Map showing the location of AVAMERE REHABILITATION OF KING CITY in TIGARD, Oregon
16485 SW PACIFIC HIGHWAY, TIGARD, OR, 97224

Overall Score

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

Where it ranks

  • OregonAbove 61% of peers127 rated homes · average 3.0★
  • Washington CountyAbove only 25% of peers9 rated homes · average 3.8★
  • United StatesAbove 61% of peers14,574 rated homes · average 3.0★

How the rating is built

  • Health inspectionsStarting point3★+0.2 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 cycles3★Above only 48% 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 staff4.43hrsAbove only 14% 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 only0.72hrsAbove 64% 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 79% of peersOR avg49%RN turnover46%
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$49,348Above only 24% 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
33citations
5inspection dates
0actual harm (G–I)
1immediate jeopardy (J–L)
Dec 5, 2025most recent

Citations by monthMar 2023 – Dec 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.

Dec 5, 20258 citationsCycle 1worst E · no actual harm
  1. F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Resident RightsD · isolatedCorrected Sep 17, 2024
  2. F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Pharmacy ServiceD · isolatedCorrected Nov 19, 2025
  3. F552Ensure that residents are fully informed and understand their health status, care and treatments.Resident RightsD · isolatedCorrected Jan 6, 2026
  4. F558Reasonably accommodate the needs and preferences of each resident.Resident RightsD · isolatedCorrected Jan 6, 2026
  5. F605Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Jan 6, 2026
  6. F679Provide activities to meet all resident's needs.Quality of Life and CareE · patternCorrected Jan 6, 2026
  7. F697Provide safe, appropriate pain management for a resident who requires such services.Quality of Life and CareD · isolatedCorrected Jan 6, 2026
  8. F740Ensure each resident must receive and the facility must provide necessary behavioral health care and services.Quality of Life and CareD · isolatedCorrected Jan 6, 2026
Jan 10, 20251 citationCycle 2worst 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 Jan 30, 2025
Jul 19, 202412 citationsCycle 2worst F · no actual harm
  1. Provide appropriate treatment and care according to orders, resident’s preferences and goals.Quality of Life and CareD · isolatedCorrected Aug 27, 2024
  2. 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 Aug 27, 2024
  3. F641Ensure each resident receives an accurate assessment.Resident Assessment and Care PlanningD · isolatedCorrected Aug 27, 2024
  4. F645PASARR screening for Mental disorders or Intellectual DisabilitiesResident Assessment and Care PlanningD · isolatedCorrected Aug 27, 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 Aug 27, 2024
  6. F676Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.Quality of Life and CareD · isolatedCorrected Aug 27, 2024
  7. F679Provide activities to meet all resident's needs.Quality of Life and CareE · patternCorrected Aug 27, 2024
  8. 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 Aug 27, 2024
  9. F805Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.Nutrition and DietaryD · isolatedCorrected Aug 27, 2024
  10. F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and DietaryE · patternCorrected Aug 27, 2024
  11. F677Provide care and assistance to perform activities of daily living for any resident who is unable.Quality of Life and CareD · isolatedCorrected Aug 27, 2024
  12. 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 Aug 27, 2024
Apr 10, 202310 citationsCycle 3worst E · no actual harm
  1. F727Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.Nursing and Physician ServicesE · patternCorrected Apr 26, 2023
  2. Ensure each resident’s drug regimen must be free from unnecessary drugs.Pharmacy ServiceD · isolatedCorrected Apr 26, 2023
  3. F585Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.Resident RightsD · isolatedCorrected Apr 26, 2023
  4. F759Ensure medication error rates are not 5 percent or greater.Pharmacy ServiceD · isolatedCorrected Apr 26, 2023
  5. 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 RightsE · patternCorrected Apr 26, 2023
  6. 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 26, 2023
  7. 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 26, 2023
  8. 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 26, 2023
  9. F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and DietaryE · patternCorrected Apr 26, 2023
  10. 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 26, 2023
Mar 23, 20232 citationsCycle 3worst J · immediate jeopardy$49,348
  1. F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Mar 24, 2023
  2. F610Respond appropriately to all alleged violations.Freedom from Abuse, Neglect, and ExploitationJ · isolatedCorrected Mar 24, 2023

Staffing

From quarterly payroll reports

Hours per resident per day

  • All nursing staffRNs, LPNs and aides combined4.43hrsAbove only 14% of peers−0.52 vs OR avg
  • Registered nursesRN hours only0.72hrsAbove 64% of peers+0.04 vs OR avg
  • Licensed practical nursesLPN hours0.52hrs
  • Nurse aidesCNA hours3.20hrs
  • Weekend nursingAll staff on Saturdays and Sundays4.01hrs
  • Oregon average
  • Research benchmark (4.10 total, 0.75 RN)

Turnover & capacity

  • Nursing staff turnoverShare who left within a year · lower is better37%Above 79% of peersOR avg 49%
  • RN turnoverRegistered nurses only46%Not ranked by CMS
  • Administrators who leftIn the past year1Leadership changed
  • Occupancy148 certified beds · ~65 residents a day44%Above only 8% of peersOR avg 69%

Fines & penalties

Roughly the past three years

Enforcement summary

  • $49,348In fines
  • 1Fine
  • 0Payment denials
  • $32,647OR avg in fines
Above only 24% of peersFewer fines than 24% of rated homes in Oregon

Actions on record

  1. Mar 23, 2023Civil money penalty$49,348

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

Operational or managerial control
  • Avamere Health Services LLC
  • Avamere Skilled Advisors LLC
  • Midcap Finco LLC
  • Tonia Clark
  • Jennifer Dana
  • Andrea Doepker
  • Cody Feakin
  • Shannon Freeman
  • +9 more
5% Or Greater Security Interest
  • Midcap Finco LLC

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 385132 · 16485 SW PACIFIC HIGHWAY, TIGARD, OR, 97224.
  • Percentiles compare this facility with every rated nursing home in Oregon and Washington 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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