries. Always visit a facility in person.