Map showing the location of AVAMERE REHABILITATION OF OREGON CITY in OREGON CITY, Oregon
1400 DIVISION STREET, OREGON CITY, OR, 97045

Overall Score

CMS Five-Star Quality Rating
3/5AverageCMS Five-Star overall rating
  1. Much below average
  2. Below average
  3. Average
  4. Above average
  5. Much above average

Where it ranks

  • OregonAbove only 40% of peers127 rated homes · average 3.0★
  • Clackamas CountyAbove only 8% of peers13 rated homes · average 3.8★
  • United StatesAbove only 41% of peers14,574 rated homes · average 3.0★

How the rating is built

  • Health inspectionsStarting point2★−0.8 vs OR avg
  • StaffingCan add or remove a star4★+0.3 vs OR avg
  • Quality measuresCan add or remove a star5★+1.5 vs OR avg

CMS starts from the health inspection stars, then adds or subtracts a star for staffing and for quality measures. Stars are assigned relative to other facilities in the same state.

Ratings & measures

Tap a row to see what it means
Health inspection ratingCMS stars from the last three on-site inspection cycles2★Above only 18% of peersOR avg2.8★U.S. avg2.8★
What is health inspection rating?

Stars assigned from the last three standard surveys and every complaint investigation in that window, weighted toward the most recent and the most serious findings. CMS assigns these stars relative to other facilities in the same state.

Why it matters

It carries the most weight in the overall rating and is the only domain based on what trained inspectors saw on site rather than what the facility reported.

Staffing ratingCMS stars from payroll-reported hours and turnover4★Above only 31% of peersOR avg3.7★U.S. avg2.9★
What is staffing rating?

Nurse and aide hours per resident day from payroll records CMS collects every quarter, adjusted for how much care residents need, plus staff turnover and weekend coverage.

Why it matters

More hours and lower turnover are the strongest predictors of fewer falls, pressure sores, and avoidable hospital stays.

Quality measures ratingCMS stars from clinical outcomes and resident assessments5★Above 82% of peersOR avg3.5★U.S. avg3.6★
What is quality measures rating?

Clinical outcomes from resident assessments and Medicare claims: falls with injury, pressure ulcers, hospitalizations, antipsychotic use, and more, for both short-stay and long-stay residents.

Why it matters

It shows whether care is working, but part of it comes from the facility’s own assessments, so read it alongside the inspection results.

Total nurse hoursPer resident per day, all nursing staff5.29hrsAbove 76% of peersOR avg4.95Benchmark4.10
What is total nurse hours?

All licensed nurse and aide hours worked, divided by the number of residents, on an average day. Reported from payroll, not self-reported.

Why it matters

Federal research links 4.1 hours a day to fewer avoidable harms. Below about 3 hours, residents wait longer for help with basics like toileting and repositioning.

RN hoursPer resident per day, registered nurses only0.49hrsAbove only 29% of peersOR avg0.68Benchmark0.75
What is rn hours?

Registered nurse hours only. RNs assess residents, manage medications, and catch changes in condition; LPNs and aides deliver most hands-on care.

Why it matters

RN coverage is the staffing measure most tied to fewer hospital transfers and infections, and it is where thinly staffed facilities cut first.

Nursing staff turnoverShare of nursing staff who left within a year · lower is better37%Above 78% of peersOR avg49%RN turnover29%
What is nursing staff turnover?

The share of nursing staff who left within the past year, from the same payroll data.

Why it matters

High turnover means residents are cared for by people who do not know them, and it is one of the strongest predictors of inspection problems.

Fines in the last three yearsCivil money penalties imposed by CMS · lower is better$85,768Above only 11% of peersOR avg$32,647Fines · denials1 · 0
What is fines in the last three years?

Civil money penalties CMS imposed after serious or uncorrected deficiencies, and denials of Medicare payment for new admissions.

Why it matters

Penalties follow the worst inspection findings. A recent fine is the clearest sign that inspectors found real harm.

Inspection history

Last three inspection cycles
62citations
6inspection dates
3actual harm (G–I)
0immediate jeopardy (J–L)
Aug 29, 2025most recent

Citations by monthJan 2023 – Aug 2025

  • No actual harm (D–F)
  • Actual harm (G–I)
  • Immediate jeopardy (J–L)
  • $Fine or payment denial

Click a month or a year to filter the findings below. Arrow keys move between months; Esc clears.

Aug 29, 20251 citationCycle 1worst G · actual harm
  1. F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareG · isolatedCorrected Jun 26, 2025
Jun 6, 20258 citationsCycle 1worst E · no actual harm
  1. F761Ensure 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.Pharmacy ServiceE · patternCorrected Jul 2, 2025
  2. F880Provide and implement an infection prevention and control program.Infection ControlD · isolatedCorrected Jul 2, 2025
  3. F688Provide 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.Quality of Life and CareD · isolatedCorrected Jul 2, 2025
  4. F644Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.Resident Assessment and Care PlanningD · isolatedCorrected Jul 2, 2025
  5. F685Assist a resident in gaining access to vision and hearing services.Quality of Life and CareD · isolatedCorrected Jul 2, 2025
  6. F610Respond appropriately to all alleged violations.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Jul 2, 2025
  7. F552Ensure that residents are fully informed and understand their health status, care and treatments.Resident RightsD · isolatedCorrected Jul 2, 2025
  8. F584Honor 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.Resident RightsD · isolatedCorrected Jul 2, 2025
Jan 17, 20253 citationsCycle 2worst D · no actual harm
  1. F624Prepare residents for a safe transfer or discharge from the nursing home.Resident RightsD · isolatedCorrected Feb 28, 2025
  2. Provide appropriate treatment and care according to orders, resident’s preferences and goals.Quality of Life and CareD · isolatedCorrected Feb 28, 2025
  3. F804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.Nutrition and DietaryD · isolatedCorrected Feb 28, 2025
Feb 13, 202431 citationsCycle 2worst G · actual harm$85,768
  1. F725Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.Nursing and Physician ServicesE · patternCorrected Apr 2, 2024
  2. Provide appropriate treatment and care according to orders, resident’s preferences and goals.Quality of Life and CareE · patternCorrected Apr 2, 2024
  3. F695Provide safe and appropriate respiratory care for a resident when needed.Quality of Life and CareD · isolatedCorrected Apr 2, 2024
  4. F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Resident Assessment and Care PlanningD · isolatedCorrected Apr 2, 2024
  5. F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Resident Assessment and Care PlanningD · isolatedCorrected Apr 2, 2024
  6. F658Ensure services provided by the nursing facility meet professional standards of quality.Resident Assessment and Care PlanningD · isolatedCorrected Apr 2, 2024
  7. F677Provide care and assistance to perform activities of daily living for any resident who is unable.Quality of Life and CareD · isolatedCorrected Apr 2, 2024
  8. F685Assist a resident in gaining access to vision and hearing services.Quality of Life and CareD · isolatedCorrected Apr 2, 2024
  9. F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Quality of Life and CareG · isolatedCorrected Apr 2, 2024
  10. F687Provide appropriate foot care.Quality of Life and CareD · isolatedCorrected Apr 2, 2024
  11. F688Provide 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.Quality of Life and CareD · isolatedCorrected Apr 2, 2024
  12. F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareD · isolatedCorrected Apr 2, 2024
  13. F697Provide safe, appropriate pain management for a resident who requires such services.Quality of Life and CareD · isolatedCorrected Apr 2, 2024
  14. F698Provide safe, appropriate dialysis care/services for a resident who requires such services.Quality of Life and CareD · isolatedCorrected Apr 2, 2024
  15. F730Observe each nurse aide's job performance and give regular training.Nursing and Physician ServicesE · patternCorrected Apr 2, 2024
  16. F732Post nurse staffing information every day.Nursing and Physician ServicesE · patternCorrected Apr 2, 2024
  17. F759Ensure medication error rates are not 5 percent or greater.Pharmacy ServiceD · isolatedCorrected Apr 2, 2024
  18. F791Provide or obtain dental services for each resident.Quality of Life and CareD · isolatedCorrected Apr 2, 2024
  19. F810Provide special eating equipment and utensils for residents who need them and appropriate assistance.Nutrition and DietaryD · isolatedCorrected Apr 2, 2024
  20. F825Provide or get specialized rehabilitative services as required for a resident.Quality of Life and CareD · isolatedCorrected Apr 2, 2024
  21. F867Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.AdministrationF · widespreadCorrected Apr 2, 2024
  22. F947Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.Nursing and Physician ServicesE · patternCorrected Apr 2, 2024
  23. F636Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.Resident Assessment and Care PlanningD · isolatedCorrected Apr 2, 2024
  24. F554Allow residents to self-administer drugs if determined clinically appropriate.Resident RightsD · isolatedCorrected Apr 2, 2024
  25. F578Honor 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.Resident RightsD · isolatedCorrected Apr 2, 2024
  26. F584Honor 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.Resident RightsD · isolatedCorrected Apr 2, 2024
  27. F602Protect each resident from the wrongful use of the resident's belongings or money.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Apr 2, 2024
  28. F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Apr 2, 2024
  29. F610Respond appropriately to all alleged violations.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Apr 2, 2024
  30. F637Assess the resident when there is a significant change in conditionResident Assessment and Care PlanningD · isolatedCorrected Apr 2, 2024
  31. F641Ensure each resident receives an accurate assessment.Resident Assessment and Care PlanningD · isolatedCorrected Apr 2, 2024
Mar 27, 20231 citationCycle 3worst E · no actual harm
  1. F725Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.Nursing and Physician ServicesE · patternCorrected May 3, 2023
Jan 13, 202318 citationsCycle 3worst G · actual harm
  1. F558Reasonably accommodate the needs and preferences of each resident.Resident RightsD · isolatedCorrected Feb 22, 2023
  2. Ensure each resident’s drug regimen must be free from unnecessary drugs.Pharmacy ServiceD · isolatedCorrected Feb 22, 2023
  3. F679Provide activities to meet all resident's needs.Quality of Life and CareE · patternCorrected Feb 22, 2023
  4. F680Ensure the activities program is directed by a qualified professional.Quality of Life and CareE · patternCorrected Feb 22, 2023
  5. F725Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.Nursing and Physician ServicesF · widespreadCorrected Feb 22, 2023
  6. F732Post nurse staffing information every day.Nursing and Physician ServicesE · patternCorrected Feb 22, 2023
  7. Provide appropriate treatment and care according to orders, resident’s preferences and goals.Quality of Life and CareG · isolatedCorrected Feb 22, 2023
  8. F744Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.Quality of Life and CareD · isolatedCorrected Feb 22, 2023
  9. F759Ensure medication error rates are not 5 percent or greater.Pharmacy ServiceD · isolatedCorrected Feb 22, 2023
  10. F802Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.Nutrition and DietaryF · widespreadCorrected Feb 22, 2023
  11. F804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.Nutrition and DietaryF · widespreadCorrected Feb 22, 2023
  12. F806Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.Nutrition and DietaryD · isolatedCorrected Feb 22, 2023
  13. F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and DietaryF · widespreadCorrected Feb 22, 2023
  14. F813Have a policy regarding use and storage of foods brought to residents by family and other visitors.Nutrition and DietaryE · patternCorrected Feb 22, 2023
  15. F867Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.AdministrationF · widespreadCorrected Feb 22, 2023
  16. F565Honor the resident's right to organize and participate in resident/family groups in the facility.Resident RightsE · patternCorrected Feb 22, 2023
  17. F561Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.Resident RightsD · isolatedCorrected Feb 22, 2023
  18. F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Resident Assessment and Care PlanningD · isolatedCorrected Feb 22, 2023

Staffing

From quarterly payroll reports

Hours per resident per day

  • All nursing staffRNs, LPNs and aides combined5.29hrsAbove 76% of peers+0.34 vs OR avg
  • Registered nursesRN hours only0.49hrsAbove only 29% of peers−0.19 vs OR avg
  • Licensed practical nursesLPN hours0.86hrs
  • Nurse aidesCNA hours3.94hrs
  • Weekend nursingAll staff on Saturdays and Sundays4.88hrs
  • Oregon average
  • Research benchmark (4.10 total, 0.75 RN)

Turnover & capacity

  • Nursing staff turnoverShare who left within a year · lower is better37%Above 78% of peersOR avg 49%
  • RN turnoverRegistered nurses only29%Not ranked by CMS
  • Administrators who leftIn the past year0Stable leadership
  • Occupancy111 certified beds · ~62 residents a day56%Above only 25% of peersOR avg 69%

Fines & penalties

Roughly the past three years

Enforcement summary

  • $85,768In fines
  • 1Fine
  • 0Payment denials
  • $32,647OR avg in fines
Above only 11% of peersFewer fines than 11% of rated homes in Oregon

Actions on record

  1. Feb 13, 2024Civil money penalty$85,768

Ownership

As filed with CMS

Structure

Ownership type
For profit - Limited Liability company
Chain
Avamere33 facilities in the chain3.0★ chain average
Certification
Medicare and Medicaid
Location type
Urban
Ownership change
None in the last 12 months

People and entities on file

Direct owners (5%+)
  • Ariso LLC
Indirect owners (5%+)
  • Ari Operations, LLC
  • Avamere Group LLC
  • Richard Dillon
  • Matthew Hilty
  • Karl Miller
  • Ronald Odermott
Corporate directors
  • Jennifer Carlson
  • Karl Miller
Corporate officers
  • Richard Dillon
  • Matthew Hilty
  • Ronald Odermott
Managing employees
  • Jennifer Carlson

Person Organization

Sources & notes

Public data, updated quarterly

Data sources

  • CMS Care Compare · Provider InformationStar ratings, staffing hours, turnover, penalties and flags · processed February 2026.
  • CMS Health CitationsEvery deficiency from the last three inspection cycles, with scope, severity and inspection cycle.
  • CMS Penalties and Ownership filesCivil money penalties, payment denials, and the owners and managers on file.

Notes

  • CMS Certification Number 385125 · 1400 DIVISION STREET, OREGON CITY, OR, 97045.
  • Percentiles compare this facility with every rated nursing home in Oregon and Clackamas County. Turnover and fines are inverted so a high percentile is always good.
  • This is an informational summary of public data, not medical, legal, or placement advice. Facilities cannot pay to change it; a facility that believes a record is wrong can dispute it with CMS.

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